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.¹ For example, disruption occurred in naval warfare when reliance on battleships was replaced by aircraft carriers,² 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 pay-for-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.³ 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.⁴ 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.⁵ Perhaps high school graduates with appropriate physician supervision could perform some tasks that currently only physicians are legally permitted to perform.

Fourth, substantial resources are invested in building places to provide health care services or acquiring new equipment. Will there be an attempt to disrupt the way medicine is currently practiced and make it a 24-hour business so that routine office visits, nonemergency tests, including magnetic resonance imaging, outpatient surgeries, and vaccinations are available around the clock? If so, will incentives be offered to individuals who use facilities at off-peak hours? Would making health care a 24-hour business protect the planet while driving down the cost of medical care because capital will not be needed to build new buildings and purchase new equipment to replace buildings and equipment that had many more uses left in their lifespan?

Fifth, can the culture of medicine be dramatically changed to root out waste? Almost every other business is determined to make better products for less money. Will waste reduction be made a central focus so that the practice of medicine changes dramatically?^{6 - 7}

Sixth, will there be a commitment to a globalized health care delivery system, thereby perhaps eliminating jobs in one country and generating them in another? For instance, elective surgery could be performed with high quality and less cost outside the United States,⁸ and x-rays could be read instantaneously by radiologists located in another country. Instead, will medicine continue to be practiced on a statewide or countrywide basis?

Seventh, will professional associations commit to being responsible for both cost and quality on a population basis and will board certification depend on performance in both dimensions? Shouldn't the highlight of any national meeting of any group of health professionals be a presentation describing how the value of health care dollars has been increased in the last year and how health and cost have been addressed simultaneously on a population basis?

Eighth, what are the rights and responsibilities of both patients and physicians? Does a clinician have a responsibility to advise a patient to stop smoking or to get a mammogram? Does the responsibility include sending a reminder for a mammography appointment, or scheduling an appointment at a time convenient for the patient?

Moreover, what is the patient's responsibility? For example, if a patient who does not receive a colonoscopy (even though the procedure is covered by insurance and scheduled at a convenient time) develops colon cancer, does that patient have the right to expect the same services that would be provided for a patient who developed colon cancer but had received a colonoscopy?

None of the potential disruptions described in this article will affect the current political window for policy change in the United States. But they need to be on the agenda for discussion so a better health care system can be built for the future.

Currently, legislators considering whether to build more medical schools look at what physicians do, determine how the population is changing, multiply those 2 factors, and compare the product with the denominator of physician work hours that would be available without expanding medical schools. The result is usually a decision to build new medical schools. But if disruptive changes in the training of health professionals are possible, the need for more physicians could be altered dramatically, and perhaps resources allocated for more medical schools could be conserved and spent on more valuable activities. For instance, some of the money should be invested to produce a new science of health care delivery that investigates changes in the practice of medicine that would be labeled disruptive. Otherwise scientific studies on health care delivery will produce, at best, changes at the margin that will have little effect on cost, quality, or health.