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, and some of them were popular for a time — but all of them produced important lessons that helped us get to where we are today.
It's in this spirit that we're sharing the stories behind three major healthcare innovations — what they are, and why they ultimately failed.
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, it never fully delivered on its promise.
The biggest outcome of traditional managed care is that it controls access to care. Patients are incentivized to use in-network providers and specialists, regardless of provider cost or quality. They're also financially penalized for getting medical care outside their network, whether it's a wide PPO or narrow HMO.
Constraining patients to a network, no matter how large or small, doesn't guarantee better health outcomes. This is particularly true when the network exists in a reactive sick care system where symptom control and disease management are nothing more than Band-Aids on underlying health problems.
In a sick care system, no one gives patients a comprehensive plan that will help them overcome their health issues, much less guide them through that plan.
Traditional managed care removed primary care — at least, the full scope of primary care services — from the healthcare experience. Instead of managing the patient's care with the training and expertise (not to mention the lower cost) of primary care, providers were forced to act as gatekeepers and steer patients to specialists.
There's nothing wrong with specialty care, but specialists aren't trained to have a holistic view of health like primary care providers are. They’re experts in a single system trained to investigate current symptoms.
The focus on specialist care results in gaps that can become significant risks for patients who don’t receive ongoing primary care. These patients may be handed off to a specialist, then receive no further care until another problem arises that requires another referral from primary care. And then the whole process starts all over again — with no one advocating for the patient’s overall health and wellbeing.
Another problem is the cost. Specialists are more expensive than primary care providers. Going to them for treatment that primary care providers are also trained in means paying more when it's not necessary — and creating, 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.
When there's an on- or near-site clinic in the mix, patients get most of the care they need right there in the clinic, reducing costly urgent care, pharmacy expenses, and emergency room visits.
Isolated wellness programs
Workplace wellness programs have grown in popularity over the last 10 years, and many companies offer them as a benefit to their employees.
In part, this is a response to rising healthcare costs. Many employers have been forced to look for more creative ways to reduce expenses. Company wellness programs offer substantial savings because they promote healthier lifestyles among employees, which should lead to reduced claims.
The most popular wellness programs include:
Fitness centers and club memberships
Health screenings and health risk assessments
Fitness and health competitions
Each of the above has a person's improved health as their primary goal. However, for them to be useful, they must emphasize behavior change. You can participate in every wellness program on the planet, but until you decide to change your lifestyle, they just don't work.
Even if patients want to get healthier, they often don't know where to start. They still need consistent help and professional support. A primary care team that includes a health coach is the perfect solution to provide patients with the resources they need to take ownership of their health, change their behavior, and get healthier.
Wellness programs can be useful, but only in concert with primary care and health coaching. When patients can get to the root causes behind their behavior, identify obstacles they need to overcome, and get equipped with the resources to change their lives and health by changing their behavior, they can succeed.
No doubt you've heard a lot about high-risk patients. Insurance companies say they're the ones that make health insurance coverage unaffordable for everyone else. 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: that high-risk patients need proactive medical care and ongoing support.
Even worse, our system creates more high-risk patients every day. With more and more people forced into high deductible insurance plans, patients often wait until they have a significant issue to visit the doctor. They're not getting the routine care they need to stay healthy, and therefore become riskier patients every day.
Pay-per-use clinics only make the problem worse.
We've found that for the clinic to have an impact on an organization's health, as many people as possible need to use it. Ultimately, reducing costs and achieving a return on investment are the natural result of your employees getting healthier.
We're also having tremendous success leveraging population data and claims history to determine utilization and identify the service that will best serve employees. For example, an organization with an aging population will want to seek providers who specialize in chronic disease management. But not everyone will use your clinic in the same way over time, so the ongoing review of claims and population data is essential for keeping a clinic effective as well as getting it there in the first place.
As you can see, these failed innovations are stepping stones on our way to a better healthcare system — and Vera Whole Health and others like us are working to continue the evolution.