The push to reimburse healthcare providers based on performance and outcomes and to participate in risk-sharing arrangements has gained significant traction. Underlying this move is a combination of electronic health records, improved information transfer, and large-scale sophisticated data analytics.
We are just now starting to feel the impact that digitized patient health information will have on our ability to measure clinician performance and resultant patient outcomes. An oft-heard rebuttal to attempts to create value-based clinician incentives has been “My patients are unique.” The digitization of patient data allows us to understand how different our patients actually are, account for those differences, and reward clinicians for outcomes that consider those differences.
To date, use of clinical decision support tools has been sparse. As large-scale data analytics mature and we are provided with guidance as to how to optimize care for each of our unique patients, clinicians will increase their acceptance and reliance on these tools to not only monitor care but also drive care.
The move from a pure productivity-based reimbursement system to one that incorporates outcomes has been a slow, gradual process. But that change will accelerate, and we will see a higher level of quality per dollar spent in conjunction with our ability to leverage newly available large-population data to create individual patient care algorithms.
For the past decade or so, we have seen more care shifting from traditional hospital settings to outpatient ones. Now, we are seeing an acceleration in this migration in care delivery location. Let’s take a moment to look at new care venues such as retail clinics and use my specialty, emergency medicine, to illustrate why these new care locations will thrive.
The first emergency medicine residency programs were created in the early 1970s, and the field wasn’t recognized as a primary specialty board until 1989. Now, a generation later, essentially every hospital in the country is staffed by physicians who recognize themselves as emergency physicians.
Although these physicians can boast skills and clinical management abilities unique to the specialty, a key value proposition that defines the specialty remains a completely non-skill, non-knowledge-based asset: real estate. One of the primary features of emergency medicine is that it’s defined by location—a single location with rapid access to the array of sophisticated medical technologies.
Now consider the much wider (yet more dispersed, conveniently located, and easily accessible) geographic distribution of clinics administered through companies such as CVS, Walgreens, and Walmart. Consider how new technologies are allowing for more sophisticated diagnostic and therapeutic options outside of the hospital and clinic walls. It’s an easy leap to see how this care venue will grow and thrive within the next generation.
Innovation in health technologies will stratify care options further, with certain types of care available at the patient’s residence or work location and other types available essentially anywhere through a virtual venue. Patient demand for care-in-place is evidenced by the volume of patients who opt for home COVID-19 testing versus seeing their primary care physician or even going to a retail clinic for a test. Not even a generation ago, COVID-19 testing would have necessitated a visit to one’s family physician. The many technologies to foster this move to care-in-place are still in their infancy.
Home dialysis, cardiac monitoring with automated identification of complex rhythms and other cardiac events, mobile blood testing, acoustic evaluation for congestive heart failure, voice biomarker technologies, mobile functional neurologic assessments (and the list goes on)—all will usher in a stratified care venue delivery system. When structured appropriately, this system will greatly increase the immediacy and accessibility of healthcare while reducing cost not only due to elimination of costs associated with brick-and-mortar venues but also because patients will access care at an earlier point in their disease processes.
Although many physicians may believe the term “healthcare provider” was coined to deprofessionalize the physician, it was much more an attempt to use a single term to describe the growing variety of clinicians providing healthcare services. This occurred largely due to the technological advances that allowed for a differentially trained labor force able to provide similar levels of care for specified conditions.
Let’s take depression as an example of how care is changing. Today, if a patient is depressed, they typically see their primary care doctor, who determines treatment options, and if serious and warranted, refers them to a psychiatrist.
Partially because of the lack of quantitative, reproducible, scalable assessment tools, and partially because of the limited number of available psychiatrists and other mental health clinicians, our current system is highly physician-centric and only screens for patients to the far left of the disease spectrum. This includes those who require physician or perhaps clinical psychologist intervention, and often those who require prescription therapy.
New artificial intelligence voice biomarker tools now hold the promise of identifying patients across the disease spectrum. This includes not only those with significant pathology but also those who suffer from lesser degrees of depression. Rather than medical care, these patients may benefit from a counselor, life coach, meditation/mindfulness app, or even a chat bot. These tools allow for longitudinal screening at home, democratize depression evaluation, and create a paradigm shift in mental health from that of disease identification and treatment to wellness for the entire population—certainly an improvement over our current care delivery model.
This type of technological advance in healthcare will result in a much more stratified approach that requires us to further diversify our clinician labor pool by expanding our definition of “provider.”
Which begs the question, where do physicians fit in?