Analysis of the second NEJM Catalyst Insights Council survey on the Care Redesign theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
METHODOLOGY AND RESPONDENTS
In May and June 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinician leaders, and clinicians at organizations directly involved in health care delivery. A total of 498 completed surveys are included in the analysis. The margin of error for a base of 498 is +/- 4.4% at the 95% confidence interval.
The majority of respondents were clinicians (49%), with executives (22%) and clinician leaders (29%) nearly evenly split. Most respondents described their organizations as hospitals (38%) or health systems (14%). These hospitals were predominantly midsized (34% had 200–499 beds) or larger (47% had 500 or more beds).
Only 10% of respondents indicated that their major affiliation was with a physician organization. Those physician organizations tended to be big — 43% had 100 or more physicians.
Nearly three-quarters of the organizations (72%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.
On a recent trip to Australia, I paid close attention to sentiments about the country’s adoption of disruptors such as telehealth and retail clinics. Australia has paced about a decade ahead of the United States in these fields, but as I learned there, being ahead doesn’t always mean better care.
I got the distinct impression that despite the prevalence of convenient health care — there are clinics in shopping malls — patients and physicians alike are dissatisfied with care relationships.
The problem, from what I gathered, is that Australia has moved so far down the path of convenience, they have lost the essence of health care: the relationship between the healer and the patient.
In this second edition of our quarterly survey of the NEJM Catalyst Insights Council for the Care Redesign initiative, we posed questions to health care executives, clinical leaders, and clinicians to assess the penetration and impact of disruptors such as telehealth, retail clinics, and health apps (such as those found on mobile devices) on the U.S. health care system. Has convenience started to erode patient-doctor relationships and, therefore, the true quality of care?
Not surprisingly, nearly three quarters of respondents said market disruptors improve convenience for patients. However, 8 in 10 believe these disruptors will lead to a fragmented patient-doctor relationship. And more than two-thirds of respondents don’t believe that these disruptors will lower the cost of care — which is a clear focus of value-based care. Notably, clinicians (23%) are far more skeptical about this potential outcome than executives (39%).
What these results indicate to me is that, if the U.S. health care system starts favoring convenience, or transactional care, over relationship-based care, then patients will sour to traditional health care altogether and seek alternative, and potentially more expensive, less effective treatments.
The good news, according to the survey, is that there is still opportunity for executives, clinical leaders, and clinicians to strike the right balance between convenience and relationship-based care. Though a third of respondents said disruptors are hurting primary care, 42% of respondents said they have no opinion yet about the impact of these disruptors — i.e., it’s too early to tell.
Widespread Adoption of Market Disruptors
At least half of respondents indicated that the disruptors listed in the survey, which also included wireless home health devices and automated/online decision support for patients, are already taking place in their local marketplace or will do so in the next one to two years. The Northeast was particularly bullish on the onset of market disruptors.
Take, for instance, retail clinics. Respondents reported overwhelmingly high presence of urgent care centers, walk-in clinics, and the like across all geographic regions.
Health apps, such as those that monitor activity levels for chronic disease, also are experiencing significant adoption.
Without a direct link to electronic medical records, however, these apps put a wall between health behaviors and health care. They might suggest improvements to diet that don’t take into consideration a patient’s pre-existing conditions or genetic factors. For instance, a health app avatar might not know that a patient is taking the steroid prednisone, which would impact his ability to lose weight.
Telehealth (which includes the range of technologies and services for remote consultation and self-care) was considered the biggest disruptor by survey respondents, with 44% penetration today. Another quarter of respondents said telehealth would reach their local market within 2 years, and 18% more said within 2–3 years. Thus 87% of people say that telehealth has arrived or will soon.
Executive, clinical leader, and clinician respondents to the NEJM Catalyst survey all agree that disruptors will force traditional care delivery organizations to improve patient experience and customer service. In other words, these disruptors are set to change the way traditional practices deliver care.
