Law & Ethics in Public Health Unit 5

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CHANGE AND INNOVATION IN HEALTH SERVICES DELIVERY

Bernard J. Healey, King’s College

Kermit W. Kuehn, University of Arkansas

ABSTRACT

The Health Care and Education Affordability Reconciliation Act was signed into law by the President on March 30, 2010. This legislation will have a significant impact on the U.S. health care delivery system. Specifically, the legislation will challenge the current operating models of health care organizations that have relied on fee-for-service revenue structures to prosper.

This changing environment will produce tremendous opportunities for those health care institutions that are prepared to positively respond to the demands of the health care consumer. Two factors will gain additional traction going forward: 1) The focus will continue to shift toward prevention and wellness and away from health restoration. 2) The focus will move toward performance outcomes in health care delivery and away from the number and type of activities being performed. Consumer education is critical to this transition. Using concepts from disruptive innovation research, this paper explores ways to develop and deliver effective health education programs to the public, particularly in the area of chronic diseases and their complications.

INTRODUCTION

The medical costs for individuals with chronic diseases account for seventy-five percent of the total health care costs in the country. In order to contain the cost of health care going forward, as well as address the access problems of many Americans, dealing with chronic diseases is critical. Health education programs designed to prevent high-risk health behaviors in individuals and communities is one way to address this daunting challenge. The answer to preventing these high-risk health behaviors lies in behavioral interventions, the focus of behavioral medicine. This type of medicine involves preventing or changing high-risk health behaviors so that chronic diseases do not develop.

Why don’t these programs exist already? The current health care business model is built around restoring people to health and not preventing illness. Health care providers are paid well for restorative activities and little for preventative ones. In order to drive change in the U.S. health care system, potent forces must be used to disrupt current behavior. Research in

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‘disruptive innovation’ conducted in other industries suggests that these concepts can be used in developing and expanding health education programs.

DISRUPTIVE INNOVATION IN HEALTH CARE DELIVERY

Clayton M. Christensen, author of the Innovator’s Dilemma, has studied innovation and management for decades. Christensen (2009) argues that the disruptive innovation theory can work in the exploitation of change in health services delivery. The three key elements of this innovation include: a technology enabler, a business model innovation and the development of a value network. Health education programs must consider each of these elements in order to have the greatest likelihood of impacting medical care.

Technology as an enabler is central to innovation in the field already, but has not resulted in the cost declines needed for a healthy and sustainable health care system. However, in education, considerable variation as to offerings is more evident and gaining wider acceptance. Adapting this delivery capability into the health care system seems plausible and necessary. Digitizing health records and telemedicine provide evidence of technology’s role in extending access and potential cost containment.

The second element of the innovation ‘triad’ relates to the business model of the health care system of the future. The emphasis on wellness and prevention, and performance outcomes, will call for new ways of thinking as to how organizations are paid. The current fee-for-service model rewards the wrong behaviors, both from the health care provider and the consumer. When it is broke, then you fix it. While the argument for prevention has been in the health care conversation a long time, the money has yet to follow.

Increasing patient knowledge of disease, especially chronic diseases, can go a long way in changing behaviors. In order to prevent the long term complications from these diseases, the patient must understand the serious complications resulting from their practice of high-risk behaviors. They must assume a more active role in the long-term prevention and treatment process, and then they will begin to influence the value networks used to meet those needs.

This third innovation element, developing a value network that is sustainable, will likely require a catalyst from outside the current networks. One source that seems intriguing is the engaging of the public health apparatus to lead the way in the reform of our current health delivery system.

Public health departments are well-experienced in population-based community education and intervention efforts. They also have a culture that is more consistent with a wellness-prevention value proposition. Finally, there is an existing organizational structure that generally has a positive standing within the communities they operate. This investment in health education and testing will likely need to be mandatory for any reform of our health care system to be successful and could be made part of the participation requirement of a program.

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Unleashing these transformational forces has worked well at lowering cost and increasing the availability of a product or service in the business world (Christensen, Grossman & Hwang, 2009). The catalyst for this type of disruption in health care could very well be public health and the preventive strategies they have developed. In order to respond to the opportunities presented by the disruption, leadership and empowered workers in public health departments are needed, as well as resources. The underlying logic is rather simple: If disease does not occur there is no need to allocate large sums of money to treatment.

Disruptive innovation allows the combining of resources in the production process in new and innovative ways that usually allows greater value to be produced by the process. This is exactly what is required for our health care system to survive and deliver better quality services at a lower price. The health care system and public health are both faced with limited resources and increasing demands from everyone for improved value of health care services. Public health departments and our medical care system have had tremendous successes in improving the health and life expectancy of most Americans. The country faces its greatest health challenge in the expanding epidemic of chronic diseases.

