In 2004, Blockbuster Video had a market capitalization of more than $5 billion, with 9,000 stores nationwide staffed by 60,000 employees. In 2010, the company declared bankruptcy before being dissolved. Like many once-proud firms before it, Blockbuster was a victim of its inability to recognize that emerging technologies had enabled a seismic shift in what consumers were demanding — in Blockbuster’s case, the convenience of being able to pick movies from the comfort of their own homes via Netflix.
Many companies in many industries have made this same mistake, focusing on what they can easily produce instead of what their customers want. Health care providers tend to focus on providing health services as opposed to producing health. Engaging patients will be easier if we give them more of what they want: better health rather than more health services.
Health care in the United States is at an important juncture. We have seen amazing scientific advances in the past century, but despite spending far more than any other country on health care services, outcomes within the United States for many portions of the population remain poor. Experts have estimated that only 10% of premature mortality in the U.S. may be due to suboptimal quality of health services provision. A much larger share — perhaps as much as 40% — is due to behavioral determinants of health.
Health care providers traditionally regarded health behaviors as out of their sphere of influence and medical training. However, recent improvements in technology, advances in behavioral science, and shifts in health financing create exciting new possibilities to change this.
We are in the midst of amazing advances in wearable and wireless technologies that can monitor blood pressure, step counts, sleep patterns, and all sorts of other physiologic parameters and behaviors. While high acuity medical care will always need to be delivered in acute care settings, the wearables/wireless market is projected to grow to $50 billion by 2018. A new ecosystem of wearable and wireless technologies, patient engagement strategies, and provider feedback could manage chronic disease far more efficiently than our current approach of using episodic clinic visits.
However, for such devices to realize their potential to both measure and influence behavior and outcomes, they will need to overcome end-user inertia and create feedback loops with patients that motivate action and sustain engagement. This is where advances in behavioral science can make enormous and as yet mostly unrealized contributions to medicine. Feedback loops can be created that are effective in keeping patients and providers alike engaged — for example, by alerting a physician office when a patient has markedly abnormal blood sugar or blood pressure, thereby allowing the clinicians to focus on patients at high risk without intervention. More broadly, behavioral science can provide important guidance in helping to improve “choice environments,” such as the choice of health plans or providers for patients, through systematic and thoughtful application of defaults to patient and provider decision making, and in the alignment of patient and provider incentives towards improving health.
People often fail to recognize that the current health care delivery system contains a lot of embedded defaults and incentives, and many of these steer both patients and providers in undesirable directions. Fee-for-service payment is often held up as an example of bad incentives, but there are also positive examples. Penn Medicine recently changed physicians’ defaults toward prescribing generics; overnight, the generic prescribing rate went from 40—90% to 99%. Many insurance benefit designs could be significantly improved by making them simpler, such as eliminating inscrutable concepts like coinsurance in favor of copayments — which consumers show they understand — and tying patient cost-sharing to both the value of the services provided and improved health behaviors.
The key to designing a better health care system is to recognize that what patients want is to be healthy, not consume health services. Through technology that centers care provision around the convenience of patients rather than providers, simplified and improved choice environments, and incentives designed to keep people healthy rather than treat them only when they get sick, providers will improve their chances of improving the health of the U.S. population.
As Lead Advisor for the Patient Engagement theme on NEJM Catalyst, I am pleased to kick off an ongoing series of articles, case studies, interviews, and other contributions from leaders dedicated to improving patient engagement. Please look here often for new ideas, and offer your own. Together we can make a real difference in how patients and providers collaborate, in improving health outcomes, and in improving the U.S. health care delivery system.