Every innovation is built on a foundation of a thousand failures. When success finally comes, it's easy to lose sight of all the mistakes it took to get it right.
It's the same story in healthcare innovation: there have been many new healthcare models claiming to be the next big thing despite ultimately failing.
Some of them were popular for a time — but all of them produced important lessons that helped us get to where we are today. These failed innovations share at least one common fault: models that rewarded inconsistent participation in primary care and preventive services.
It's in this spirit that we're sharing the stories behind three major healthcare innovations — what they are, why they ultimately failed, and what we can learn from these failures.
Original managed care
Managed care has served as a framework for benefits plans for decades. It promises to centralize patient care within a single network or provider system aimed at containing costs and improving patient health outcomes. The problem is, the traditional version of managed care never fully delivered on its promise.
While traditional managed care helped control access to care, it also constrained patients to a network that, no matter how large or small, couldn't guarantee better health outcomes. Instead of managing patients’ care with primary care resources, providers were forced to act as referral machines — steering patients to specialists.
The focus on specialist-care resulted in gaps that became significant risks for patients who didn’t receive ongoing primary care. These patients often felt stranded after visiting with a specialist — while specialists were unaware of patients’ underlying health issues because the referral was made too quickly.
And of course, specialists were (and are) more expensive than primary care providers, so getting treatment that otherwise could have been provided through primary care meant paying more when it wasn’t necessary — and created, over time, a tremendous amount of waste.
But the theory behind managed care has the potential to be effective, especially when it empowers primary care providers and care teams to do their jobs. This is about being less like a gatekeeper and more like a hub that plans and coordinates a patient's entire care journey.
When primary care is done right as a part of an updated managed care model, each patient works with their provider and health coach to develop a personalized care plan. Once a plan is in place, the care team guides them through the program and coordinates their care from start to finish.
Patients can get most of the care they need from their primary care center — reducing costly urgent care, pharmacy expenses, and emergency room visits.
Isolated wellness programs
Organization’s wellness programs have grown in popularity over the last 10 years, and many companies offer them as a benefit to their members.
In part, this is a response to rising healthcare costs, which many organizations are understandably eager to reduce. Wellness programs offer substantial savings by promoting healthier lifestyles among members which promote reduced claims.
The most popular wellness programs include:
Fitness centers and club memberships
Health screenings and health-risk assessments
Fitness and health competitions
While each of these programs are well-intentioned about improving health, behavior change is an important component that’s too often absent.
Even if patients want to get healthier, they often don't know where to start. They need consistent help and professional support. A primary care team that includes a health coach is a great solution. It provides patients with the resources they need to take ownership of their health and change their behavior.
When patients can get to the root causes behind their behavior, identify obstacles to overcome, and equip themselves with the resources to change their lives — success follows.
No doubt you've heard a lot about high-risk patients. Some propose creating high-risk pools that will move the riskiest patients into alternative buying groups so they won't impact everyone else's premiums.
However, such a move does nothing to solve the underlying problem that is driving costs higher every day: High-risk patients need proactive medical care and ongoing support.
The traditional healthcare system compounds this problem by creating more high-risk patients every day. With more and more people forced into high-deductible insurance plans, without low- or no-cost primary care, patients often wait until they have a significant issue to visit the doctor. When high-risk patients aren’t getting the routine care they need, they become riskier patients every day. And pay-per-use clinics are an unfortunate extension of traditional healthcare’s limitations in this area.
For any clinic to have a positive impact on an organization's health, the right kind of utilization is key. Ultimately, reducing costs and achieving a return on investment are the natural result of members getting healthier, and that hinges on consistent participation in primary care and preventive services.
What the pandemic taught us
The pandemic has been difficult and clarifying for many, many people. Now more than ever, individuals and families need important (and historically less adaptive) things like work and healthcare to better fit into the realities and pandemic-related safety measures in front of them.
COVID-19 has underscored the value and utility of virtual care appointments which are only increasing over time. In fact, research firm Frost Sullivan projects virtual care usage will grow at a compound growth rate of 38.2% through 2025.
To meet members where they are today and tomorrow, our advanced primary care (APC) model upends status quo healthcare and overcomes the limitations of these three failed innovations:
In place of original managed care, providing low- or no-cost primary care with convenient physical and virtual appointments encourages members to take ownership of their health where pay-per-use clinics taught members to stay away until the symptoms were more urgent.
Replacing isolated wellness programs with health coaches and behavioral health clinicians embedded in primary care teams encourages member behavior change for challenges like substance abuse or poor sleep — real-world support that well-intentioned (but indirect) wellness programs lack
Correcting the problems of pay-per-use clinics with value-based healthcare and longer appointments empowers primary care providers to practice the full breadth of their training as they deliver personalized care — a stark contrast to managed care plans where primary care providers are incentivized to act as a referral machine for costly specialists
Members should never have to feel stranded by their healthcare’s complicated benefits and siloed specialty care. Failed innovations are instructive: stepping stones on our way to a better healthcare system — and Vera Whole Health and others like us are working to continue the evolution.
Editor’s Note: This post was originally published on June 19, 2019 and has been recently updated to include the latest insights and best practices.