Wednesday, March 10, 2010

Can an aggregator model really work in health care?

Brandon posted a comment on my previous post about aggregators and health care that I thought deserved a thorough response.

First, let me say that I very much appreciated Brandon’s comment. This is such an interesting topic, and one that deserves much attention and discussion as all parts of the care delivery spectrum—providers, patients and their families and even lawmakers and regulators—determine how we can redesign our current health care system to provide the highest quality care at the lowest cost.

However, I believe that perhaps the metaphor of the travel industry was taken too seriously—there are many aggregators outside the travel sector, like EBay, Craigslist, and Google. We’ve been unable to find a good example of an aggregator within health care, but hope to be the first to establish some future models! Regardless, it’s clear that health care providers must take ownership of the need to connect the dots between the various points of service on an individual’s journey to maintain wellness and health, some of which will require health care services.

This will be a slow process, and probably happen on a region-by-region basis within the CHRISTUS system—we will not jump into an Expedia model overnight! But we may begin by providing service-line-specific or disease-specific or demographic-specific aggregators that link necessary services. All these partners may not be on the exact same computer platforms, but we can develop the necessary interfaces to link critical information to allow us to manage care across the continuum and to reduce cost. Imagine a cancer aggregator or a knee replacement aggregator – we may have to begin in a very informal and inefficient manner and take incremental steps forward, but if we align incentives correctly, we will improve service and reduce cost.

We’re trying to keep in mind that most great ideas—including the great aggregators we’ve run across in our research—were not initially intended to be aggregators. Great ideas like were born by two guys who wanted to listen to college basketball games and turned their need into a multibillion dollar internet broadcasting business. The founders of Yellow Dog Fly Fishing did not set out to build one of the world’s largest flyfishing Websites (aggregators) in the world—they started by answering questions from people who wanted to flyfish in Montana, and have ended up with a service that brings together busy people who didn’t have the time or energy to research flyfishing trips with flyfishing services around the world that have been vetted and experienced. Aggregators must be able to overcome the barriers to coordinated care that health care providers in the U.S. have been thus far unable to address effectively and efficiently, and we believe that is a possibility.

That’s a very lengthy response to Brandon’s comment, but I look forward to continuing the conversation!


Jason Cunningham said...

Dr. Royer,
I appreciate your blog and especially your willingness to engage in open conversation. Your recent posts on “aggregator models” were interesting and I enjoyed the thinking of the “what if’s”. Due to the recent happenings in Washington D.C. last night (Sunday, March 21st), I really believe that your posts on “aggregator models” are more important than ever. You recently posted, “Aggregators must be able to overcome the barriers to coordinated care that health care providers in the U.S. have been thus far unable to address effectively and efficiently, and we believe that is a possibility.” This is true more than ever considering the world that we deliver healthcare in will likely be changing in the near future. What barriers do you see us having to overcome in order to successfully implement this model? Of course there are technological issues and lack of price transparency due to the complex third party payor contracts, but what else do you see standing in our way? While it easy to sit and wonder about healthcare and the pros and cons of this new Healthcare Bill, this does provide us with an opportunity to take action. That knocking that we hear is opportunity knocking, and I look forward to watching us take full advantage of the opportunities that change is bringing us.

One last thing, Brandon’s post did bring up some interesting points. One point that I feel the need to disagree with was his post saying….”But I think those of us in health care need to be realistic and manage people expectations in terms of what the industry can actually deliver.” We have to meet the expectations of our customers (patients). If we don’t, someone else will. When the customer has a choice, they will choose the provider that meets there expectations. The industry can deliver their expectations and we should expect no less from each other. Sorry for the rant!

Thanks again for your time and attention to your blog.

Jason Cunningham, Spohn South

Dr. Tom said...

