Rethinking the Hierarchy
Law Professor Proposes New Health Care Architecture
It’s tough to innovate on a large scale. There comes a time, though, when advances within a sector compel us to reevaluate the bigger picture.
Dr. Barak Richman, a professor of law and business at Duke University, proposes a new framework for the U.S. health sector, one he believes would be more affordable and sustainable. He shared his ideas at a recent virtual NIMH Director’s innovation lecture.
Within our current health care system, there’s been great modular innovation over the years, from new medicines to surgical techniques, among other groundbreaking interventions, he noted.
“But if the last 40 years of innovation have taught us anything,” said Richman, “it’s that we also need to pursue organizational innovation. We need to develop a new architecture that can really harness new capabilities, reduce costs and improve quality and productivity.”
Such a transformation involves rethinking our approach to health care delivery, he said, so we’re no longer constrained by the existing architecture. Rather than centering care around available resources—hospitals, physicians, payors—the new structure would be built around patients, who could then better access the kinds of medical services they need.
“We really want to resist thinking only about how we deploy our resources,” Richman said. “Instead, we might want to think about how we can deploy or create or provide high-value services.”
The current hierarchical architecture puts hospitals at the center of health care delivery. But in this top-down system, doctors have increasingly become tethered to hospitals and insurers, which continues to inflate health care costs, he said. Meanwhile, despite the digital advances of the past 25 years—from the internet to smartphones—health care productivity remains ossified.
“The way we have delivered health care has not really responded to dramatically significant technologies that have really transformed and reorganized most other sectors in the economy,” argued Richman.
Digital technologies have unleashed myriad opportunities for health care, linking patients to health information sources and telemedicine consultations, digitizing health records and enabling data analytics to automate diagnostics and guidance. These technologies, he asserted, enable and necessitate a reorganization of U.S. health care delivery.
Richman suggested a business model that reworks power centers and priorities. Interrelationships are critical in providing high-quality care, along with the location and organization of care, which affect cost, quality, patient behaviors, convenience and optimized use of new technology.
Empowering the Patient
The new model would sever the local hospital from the main architecture of health care delivery. Instead, doctors and insurers would collaborate with patients, who could shop around for hospitals and other primary and chronic care needs.
Richman’s work on antitrust issues led him to consider a new health care model. Removing hospitals from the epicenter of the current architecture offers new possibilities to contract with other hospitals, which in turn resolves antitrust problems by stimulating competition. Providers would still be the main organizers and visionaries of health care, but they wouldn’t have to play a role in day-to-day delivery.
“With digital medicine and different kinds of arrangements and relationships, we can think more of a bottom-up approach,” he said, which delivers care to patients in a cost-effective way.
Need for a New Framework
One case that exemplifies how an innovative idea was hampered by our existing health care architecture is the effort to develop an electronic health records system. After 8 years and a massive federal subsidy, an integrated, interoperable system remains elusive. Why? “Hospitals built the electronic health records to duplicate and reinforce the kind of architecture we currently have,” Richman explained.
Another model, one undertaken by France, instead organizes health care delivery around the patient. There, individual health records are stored electronically on insurance cards, allowing patients to bring their personalized information to any provider.
In the U.S., some tech companies are investing in new patient-centered health services. But can this be done, asked Richman, without constructing a new architecture?
Lessons of a Pandemic
Our relationships with each other, our health providers and digital technology have evolved over the past year due to the Covid-19 pandemic. In March, telemedicine surged 50 percent; by August, these video-calls with doctors rose by 3,500 percent. But the pandemic also illuminated a problematic side of technology—the proliferation of misinformation and conflicting sources of health information.
“We need to shift the source of information…to trusted providers,” said Richman. “The entire information ecosystem really needs to change, and there’s no reason that our providers—who know us and our communities and who we have relationships with—cannot be much more active in disseminating information to us.”
Looking to the Future
Richman envisioned several scenarios within a restructured health sector. With telehealth, a parent with a sick baby could receive care without having to leave the comfort of home. Caring for an aging parent also could be done digitally, suggested Richman. The technology already exists to monitor potential emergency triggers in the caregiver’s absence. A new architecture, he said, could offer safer, more cost-effective independent living.
Another prospective improvement is surgery, such as hip replacement. Local hospitals often charge high prices yet may not even specialize in that area, said Richman. Imagine implementing destination medicine—the potential to shop elsewhere for care—reducing costs by expanding both competition and patient choice.
A new architecture could integrate specialists into primary care, while telemedicine further expands patient choice and the radius of care, since doctors wouldn’t necessarily have to be local. Rather than a hierarchical relationship with doctors, patients could have a more direct relationship, perhaps through a new information ecosystem.
Even though patients might not regularly see doctors physically, Richman said, “We’d have them much more integrated into our daily lives—whether through telemedicine, some kind of digital interface or other information system—having them much more actively engaged in providing us with information and direction.”
During the Q&A, Richman was asked how a new framework might affect vulnerable and marginalized populations. Caring for low-income and other vulnerable populations, who likely suffer from comorbidities, requires an integrated strategy, he said, which individual providers can’t accomplish.
“That only accentuates the need to have a comprehensive approach to delivering care in a different kind of architecture that’s patient-centered,” Richman said. “All of the intersections between the social determinants of health and health care delivery are going to have to be a part of developing this new architecture.”