How Traditional Care Organizations Should Respond
Primary care practices should embrace the factors that make retail clinics attractive to patients: great access, flexible timing, and easy navigation. Retail clinics have figured out how to break down the barriers to care.
Traditional care delivery organizations should become more flexible and open with the flow of good information, rather than enabling an environment of fragmented care, inaccurate medical information, and less coordinated care — which are all negative outcomes for U.S. health care that the survey respondents fear.
Some traditional providers and academic institutions already have responded to the retail clinic threat by starting up their own branded urgent care clinics, including Beth Israel Deaconess Medical Center and my own organization, Providence St. Joseph Health.
Now is the time when the industry also has to look at opportunities such as linking mobile apps to a patient’s medical record and their physician for insightful care pathways.
Nearly half of respondents to the NEJM Catalyst survey believe that a positive outcome of telehealth, retail clinics, and other disruptors will be improved self-care. That consequence could benefit primary care and ultimately move the needle on value-based care and healthy outcomes overall.
The classic 1993 JAMA article “Actual causes of death in the United States” (McGinnis and Foege) reported that about half of all deaths come from behaviors. So if patients can take care of themselves by better eating, sleeping, exercising, and stress management, then they’ll need less medical intervention. That’s a win for everyone. And if health care providers can improve coordination of care for patients with chronic conditions — which 44% of respondents believe will be the outcome of these market disruptors — then we have a better chance at ensuring the best possible health outcomes for the patients and families we care for.
Namita Mohta, MD, Clinical Editor for NEJM Catalyst, contributed to this Insights Report. Check NEJM Catalyst for monthly Insights Reports not only on Care Redesign, but also on the New Marketplace and Patient Engagement.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
Are retail clinics helping or hurting primary care?
“Primary care clinics are not meeting the needs of patients and thus retail clinics attract business. Eventually health care systems will absorb or co-brand with retail clinics as we advance towards ACO models.”
“Let me honest about this. The retail clinics are a cash and carry business.”
“May be decreasing volume slightly, but I suspect a significant number of patients would either defer care or go to ER.”
“Decreased continuity and substandard care. It’s a logical reaction though to the disruptions caused by the constant churning and disruption for-profit health plans intentionally introduce into health care delivery.”
“This is not a black and white issue, all depends on the skill level of the provider. A well-trained NP at CVS may be better for a patient than an overworked, underpaid, burnt-out MD, however we have all seen numerous patients coming in as train wrecks with simple problems because they have only been treated at an urgent care. Additionally, when only extremely complex patients are seeing their provider in the office, this makes the day of the physician extremely arduous, and I think would increase wait times for patients, as well as decrease the physician’s professional satisfaction. Everyone needs a minute to breathe in the day.”
“We need changes in the delivery system and not another competitor. I do not see how Walgreens, CVS, or a for-profit urgent care physician group are interested in true transformation or a truly new delivery system.”
“It is mixed — they duplicate services that may be repeated by misdiagnosing patients, but they also relieve some volume, and in light of current scarcity of primary care docs that is a positive.”
“Provide patients with another choice making it more likely that the patient will access timely care. The challenge will be to ensure that the medical record is seamless across all delivery sites.”
“Inconsistent care. Increased medication interaction errors. High utilization of unnecessary antibiotics. Lack of quality incentives to guide care with a greater concern of meeting the patient’s perceived expectations instead of molding expectations toward better health through quality care delivery. That requires a trusting relationship.”
“There is no reason that patients have to be forced into waiting for a unique appointment time, in a doctor’s office — which is typically unappealing, poorly designed, and requires waits in excess of the appointment time.”
“The providers in these settings aren’t as well trained. The care fragments the PCP-patient relationship. The providers in these settings have no mandate to adhere to quality (HEDIS) guidelines, which has a negative impact on PCP metrics and a downstream negative impact on the ability of the PCP to capture incentive dollars, which is especially important in markets where FFS payments have not increased.”
“Patients want and need convenience; you do not need to see your primary care provider about everything but primary care providers do need to be notified that care took place.”
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.