Hi Jason,
Thanks so much for your thoughtful comments! I think you pose some great questions about health care delivery. I couldn’t agree with your last paragraph more. I think you have perfectly described the rationalization for the “convenient clinic” phenomenon we’ve seen in the last few years—if the care we provided was more convenient for our patients (instead of just convenient for us!), this model would be largely unnecessary. Instead, we know that most of the users of convenient clinics are not the uninsured like we expected, but are consumers who have insurance but need treatment at times that are convenient for them.

To address your questions, I think that there are a few other barriers to implementing an aggregator model that we must overcome to be successful. One of those barriers is territorialism. The key to an aggregator model is pulling all parts of a continuum of care together to provide seamless service for a specific population. However, to accomplish this, all parts must be willing to agree on who will take the lead (the “aggregator”) and how the remaining aggregated pieces of the puzzle will work together. This may be difficult for many providers or groups who are used to “calling the shots” or designing services to meet their own needs instead of the needs of their consumers/patients. We have seen some other health systems start down this road with positive results, forming accountable care organizations that provide many benefits. However, all the pieces in that health care delivery system must be willing to work together on an equal plane to provide the most efficient and effective care. This would be a large jump for some organizations and providers in the health care business.

Second, we both know that health care is notoriously slow-moving! Because ours is an extremely complex business, we must balance many different needs and priorities simultaneously. (Just like CHRISTUS’ Journey to Excellence, which requires that we improve in each of our 4 directions all at the same time.) Some would argue that all these priorities have already filled our plates so that planning far into the future is impossible. However, I would argue that our patients—not to mention our priorities—have already begun to demand that we begin providing the care of the future today. And rightly so; they deserve the highest quality care at the lowest cost. To do that, we must know that we are investing our energies and resources in the proper place to meet the needs and expectations of our patients as they grow and age.

Third, we must be careful not to confuse “volume” with “preference” or lose sight of the customer. Aggregators aim to serve our patients better, and we need measurements in place to ensure that is truly what we are doing.

Our patients turn their lives and the lives of their loved ones over to us every day, and this sacred responsibility necessitates that we honor their trust by providing excellent care in every single interaction. We continue to honor this care by building—and aggregating—systems that work for those who depend on us, and not just for us as providers.

Thanks again for your comments, Jason. I’m looking forward to continuing this conversation!
-Dr. Tom

Jason Cunningham said...

Dr. Royer,
I enjoyed your response and thank you again for taking the time. It appears that the healthcare system as a whole has been and continues to evolve into something different and larger. Stand alone hospitals are fighting the strain of a down economy, and are being forced to join forces with larger systems that have the capital available to distribute from one facility to another in order to gain a certain market position. CHS, UHS, and especially HCA seem to be driving towards this oligopoly market control that could result in an “aggregator” model. I agree that it is definitely territorial in nature and requires partnerships, but doesn’t CHRISTUS have this territorial advantage in some markets that would allow this “aggregator” model to function with minimal partnerships. There is a large amount of power that exists when a healthcare system has positioned themselves as the provider of choice in a community because of service and volume.
I also agree that healthcare is complex and slow moving, but is it this way because we make it complex? I really like the idea of convenient care clinics. I remember reading an article that said around 50% of PCP visits could have been seen by a physician extender (NP or PA) allowing the PCP to better educate and serve the patients that require more detailed care for chronic conditions. Combine CHRISTUS Medical Group, CHRISTUS convenient care clinics, CHRISTUS ambulatory surgery centers, CHRISTUS Rehab and CHRISTUS acute care facilities, and the framework for an “aggregator” model exists. We have access of the patient from point of entry to discharge. The “Orbitz” of healthcare. I realize that I am drastically over simplifying this, but I think we can do it.
Finally, thank you for looking to the future. It is easier to rest assured knowing that “business as usual” isn’t our only priority, but focusing on what it may look like in the future is important to you. Opportunities will be there for us as an organization and only a hand full of healthcare companies will be able to take advantage of them. I feel we are in that hand full.

Jason Cunningham, Spohn South