Innovation in Healthcare

“You can’t get there from here.” It is both a punch line from an old joke and a common comment on the process of reforming the current US health care system. While we long for a comprehensive reform that would sweep away all of the dysfunction and waste, the reality is that culturally and politically we are incrementalists and are far more likely to nibble away at the edges to improve the system a little bit at a time. These small scale improvements are frustratingly slow; the challenge is, after all, changing one of the top ten economic undertakings on the globe and we are doing it with dental tools. What prevents us from moving faster and a bit more expansively on these reforms? I believe there are four areas where new policy and practice could help promote innovation.

Perhaps most pressing are the ways we pay for health care. As the health care system emerged in the past century it was focused on confronting and curing a host of acute care maladies. Not surprisingly the professionals, institutions and the ways in which they are financed are driven by addressing these needs. It is confounding enough that there is little finance that goes to promote prevention, but the real tragedy today is that the chronic care needs of the population cannot be paid for until the condition deteriorates into an acute manifestation. This means substandard care, poor use of resources, and confusion for the patients. Pay for performance arrangements are a step in the right direction, but they remain focused on acute conditions. Policies are needed to promote new types of interactions between patients and professionals. In part these are being brought about by the use of new types of technologies and professionals with new skills and orientations. But most of these innovations are paid for as demonstration projects or special grants, not as a part of basic reimbursement to providers. If innovative treatments continue to be paid for in this way they will always be thought of as an unsustainable “add on.”

Financing policies are of course part of the regulatory structure of health care. Beyond what is paid for and how it is paid, however, are a host of regulations that the system imposes on itself as a way of assuring quality, protecting patient privacy, and promoting access. Some of these are public or are enforced by public sanction, particularly around the threat of loss of Medicare payments. Increasingly I find that leaders in provider organizations are absorbed in ensuring response to these demands. Standards are definitely needed, but if they become redundant, conflicting and non-aligned they will lose their value and purpose of improving patient care. Clearly regulations and standards have been put in place to address shortfalls of the system, but many of them now seem to have taken on a life of their own and make it difficult, if not impossible, for health care leaders to address core issues and bring the innovations that are needed to their institutions and practices.

Education is a third barrier to innovation. For years the primary issues that needed to be addressed in health care were proposed as additions to health professions’ curriculum. Though faculty resisted many of these changes, for the most part they have been added incrementally over time. A little cultural competency here and a little patient center care there, topped off with a lesson or two about quality. At best these micro fixes have only added to the confusion of becoming a health provider, but at worst they may have distracted faculty from developing and modeling new practice formats that could begin to address the larger health care challenges. These new delivery models could be designed with different outcomes in mind, draw on new sets of inputs - meaning new practitioners, technologies, and patterns of care - and would be tested in a setting where they could be appropriately evaluated and assessed. If they worked, then students could learn in these settings and carry the new models out with them into practice. Instead schools and their faculty have added piecemeal to the existing curricula, without ever asking whether or not the overall program was relevant to the needs of the public now and ten years from now when most students, currently trained, will be practicing.

Finally, workforce as it is currently configured is an impediment to innovation. In many ways the workforce we have is a derivative of the financing, regulatory and education policies and programs critiqued above. We only pay certain types of professionals, so we don’t have other kinds of professionals. We limit practice of certain types to particular professionals, so we don’t have openings for others to serve. We don’t educate professionals together, so they don’t know how to practice together. If health care workers don’t have the skills, orientation, rewards and regulatory approval to make change happen, there seems little likelihood that innovation of any significance will occur. Empowered to address these challenges they could become the source for much needed change.