Generation (jĕn‘ə-rā‘shən) n.
- A group of individuals born and living about the same time.
- A group of generally contemporaneous individuals regarded as having common cultural or social characteristics and attitudes.
- A stage or period of sequential technological development and innovation.
* This is a reposting of the article I wrote for the May 2008 issue of MDNG and is related to the recent blog post on Millennial Health Care Delivery.
Modern medicine has adopted technology and pushed the boundaries of science in impressive ways. We see this in the use of high-tech imaging, advanced pharmaceutical agents, innovative medical devices, and recent advances in proteomics and genetics. However, in the actual delivery of care (how physicians interact with patients, manage health information, and pay for care), we still have paper records, we still hand write prescriptions, and we still have as much as 30–40% administrative overhead. This health care delivery “adoption lag” is predictable, and typically averages five to seven years, but may be as long as 10 to 20 years. The automation of financial transactions, the movement toward electronic medical records, or even the adoption of Linux within the health care enterprise have all followed the predictable delayed adoption pattern seen in other industries.
However, this delay can be used to the strategic advantage of astute physicians and health care entrepreneurs. By observing the wider technology adoption patterns in fast-adopting industries like financial services, we can reliably predict what trends will soon be impacting health care. We can also get a sense of how consumers, traditionally called patients within health care, will respond as they adopt—and push their providers to adopt—the technologies that will simplify their health care interactions. This millennial generation of patients will expect to be able to use Internet technology to shop, compare, chat about, purchase, and report their experiences just as they do with nearly all the other services they consume. Welcome to next generation health care and what I like to call the Millennial patient.
The millenial patient
Millennial patients can best be defined by their behavior, rather than their age, sex, or demographic. Millennial patients are the first generation of Americans to grow up with the Internet as a pervasive part of their lives. They use the Internet in their everyday life to research information, purchase tickets, pay bills, and meet their personal, social, and professional needs. They are amazed, bewildered, and ultimately angry with the inability to access their healthcare services in this way. They cannot understand, and they will not tolerate, this disparity in the ability to manage healthcare transactions as simply as they manage their financial transactions. They are knowledgeable, intelligent, are typically prepared for their appointments, and inherently expect and demand a far higher level of service from their healthcare provider.
In contrast to the widely publicized TIME magazine article by Dr. Scott Haig, most Millennial patients are not “Googlers” in the derogative way he uses the term. Most do not use this information as a weapon against their physician, but rather use it to become an informed participant in the delivery of their care. They value the trusted relationship with their healthcare provider and want to work together to optimize their health. Having used professional advisors in other areas of their life, they understand the need to have a relationship with their healthcare provider based on trust, mutual respect, and open communication. In order for physicians to most effectively engage the Millennial patient, it is import to understand the different types of next-generation patients.
Patients as consumers
The days of passive patients cowering under the commanding voice of their all-knowing physician are gone. The outsourcing of medical decision making will continue to wane as the outsourcing of financial responsibility continues to be reduced. As the cost shifting returns back to the patient, the increased financial accountability means that patients will be more involved with decision making, including treatment decisions, because these directly affect costs. The notion of “shared medical decision,” pioneered by Jack Wennberg’s team at Dartmouth, describes the collaboration that occurs in reaching an agreement about a healthcare decision. Part of these conversations will include discussions regarding the pricing of services, which will force providers to reconsider what they are willing to accept for payment for their services. How much does that treatment cost? What are the alternative therapies, and how much do they cost?
It is important for providers to realize that patient consumers are not asking these questions to challenge their clinical judgment. There is no plausible medical tenet or practice bylaw that states the patient “shall not” know the price they are about to pay for a service. They are asking because they need this information to formulate in their own minds the value decision (outcome/ price) that will aff ect what they ultimately decide to do. While providers may believe that the patient will always choose the therapy that potentially leads to the best outcome, patient consumers may not be willing to pay the price to obtain the recommended outcome.
In addition to getting comfortable discussing pricing, providers will need to be able to complete healthcare transactions at the point of service. As more consumers pay a higher percentage of their own healthcare costs (consumer payments are about $50 billion today), healthcare providers will need to adopt new technology and business processes. Failure to do so will result in an everincreasing uncollected payment burden. The McKinsey Quarterly has documented the need to transform the point-of-service transaction capabilities in several papers. Part of this transformation includes eligibility verifi cation, real-time co-pay/ deductible accumulators, card/reader technology, and fi nancial integration with consumer accounts. In addition, providers will need to become much more transparent with regard to pricing for their services. Retail clinics have led the way in posting cash prices, and physicians will need to learn to not penalize consumers with much higher cash prices. Rather, they’ll need to reward them for the real and tangible savings that cash payments make possible by avoiding the Byzantine insurance payment process. Companies like Recondo, TriHealix, and even practice management companies like athenahealth are leading the way.
Physicians will need to realize that pricing information is only the first wave of the oncoming transparency initiatives. Savvy consumers will quickly become interested in outcomes information, wanting to know the specifi c results achieved by a specific physician for specific procedures. Furthermore, they are going to want to talk with the “patients like them” who have actually undergone the procedure from the physician to get a sense of experience, service level, and outcomes. Social networking has already significantly impacted this, and companies like HealthGrades, Xoova, Vitals, and others provide basic rating information right now. This will become much more sophisticated and ultimately include relevant outcomes data in consumer-friendly formats.
