Disruption and Innovation in Health Care

SUCCESSFUL HEALTH CARE REFORM MAY PROVIDE VIRTUally all individuals in the United States an adequate health insurance package. However, the need to increase value for health care dollars will extend far beyond the current policy window. Achieving that goal will require disruptive innovation in the health care system. Disruption occurs when the expectations of individuals and the services provided are so vastly different that linear change is no longer likely. For example, disruption occurred in naval warfare when reliance on battleships was replaced by aircraft carriers, and in medicine when anesthesia and vaccines were introduced. Could similar kinds of successful disruption happen in the delivery of health care? There are 8 potential disruptions that could increase the value of health care. First, the planet earth is no longer a stable environment, and its future, and that of the world’s population, depends on how well it is treated. Therefore, it is reasonable to ask how changes in health care delivery would affect not just individuals, but the planet. A disruptive change would expand the view of health care policy beyond Congressional Budget Office scoring for cost and consider what proposed policies imply for the future of the planet. For example, how can the carbon footprint of new technologies and health facilities be reduced, and should new facilities be located in energy friendly places? How will increasing life expectancy affect the ability to reduce carbon dioxide emissions? Second, improving delivery of health care services as they are now defined will do little to erase the difference in mortality and morbidity that exists in the United States as a function of where a person lives or who he or she is. Will the approach to health care delivery change to include at least some social determinants of health? Physicians do not spend sufficient time examining the social and mental health of patients, and do not view as their responsibility helping patients become better integrated into the community or developing positive mental health attributes that could make patients happier and, potentially, healthier. Disruptive change could reach even further. What if the practice of pediatrics included examining the report cards of children or performing an independent assessment of a preschool child’s readiness to read? What if a clinician explained to parents the importance of education and reading in being able to support a healthy lifestyle? What if payfor-performance included measures of educational attainment in addition to whether diabetes, hypertension, or asthma were controlled? What would happen if the same fundamental disruption occurred in the school system so that teachers were responsible not only for the educational achievement of students, but also for their health? Would there be more willingness to spend education dollars to reduce posttraumatic stress and depression in children so they were ready to learn? Until now, education and medical care have operated in 2 silos. Will there be a disruption that at least brings these 2 great social systems together to integrate some aspects of the social determinants of health with the delivery of personal medical services? Third, society has made substantial efforts to protect individuals against health practitioners who may do more harm than good or are not qualified to treat a given condition or a specific patient. Traditionally educated but independent nurse practitioners with physician backup can produce, for selected patients, a comparable level of care as physicians. Likewise, women with low-risk pregnancies managed during delivery by midwives with physician backup vs those managed in a consultant-led labor had fewer interventions without differences in fetal outcomes. Will the system be disrupted by allowing and fostering the development of educational models that base acceptance on whether a clinician can do something as opposed to how that clinician is educated and trained? The health services research literature is replete with information about the volume-outcome relationship; for selected procedures, doing something more produces better results. If the sole focus of a clinician is removing cataracts, performing colonoscopies, injecting Botox, or reading mammograms, why can’t individuals be trained to perform these activities without requiring them to graduate from medical school? Perhaps a new approach to training should be considered that combines skills from nursing, public health, and medicine. Perhaps high school graduates with