The Doctor Will See You, NOW

Changing who’s in the driver’s seat for healthcare delivery using digital health and the power of markets.

Uber - and many similar providers - is a great example of the precise and timely matching of consumer (riders) needs, with a capacity that exists to deliver those needs (driver’s) where both sides of the equation are synchronized in terms of accessibility, price, timing, quality etc. through clever software, tracking and communications. Just like most things in life, you make appropriate trade-offs and voila, you have your ride.

Typical service-seeking behaviors involve the use of appropriate information about the service, sufficiently speedy access relative to the need, pricing and price-comparison information, and a range of options for the delivery of that service – where you might pay more for a superior experience (think Uber Exec or Business Class), but in other circumstances you may opt more for a standard offering (Economy is just fine today). The price you pay for your service would depend also on where you are willing to obtain that service, with proximity demanding a higher premium and the speed with which you could access it – today, tomorrow or in 4 weeks’ time.

So, why not with healthcare? An efficient patient-centric system of healthcare access should, and very easily could, be just the same. However, to limit cost, to control and to standardize healthcare delivery, regulators, insurance companies and governments have created a huge hurdle for innovation to overcome; a CPT- and other code-driven reimbursement system that attempts firstly to ‘pay-for-treatment’ (personally, I’d rather my doc focused on keeping me just healthy please) and causes medical procedures to be fungibles – a 10-minute routine visit at location X by one provider is equivalent to a routine visit at location Y by a different provider. Except, of course, they couldn’t possibly be. Further, the entity best suited to make that call – whether those services are the same, and what they are worth – is the patient herself.

This brings me to my good friend Dr. Lorin Brandon, founder and CEO of Elixr – a digital-healthcare market creator and patient-physician interaction forum that is helping to bring efficiency and clarity to healthcare and its delivery. Elixr’s approach focuses on providing a secure patient-driven healthcare access platform with variable pricing, the creation of a healthcare market and demand-driven pricing via a bid-ask system, full EMR integration and a series of healthcare indices to rank price-value in healthcare.

 Restoring the Patient-Doctor Relationship for the Long-Term

You are now (here in the USA) paying more for your healthcare, double that of most developed nations, but do you have twice the access to your primary care doctor, at twice the speed and double the improvement in clinical outcome? Are you getting real value for money? Remember the good old days when your doctor spent time with you, understanding your total well-being and health, not just what’s wrong? That’s what Elixr plans to address. By providing an event- and subscription- (it’s your choice after all)-based tiered access model (if you are young and healthy you might opt for the former, if like the author you are old and decrepit, you might opt for the latter), you will be able to pay to speak remotely and in person with the physician of your choice. If you want more time in that consultation, you pay more per extra 5-minute segment. You gain access when you need it, the doctor gets paid according to actual time spent (not capped by a protocol, e.g. '10-minute routine visit'). Being able to access the provider of your choice – and remember those providers better at ‘routine visits and check ups’ can then specialize and provide details of their performance metrics, thereby gaining more patients and face-time, allows you to speak with your doctor when you want, how often you want, for a price that is set based on the overall demand for, and value of, that provider, for those services. I would envisage many of us might like to find, stay with, and dive a little deeper on our total health in terms of prevention – if you could stick with a physician who knows you and your family very well.

Facilitating Data-Rich and Accurate Medical Health Records

If you have multiple health conditions during your screening consultation either remotely or in person, you can discuss these with your doctor during the session, he/she captures those details, and you have the beginnings of better and accurate medical health records. If you wish to see a different provider on your next consultation, those records follow you, not your provider – they are completely your health records, accessible by you in an easy format, with a focus on wellness and health, not just which procedures or drugs you are taking. A focus on health and wellness will be defined by you as the patient. You know best if you are getting well, or not, and that’s a pressure you can exert on your doctor, ultimately by choosing to go to a different provider – if you believe you can get a better outcome elsewhere. On the physician (or other clinically approved provider) side, physicians will (as they do today) provide their metrics of success at treating various conditions or for a suite of offerings – e.g. 6 weeks post-surgical follow-up, routine checkup with blood work, routine checkup with extensive family medical history screening, etc.

Exerting Patient-Driven Price Pressure and Responding to Defined Needs

Providers then, in this ‘created’ healthcare market, will be able to differentiate themselves as other providers of services do in their markets. Patients will be able to make informed decisions on those differentiation factors and price. Ultimately, insurance companies will likely either acquire such systems and incorporate into their own suite of offerings, or provide some aspects of care that they will cover via systems like Elixr. The Cleveland Clinic is already using such a system for benefits on both sides – physicians/care teams and patients – and using these systems to better understand patient expectations and needs and in the transition to value-based care. Imagine an orthopedic surgeon then who performs ACL’s as one of his or her primary procedures. Is it always necessary for the patient to visit the surgeon for all post-surgical visits – maybe not? And if that surgeon constructs a post-surgical exercise regime and in-person and online follow-up sessions for a certain price, and with posted metrics on its success – so much the better. That’s more differentiation for the surgeon, and more information upon which a patient can decide. The movement towards value-based care and objective clinical outcomes align both patients need and physician’s proven capabilities. An index is created with a running price for specific procedures at tiered levels. Physicians must compete for patients including with price visibility. Patients will be able to demand additional or adjacent services based on their specific clinical situation – think Amazon – ‘patients who chose X procedure also chose Y rehabilitation package’.

Tracking Price and Quality of Service Delivery – Indices You Can Easily Use

Inherently then, as patient volumes for any given procedure or event are driven towards certain providers at a price point it becomes possible to rank providers, index pricing, and provide outcomes-based objective metrics for patients to assess quality. At the aggregate level, this data becomes a meta-analysis to determine price-value, price-outcome, price-access and other dimensions of quality, capturing all aspects of the continuum of care and metrics of service provision along the way. That data might be useful also for insurance companies to improve their approaches.

Patients using Avera’s telehealth system (https://www.averaecare.org/ecare/) have shown high resonance with the concept, with many formerly routine clinic visits now conducted online. If you had to predict, it seems highly likely that clinical  vitals, and indeed even quite sophisticated biochemical analyses, will be able to be captured with high fidelity remotely - blood pressure, temperature, maybe one day imaging and basic diagnostics via an attachment to your laptop. It’s no longer science-fiction. These enabling technologies alone won’t solve the pricing questions, that takes an accessible, transparent market – and platforms like Elixr will serve that piece well. Waiting for reimbursement to follow technology is an arduous and slow path. There are many aspects of healthcare that patients are willing to pay out-of-pocket for now (e.g. https://www.finsmes.com/2017/07/maven-raises-10-8m-in-series-a-financing.html) – reimbursement will be brought along, kicking and screaming if necessary, I hope we can do that remotely then. The thesis that telehealth is a logical extension of EMR doesn’t seem to be delivering. More likely EMR’s will be seamlessly integrated into telehealth and digital health – indeed the requirements for future EMR’s is likely to be driven by patient’s telehealth needs. There is more uncertainty on the mode of market adoption of digital and telehealth plays, but given how discrete, innovative, efficient and effective it can be, it seems more likely that existing healthcare players will work with the platform providers and embed within their broader operational plays with clinics, hospitals and other resources (e,g. https://intermountainhealthcare.org/campaigns/connect-care/).

The shift here is that healthcare is realizing, responding and implementing a delivery system that puts patients in the driver’s seat for access, quality and pricing – and that’s a change that is long overdue.