Creating a new, more affordable, more accessible and higher quality healthcare

Healthcare today can be all things for everyone

I was born in the UK. I qualified as a medical doctor in the UK. My experience of healthcare therefore is of a service free at the point of us. The NHS. I never worried about paying to see a doctor. Nor did I regularly stress about the quality of care once I received it (Although I was aware of the racial bias that exists within the system). The regular concern I had was how long it would take to access care. Extremely affordable and relatively quality care but with challenges accessing it. Across the pond things are different. If you have the means, quality and accessibility of care is within reach. But healthcare is so expensive that such reach is limited to only a few. For most people in the US, healthcare is single biggest reason for bankruptcy (source). Neither system is perfect. 

What I describe here is this notorious balance between affordability, accessibility and quality of healthcare. These factors are what unpins the structure of every healthcare system in the world. No system has these forces in perfect equilibrium. And arguably no system ever will. But after many years thinking about this problem I realised the way we deliver healthcare will never allow us to ever come close to any form of equilibrium between affordability, accessibility or quality of healthcare. For that, we have to go back to the drawing board. I have been thinking about this problem for many years now. And I think I’ve finally come a conclusion. 

To truly strike a balance between these pillars of healthcare. We need to change healthcare along three fundamental means - they way we pay for it, they way we deliver it, and the way we improve it. The most important of all three is the way we pay for healthcare because it sets the incentives that defines the changes in how we deliver and improve healthcare. Let me explain…

Changing the way we pay for healthcare

I strongly believe the greatest innovation that can happen in healthcare is in the business model of paying for it. Paying for healthcare has had economists thinking about this problem for decades. It is complex because the holy grail is have to find a way for healthcare to be affordable for all types of individuals, with varied needs and yet provide equitable access and high quality care. Not easy! So far we have taken a common approach of insuring healthcare as a way of financing the system. The concept of healthcare insurance is quite simple, pay a regular smaller amount now in order to prevent you paying a larger amount latter when you need it. As a result you pool your regular smaller amount with others and have access to that pool via your insurers if and when you require it.

Another approach more popular across UK, Europe and Asia is through taxes. This government led approach works similar to private health insurance - pool money (via taxes) from a population to fund healthcare for those that require it. The biggest challenge with a public health system is that change is often linked to whimes of political opinion. Therefore only absolute basics of healthcare are provided and there is limited incentive to invest in evolving the system for the better outcomes in the long-term.

Largely both models of financing healthcare do work for what they originally intended. The problem is that both models have failed to adapt to the changing healthcare needs of our society. As such healthcare insurance today is expensive, limits quality of care is for so many people - inaccessible. And publicly funded healthcare requires increasing taxes with limiting quality and access of care.

What I propose is evolving healthcare insurance (either private or public) to healthcare assurance (source). Broadly this is where you pay your providers directly, not an intermediary to keep you in good health. Providers make money if over your lifetime you require less from the healthcare system and remain healthy for longer. They lose money if they are unable to do so. Membership payments to your health assurance providers are used as the pool to pay for those that require more expensive care. This incentivises your clinical team directly to prevent ill health rather than just treat it. But why hasn’t this been done before? Well it has. The primary care system in the UK has similarities to this. GPs are paid a fix fee every year to look after their patient list. The problem is they are not paid near enough in order to make the incentives of trying to prevent ill health worth it. In the states, ACOs are groups of providers who are aligned with insurers to deliver quality care at lower costs. The problem is these providers are largely still incentivised via the fee-for-service model  of care and so, early on, most ACOs are less able to make the savings necessary to gain the bonus payments from potential cost savings available to them. Research suggests it could take up to 3 years for that shift to cost savings to be profitable (source). The opportunity therefore is to build new provider organisations well compensated from day one, built to service a completely value based care model. Providers like Oak street, Cityblock and Iora are the vanguards in this respect.

Changing the way we deliver healthcare 

With a more value based approached to financing care, there is an opportunity to change the way healthcare is delivered. Investing earlier in good health becomes more an incentive - a must than a should. This move from reactive to more proactive healthcare is the second change I propose needs to happen to truly drive the perfect equilibrium of affordability, accessibility and quality of healthcare. The problem is proactivity of care is not how we deliver healthcare today. The technology, processes and training provided to Clinicans are all based on a reactive approach to healthcare. As a newly qualified doctor, I can safely say I won’t know where to start to treat all my patients proactively. Data driven processes and decisions will be more important in order flag insights that are not immediately obvious. Patients will be supported to self care over seeking care. All of these mindset shifts and more will be necessary for what I like to call the delivery of a continuous healthcare system (also referred to as always-on triage). So again, why hasn’t this been done before? A big reason is data and how we interact with it. More specifically - quality continuous data, the mechanisms to analysis it and importantly the means to implement data driven insights into action. The amount of data required to be proactive with care has only recently been available to Clinicans. As we continue to carry around mobile devices that understand our behaviours and actions, link those behaviours to more regular non-intrusive biometric tracking (eg via Apple Watch), and support those actions with virtual care - we are only now at the stage of building the foundation of a truly proactive healthcare system.

Changing the way we improve healthcare

So brings us to my final point behind changing the way we improve healthcare. For the longest time in healthcare we have practiced an approach of improving medicine through evidence. Evidence based medicine to be exact. This is the concept of using research to create insights that drive better outcomes for more people. This approach  of improving clinical medicine has shaped the last 100+ years of healthcare delivery. With new access to the data we have today within a more proactive healthcare system, I propose a more personalised approach to improving healthcare. This approach will reduce individual error, improve overall outcomes and drive down the cost of care. This personalised approach to healthcare is about creating a tighter feedback loop better action and outcome and use that information to improve the further action and outcomes. This is what I call an actively personal healthcare system. This approach will require (along with the other changes proposed) a new way of doing things. A better standard for handling and sharing data will be required. Patients will need to be better supported to understand what their data means. And Clinicans will need to be more coaches of wellbeing than decision makers of health - working with the patient and their data to promote the life they desire over fixing ill-health. Why hasn’t this happened before? Will it has and it is. The likes of genomic companies and consumer diagnostic services are enabling a more personalised servicing of healthcare. The opportunity that still exists is for this personalisation of care to be integrated and aligned with providers who are incentives to act proactively, via a business model that optimises for early intervention. All three changes need to coincide for either to be truly effective!

So this is where I have landed. On the road to truly balancing the desired pillars of affordability, accessibility and quality of care. The healthcare system has to change. It has to be change the way we pay for healthcare, the way we deliver it and how we improve it. These are the changes, I hope to drive within the system. And I write this with the hope that you will also join me on this journey!