Kenneth Kaufman: Healthcare without gatekeepers

Consumers have long experimented with ways to access healthcare without going through physicians, from home remedies to alternative medicine. Today, however, powerful new forces are motivating and enabling access to healthcare along a path that does not include a physician gatekeeper.

Recently, a colleague of mine perceived that his hearing didn't seem as clear as usual. He considered making an appointment with an audiologist, but decided first to see what online tools would allow him to test his hearing on his own. Using his computer and earphones, he took three different tests, each of which plotted his results on a graph and provided an interpretation that suggested his hearing was OK. He decided to forgo the audiologist appointment.

A few years ago, the only option for someone who suspected hearing loss was to make an appointment with a specialist or with a primary care physician for a referral to a specialist. The specialist would have conducted a hearing test. Even if the patient's hearing was within acceptable limits, there may have been a follow-up visit and possibly more testing.

Physicians as gatekeepers

The traditional access points into our healthcare system almost exclusively involve an in-person physician visit. For healthcare providers, this approach has produced both an opportunity to manage care and a revenue stream for diagnosis, testing and referral. For consumers, this approach has created significant inconvenience associated with scheduling, waiting for, and traveling to appointments for physician visits and tests.

Consumers have long experimented with ways to access healthcare without going through physicians, from home remedies to alternative medicine. Today, however, powerful new forces are motivating and enabling access to healthcare along a path that does not include a physician gatekeeper.

Perhaps the most potent force behind the healthcare-without-physicians movement is that consumers for the first time are shouldering a significant share of their healthcare costs through rising co-pays and deductibles, motivating consumers to avoid expensive office visits or tests.

At the same time, online resources and apps in all walks of life have trained consumers to expect highly convenient access to information, products and services. In healthcare specifically, advances in technology have opened the door for individuals to use apps and wearable devices for a variety of monitoring and diagnostic functions that previously required expensive equipment and in-person visits.

Finally, coverage expansion through the Patient Protection and Affordable Care Act, along with the so-called epidemic of chronic diseases, have put a strain on physician resources, making timely access through the traditional physician gatekeeper even less convenient for consumers and more challenging for providers.

New access points

With few exceptions, companies driving healthcare without physicians are looking to take low-intensity market share and revenue from traditional providers. Perhaps the most visible examples are retail clinics through companies such as Walgreens, CVS Health and Wal-Mart that provide care almost exclusively by nurse practitioners or physician assistants. Beyond retail clinics, these companies are beginning to offer other non-physician services designed to position the companies closer to the role of primary care provider. For example, Walgreens offers follow-up calls to patients starting new medications, online chats with pharmacists about medication regimens and mobile tools for prescription management. Walgreens also offers blood pressure, cholesterol, blood glucose and other tests, and promotes its ability to help patients with complex conditions "navigate the complexities of their treatment and receive comprehensive support."

Mobile tools for health diagnosis are another exploding area. One high-profile example is the Qualcomm Tricorder XPRIZE, a competition that will award $10 million for developing a device intended to help consumers capture key health metrics in order to self-diagnose 16 health conditions, including chronic obstructive pulmonary disease, diabetes and stroke. The contest's stated intent is to help remove the bottleneck of physician-controlled access to the healthcare system.

In many cases, diagnostic apps involve physicians, but not a consumer's traditional provider. For example, a company called CellScope has developed an app-based tool to diagnose ear infections, the leading cause of pediatric physician visits. Using an app and an ear probe that attaches to a smartphone, consumers can take a video of the inside of the ear and send it to a CellScope physician, who will provide an assessment and, if needed, a prescription within two hours for $49.

Self-referral testing is another growing area that operates outside the traditional channels of physician-controlled access. For example, the company Any Lab Test Now, which has more than 150 locations, provides direct consumer access to clinical lab tests. For patients without a physician's order, Any Lab Test Now will provide one. Results are given to the consumer, rather than to the physician.

The role of provider organizations

Some forward-looking providers have incorporated the healthcare-without-gatekeepers concept to engage consumers, promote wellness and direct consumers to services within the organization's network. Kaiser Permanente Northwest began a self-referral mammography process in 1991. As of 2011, self-referrals accounted for almost half of mammograms and more than 25 percent of cancers diagnosed. For some conditions, Kaiser Permanente's website allows patients to enter symptoms into programs that assess whether patients should consult a provider.

Downers Grove, Ill.-based Advocate Health Care offers women 40 and older access to same-day mammogram appointments without a physician referral. This service is part of a comprehensive website designed to engage users in conversations and education about breast health. Advocate's heart program offers an online assessment to determine a consumer's risk for developing cardiovascular disease.

Organizations in a pre-paid environment — like Kaiser — or with a significant portion of value-based revenue — like Advocate — have multiple incentives to embrace some degree of healthcare without physician gatekeepers. Such services can help reduce unnecessary utilization and help ensure that potentially serious conditions are spotted early. In addition, by hosting these services, a provider stands a better chance of managing the health of the consumers who are using these services.

For organizations in predominantly fee-for-service markets, embracing healthcare without physicians on the surface seems a mixed economic bag. Such services could drive additional revenue by bringing individuals into the system who otherwise would have gone undiagnosed and untreated. Yet, such services also will inevitably reduce revenue associated with physician visits and testing.

Consider again the example of my colleague and the online hearing tests. From my colleague's perspective, this was an entirely positive healthcare experience. He paid no money, he didn’t need to leave his house or even make a phone call, and he got his results immediately. Why would any consumer not pursue this approach? And yet, no physician or traditional provider played a role in the experience. Imagine this transaction happening thousands or even millions of times across different diagnoses and different markets, each instance taking revenue and patient contact from traditional providers.

As technology for this type of interaction improves, as companies find more innovative ways to connect with consumers without physicians or even facilities, and as healthcare consumers have more financial responsibility and choice, healthcare without physician gatekeepers will gain momentum. Consumers in multiple industries have shown that they are more than willing to forgo legacy organizations when more convenient and less expensive options present themselves. Just ask Kodak and Borders. Healthcare will be no different.

As healthcare without physicians takes hold, traditional providers need to avoid being on the outside looking in. Provider executives need a strategy to develop sophisticated, consumer-friendly services such as readily accessible physician extenders, self-referral testing and app-based diagnosis and monitoring. They need to determine how to acquire the necessary new competencies, technologies and, in some cases, partners for these services. And they need to integrate these offerings into their care protocols, information systems, and ambulatory and acute-care services.

More than revenue is at risk. Also at risk is the ability of traditional provider organizations to retain their position as a central influence on the health and healthcare of their communities.

Your comments are welcome. I can be reached at kkaufman@kaufmanhall.com.

This column is reprinted with permission from Kaufman, Hall & Associates.

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