I am responding to feedback from a seminar participant who asked for summaries of books relating to healthcare.

Through Executive Book Summaries to which I subscribe, I came across a provocative recently published book, The Innovator’s Prescription: A Disruptive Solution for Health Care, by Clayton Christensen, Jerome Grossman, and Jason Hwang.  Although I do not usually summarize books that I have not read in their entirety, the content motivated me to alert readers to this 441 page tome, in the hope that others will agree that perfection can be the enemy of good, to paraphrase Voltaire.  I give thanks to the beeper gods and godesses who permitted me to read the summary and write a blog post while providing general surgical coverage in Maine this weekend.

Warning: something in this book is bound to upset and unnerve all of us who may not realize how invested we are in the present non-system of care.  What I write should be viewed more as confessional than prescriptive.

The premise is that the need to transform expensive, complex offerings into higher-quality, lower-cost offerings is not unique to healthcare.  For example, Dell’s entry into the personal computing marketplace forced IBM to reevaluate its business model and focus on providing value-added business consulting services rather than building personal computers as its primary source of revenue.

According to the authors, healthcare provides two distinct services:

• Solution shop: activities that focus on diagnosing patients’ problems
• Value-adding processes: activities that fix problems that have been diagnosed in solution shops

 The reasons that the two services must be separate is that solution shops need to be paid on a fee-for-service basis; they require advanced technology and specialized expertise.  However, value-adding processes are outcome-driven,  can sell their output for a fixed price, and (for example, Geisinger Clinic’s Proven Care for heart bypass grafts and hip replacements) can warrantee results.  Only when the organizational resources, processes, and business model are focused around a job-to-be-done, can they be integrated and optimized to obtain outcomes as close to perfection as possible.

Therefore, the authors recommend that hospitals build distinct facilities (or at least a hospital within  a hospital) to deconstruct their activities operationally into solution shops and value-adding processes.  In the future, general hospitals will no longer be able to subsidize low-volume non-standard solution-shop (diagnostic) services with high-volume value-added work (procedures).

The authors feel that only a minority of chronic diseases, such as Alzheimer’s, Parkinson’s, lupus, epilepsy, and infertility necessitate a multidisciplinary solution shop.  The majority of chronic illnesses are rule-based, meaning that they can be competently managed by an individual caretaker; rule-based diseases include hypertension, osteoporosis, HIV, type I diabetes, and myopia.  The rules for treating many rule-based illnesses are so widely accepted that nurse practitioners can care for these patients without compromising clinical outcomes.

We cannot count on traditional physician practices to police patients to enforce compliance with therapy.  The business models that can help patients succeed are different from those that diagnose and prescribe the original treatment plan.  The authors cite as examples disease management companies like OptumHealth and Healthways.  That only a fraction of patients are cared for by disease management companies and integrated providers like Kaiser Permanente and Geisinger suggests an opportunity for those willing to embrace change rather than cling to familiar models. 

The Patient-Centered Medical Home represents an opportunity for primary care physicians to provide systematic, patient-centered, coordinated care management processes.  The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

The authors feel that quality results from proper integration of care and that lower costs come from focus that promotes lower overhead.  Large employers are initiating disruptive change by outsourcing the care of patients to coherent solution shops for diagnosis and to integrated providers for patients’ treatment plan and compliance monitoring. 

Similar technologic disruptive forces introduce patients to devices that have provider experience built into their logic circuits, which will allow patients to monitor their own health in an improved fashion, for example scales and blood pressure cuffs, that wirelessly transmit patients’ daily weight and blood pressure to nurses experienced in the management of patients with congestive heart failure, that help patients thrive outside expensive hospital settings.

I ask with anticipation, “What do you think,” because a book like this lends itself to wide-ranging discussions on a variety of topics, including:

• Do we need a more coherent business model to guide 21st century US healthcare
• What are the strengths, weaknesses, opportunities, and threats implicit in The Innovator’s Prescription
• When is the ideal time and where is the ideal place to start

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
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