BLOG STARTUPS, VENTURE AND THE TECH BUSINESS

The Doctor/Patient Relationship Is At A Crossroads

[This post first appeared at blogs.forbes.com/toddhixon on January 13, 2015.]

The relationship between doctors and their customers (aka “patients”) is changing fast, driven by the forces underlying healthcare reform. Three new models are emerging: integrated health systems, direct primary care, and retail care. Their strengths and weaknesses are very different, and our lives and fortunes depend on getting this right.

In the 1950s and 1960s, medicine centered on the relationship between the customer and the family doctor. Doctors made house calls (I remember one when I was a child) and supervised care delivered in the hospital. Family doctors managed customers’ interactions with the rest of the medical system. They were highly respected community members: recall Marcus Welby, M.D.

In the 1980s and 1990s, as the cost of healthcare became burdensome for corporate and government payers, the dynamic changed. The federal government and the insurance companies created a structure of procedures and payment rates for each. Procedures based on higher levels of training and technology received higher fees. The Feds and insurers tried to push down prices of procedures, but at the same time they rewarded advances in medical knowledge and technology, and the result was highly trained specialists were well paid for performing sophisticated procedures, and family doctors were squeezed. Prestige followed income: a young family doctor recalls that a medical school mentor told her: “You’re too smart to be a family doctor.”

Family doctors also faced rising frustration. With low fees they needed to see large numbers of patients for 7-10 minutes each to earn half as much as specialists. Family medicine became an assembly line, and doctors became triage nurses. Volume plus the insurance system created a huge paperwork burden. Family doctors no longer had time to follow their patients in the hospital: that role was handed off to a new doctor called a “hospitalist”. Young doctors, burdened with large medical school debts, tracked to specialties earning more dollars and respect. A shortage of family doctors developed. And new medical disciplines, e.g. nurse practitioners and physician’s assistants, grew up to take some of the burden of first line care.

Now the U.S. healthcare system is changing profoundly. The cost control efforts of the 80s and 90s lost traction. The U.S. faces a slow, silent epidemic of chronic diseases rooted in lifestyle choices, which drive >80% of healthcare spending. The fundamentally reactive posture of American healthcare — curing problems when they present with ever-increasing degrees of technology and skill — does not deal effectively with chronic diseases, which are usually deeply rooted when symptom occur. Plus, this decade is bringing large new demands on the health care system from expansion of health coverage and aging of the large baby boom cohort. These changes are forcing change of the structure of the healthcare system and particularly the doctor/patient relationship.

Three models for the relationship between family doctors and their customers are rising in importance:

•  Integrated Health System: the doctor is employed by the health system and coordinates its resources to care for the customer (over 75% of U.S. doctors are now affiliated with a health system). The customer may be seen by the doctor or other “care team” members depending on needs.

•  Direct Primary Care: the doctor works for the customer (individual or plan sponsor): s/he is paid a fixed monthly fee and does not bill for procedures. This enables the doctor to spend more time on prevention, disease management and helping the customer manage the rest of the medical system.
•  Retail Primary Care: the doctor sits in a store front (physical or via tele-presence) and provides convenient, cost-effective, basic care to customers as-and-when-needed.

The approaches are very different in their strengths and weaknesses. Here’s a brief comparison.

*specialists and inpatient care

Leading practitioners have shown good results with each of these approaches: Kaiser, Mayo, and Cleveland among integrated health systems, Iora Health and others among direct primary care providers, and MDLive, MinuteClinic, and many others among retail providers. Many of the new model companies have been created by entrepreneurs and venture Capital investors: e.g., Iora and MDLive. I don’t think I know yet which is best, and probably no approach is best all the time.

In the next decade we will sort out which approach, or which cocktail of approaches, is right for each patient segment. The goal is clear: make medicine more proactive so that it can reduce chronic disease early, before the damage is done, and better manage the overall medical system on behalf of the customer, to take the right actions fast and reduce un-necessary procedures and cost. Reviving the close and respectful relationship between doctor and customer will be a key part of the answer.

 

 

 

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