Finally, the consumer patient will want to engage their healthcare provider in the convenient ways in which they engage every other service. They will demand the ability to schedule appointments online, check laboratory or radiologic results, and communicate with their physician via “new media” like e-mail, chat, and video. These technologies are all well-established commodities, and they enable providers to meet their patients “where they are” in terms of how, when, and in what manner they would prefer to communicate. New services like American Well, Hello Health! and Organized Wisdom are all representative of enabling technologies that patient consumes will want to utilize to engage their health providers.
Patients as providers?
Enabling new technologies works both ways in allowing patients and physicians to interact in new ways. For physicians, that means the ability to empower patients by helping them become more informed, involved, and in-tune with their own health. Just as the use of mid-level providers served as an eff ective extension of the physician, many of these new technologies can push outsourcing of care all the way down to the patient. In this paradigm, the patient becomes another provider, perhaps a much more accurate and appropriate description of the term primary provider.
David S. Sobel, MD, MPH, Medical Director of Patient Education and Health Promotion for The Permanente Medical Group at Kaiser Permanente, is responsible for 3.3 million members who interact with the Kaiser system and has a simple mantra for success: “Keep the patients healthy, happy, and at home.” Beyond the trite saying is a powerful philosophy about patient empowerment. Namely, Sobel considers his patients as providers and collaborators in the care process. “Patients are most often viewed as consumers of healthcare, and health professionals are seen as the primary healthcare providers” Sobel says. “In fact, 70 to 90% of all symptoms are self-diagnosed and self-treated without the help of health professionals. The true primary care providers are people themselves.” What would happen if providers considered their patients as colleagues in optimizing health? How would patients respond to not only an increased fi nancial stake in their care, but also an increased clinical stake as well?
Patients as Partners!
While we may still be a long way from patients as providers, initiatives like shared medical decision making are helping break the paternalistic perspective and embrace the patient as a member of the care team. Patients can be reliable reporters of treatment regimens, can assist with care coordination, and with appropriate oversight, can serve as outsourced low-level providers. The physician role in this setting is to create an aligned relationship of trust that leads to health optimization; the physician becomes the trusted advisor who guides the partner patient through the labyrinth of healthcare decision making. This is the physician counselor who can facilitate decision making along clinical, fi nancial, and social/cultural lines. Sounds suspiciously like the primary care model, right? What is so novel about the patient as a partner? Get real. Primary care delivered in this way is exceptionally diffi cult to find. You cannot create a trusted, advisory relationship in the 7- to 12- minute patient interval treadmill that most primary care physicians run on every day. However, there is a growing awareness, perhaps even a growing movement, among the proponents of throwback traditional medical practices, with an updated technology twist.
The millenial provider
Having already defi ned Millennial patients, it would be appropriate to also describe Millennial providers. These are the enlightened physicians who realize that technology can help them in delivering an entirely new range of personalized healthcare services that meet specifi c individual needs. While some remain concerned that technology gets in the way of developing meaningful relationships, Millennial providers use technology in such a seamless way as to abstract it nearly completely out of the relationship. Instead of decreasing the intimacy of the relationship, it actually allows healthcare services to be delivered in a much more personalized way.
This style of medical practice is allowing a sense of freedom and fulfi llment that had previously been extinguished in the crushing cycle of managed care. “I couldn’t handle the frustration of traditional managed care practice paradigm,” said Jordan Shlain MD, CEO of San Francisco On Call physicians group in San Francisco. Schlain begin his own on-call, personalized medicine service just two years out of residency. “I was not happy, not in control, and not enjoying my patients or myself. I chose to create the type of practice that I wanted to go to, that I would actually use as a busy, young professional.” Schlain discontinued his practice, stopped taking insurance, and instead created an on-call service whereby he would go to the offi ces of his patients to provide care. He adopted an electronic medical record, wireless technology, and several practice innovations that allowed him to coordinate his practice with that of his patient partners. He worked holistically with the patients, to meet their ongoing health, prevention, and wellness needs. He works reasonable hours, makes more money, and couldn’t be happier practicing medicine on his own terms, using technology-enabled, personalized services that treat the specialized needs of his unique patient population.
Millennial patients are beginning to demand a higher quality of service and a more meaningful relationship with their provider consistent with their experiences in other sectors of the market. Millennial providers will create service off erings that will address patients’ specialized needs and help deliver appropriate health services within a personalized context. This partnership of care relationship will need to be supported by the very best technology, products, and services associated with the pricing, quality, and effectiveness information required of a value-driven system. When these elements become transparent and aligned with appropriate fiscal incentives, the US healthcare system will approach the efficient, next generation healthcare system that can continue to serve our countries healthcare needs well into the new millennium.
Scott Shreeve, MD, is interested in the convergence of medicine, technology, and business. He works to design, develop, and distribute healthcare technologies that enhance patient safety, increase clinical efficiency, and improve overall quality of care. His blog, Crossover Health is dedicated to ensuring that these technologies are eff ectively applied to healthcare delivery in order to create a true consumer market for optimal health.
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