THE USE OF TECHNOLOGY TO PREVENT DISEASE

As introduced earlier, technology can help in the battle against the growing epidemic of chronic diseases. Technology is available to improve the communication of the prevention of risky behaviors to large portions of our population. Public health departments have the information that can help individuals prevent chronic diseases from developing. The challenge has been that the money received for public health departments has never been sufficient to develop, implement and evaluate the massive dissemination of chronic disease information to the entire population. This is not to say that there have not been chronic disease education efforts by health departments. There have been many successful programs developed and implemented in schools, workplaces and the community designed to prevent chronic diseases and their complications. These educational efforts need to be expanded to larger and more diverse population segments.

According to Turnock (2009) computers and electronic communications have improved the ability to gather, analyze and disseminate health information. This technology has to be expanded to deal with the chronic disease epidemic through the provision of a continuous stream of information about these diseases to the entire population. There are already examples of success stories concerning the innovative use of technology by public health departments and the Centers for Disease Control and Prevention (CDC) that includes Epi-X and ECards. On a local level, low cost activities such as voice-narrated power point slides to educate large numbers of people about colorectal cancer and H1N1 influenza have been used successfully.

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One of the best examples of a public health surveillance and information systems is Epi- X. This system offers web-based communications for public health professionals. State and local health departments and poison control centers to access and share preliminary health surveillance information with large numbers of health care professionals. This system supports postings of up-to-date medical information and discussions about disease outbreaks and other public health events that involve many parts of the nation and the world.

The CDC currently has available over 100 free Health-e-Cards (electronic greeting cards). These cards contain a colorful greeting that encourages healthy living, promotes safety and can even celebrate a health and safety-related event. This concept could also be expanded to include chronic diseases along with ways of preventing the complications that can develop later in life as a result of practicing the unhealthy behaviors that lead to chronic diseases.

EXAMPLE OF AN INNOVATIVE PREVENTION PROGRAM

Last year, a colorectal cancer task force in Luzerne County, Pennsylvania developed a colorectal education program. The program utilized a marketing approach to increase the awareness of the need for screening for colorectal cancer in the county. Two businesses were chosen to participate in this program which began in May 2009. The program was made available to all employees of these businesses.

This educational program was developed on a SharePoint software site at a local College. It consisted of a pre-test, a colorectal cancer educational program and a post-test of knowledge gained from the education program. The educational program consisted of a series of voice- narrated power point slides about the risk factors for developing colorectal cancer, the various tests available for this disease and recommendations for those at high-risk for developing this disease.

The results from this program offer support for this approach. A significantly higher percentage of participants stated they were more likely to ask their doctor to be screened for colorectal cancer on the post-test than on the pre-test. All participants indicated that they were likely to share what they learned from the program with friends and family members. And as a side note, this program resulted in the discovery of colorectal cancer at an early stage in two participants resulting in life saving surgery for both individuals.

This colorectal education program is an excellent example of the use of disruptive innovation in order to develop a health education effort designed to reduce the incidence of colorectal cancer in a large population. This program was very inexpensive to develop and implement on a community basis. It is now being duplicated in other counties in Pennsylvania. The health care delivery system in the United States is consumed with the cure of illness and disease as the only way to deliver medical services to patients.

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DISCUSSION

The concept of preventing medical problems before they occur has never been an accepted practice of modern medicine. Since the benefits of prevention and public health departments are found in the future, there has never been any real interest in providing adequate funding to public health departments. This is no little challenge.

Therefore, health education programs need to be looked at as a long-term investment that is capable of producing large payoffs in terms of improved health for the population over time. Although these educational innovations will require resources and costs in the present, they offer the best solution for containing health care costs tomorrow.

The need for creativity and innovation in the delivery of health care services has never been greater. Consumers are expecting more emphasis on prevention of illness and disease. These changes offer opportunities for the medical care system and public health agencies to form partnerships in the prevention and treatment of chronic diseases. Public health departments must find ways to share the science of prevention with larger segments of the population in order to reduce the chronic diseases epidemic impacting the health care system. The concept of disruptive innovation outlines the ingredients for a successful transformation.

REFERENCES Christensen, C. M., J. H. Grossman & J. Hwang. (2009). The innovator's prescription: A disruptive solution for

health care. New York, New York: McGraw Hill Publishers. Turnock, B. J. (2009). Public health: What it is and how it works (Fourth Edition ed.). Sudbury, Massachusetts:

Jones Bartlett Publishers.

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