Full Self-Driving Healthcare

When Innovation and Care Delivery Collide...Figuratively

Healthcare innovation paradox: there is both too much and not enough access to care.

The latter situation applies to high touch, comprehensive, value-focused primary care. High deductible health plans, a shortage of primary care providers, consolidation of practices, and a system that fails to properly reward preventive, holistic care have all contributed to the problem. Many argue the former situation applies to specialty care. Over-referrals, liberal indications for tests and procedures, and a compensation system that emphasizes volume over quality are the culprits here.

Overgeneralizations aside, striking a balance between “too much” and “not enough” will be a critical component of evolving to a more efficient, effective system. Balancing primary care and specialty care is an equilibrium that requires careful consideration.

Primary-Specialty Care Equilibrium:

High value, holistic, comprehensive primary care ←→ High yield, cost effective, value-focused specialty care

Getting one side of the equation right naturally helps balance the other side. Skew too far in either direction, and value, care quality, and efficiency suffer. Put another way, primary care cannot function at its highest level without the support of good specialty care, and specialty care cannot offer its greatest value without the support of effective, accessible primary care.

Past and present healthcare innovations have largely focused on only one side of the equation. We have advanced (alternative) primary care models that aim to improve access and do a better job of care coordination. We also have any number of solutions serving as gatekeepers to specialty care -- navigators, Centers of Excellence, and chronic care digital health platforms (e.g., virtual MSK companies). Few excel at achieving equilibrium and thus offer limited ability to provide maximum impact through balanced care.

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There are three options to solve this problem:

• Have primary care doctors do more specialty care (Option 1)

• Have specialists do more primary care (Option 2)

• Add a middle layer that bridges the gap between the two (Option 3)

CMS/CMMI have hinted that their next attempts at VBC will involve some form of Options 1 and 2 above. The bigger and better opportunity might be Option 3.

The goal is (and should be) to do what's right for the patient. Forcing physicians to deliver care outside their comfort zone or area of expertise doesn't achieve that goal. Neither do gatekeepers who serve their own perverse incentives while offering the pretense of "value-based care." (Forcing patients into convoluted care pathways to avoid specialists does not absolve you of the sin of unnecessarily delaying definitive treatment).

Adding a layer between PCPs and specialists seems antithetical to the idea of more efficient, cost-effective care. Middlemen have heretofore added costs and increased complexity of care delivery. It's all in the execution. PCPs would benefit from a trusted resource to help them feel confident in managing what they may feel are specialist-level problems (including when, how, and where to refer). Expensive, limited specialty care resources are better spent on patients who have had appropriate initial evaluation and management in the primary care setting. Achieving Primary-Specialty Care Equilibrium through aligned incentives, shared risk/reward, and tight care integration is the Holy Grail of advanced care delivery.

(One might argue that ACOs, CIN, IDNs, and health systems already exist to serve this function. Others might argue they have, on average, produced middling results).

Herein lies the opportunity. As CMS pushes in the direction of PCP-specialist collaboration and away from Medicare Advantage as the engine driving (supposed) innovation, care coordination will take center stage. Again, this doesn't necessarily mean acting as a self-serving arbiter with the pretense of helping patients find the right care. There are plenty of gatekeepers already whose effectiveness, value proposition, and long-term return on investment remains dubious. The goal is to offer meaningful care coordination and integration, balance both sides of the equation, and provide value to all involved.

Think of it as fully self-driving healthcare (FSD-HC) — a layer that operates in the care gap and behind the scenes to seamlessly get patients from Point A to Point B along the primary care <—> specialty journey. The key to avoid embarrassing deviations from course (“therapeutic misadventures” if you will) is to leverage clinical expertise, thoughtfully implement technology (yes, including AI), and foster a deep understanding of care pathways. Payers, employers, and care providers must collaborate to ensure reward and incentive mechanisms make sense and align goals. We can continue to steer aimlessly, weaving in and out of traffic with no clear direction, or we can build a robust guidance mechanism that gets patients from start to finish in the safest, most efficient, and most cost-effective way. FSD cars might never leave beta, but FSD-HC is achievable.