JAMA Forum: The Health Innovation We Need

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The word innovation is omnipresent in health and health care, describing new uses of technology and data, entrepreneurial ventures, and public sector efforts. Given the many challenges in the US health sector—including decreasing life expectancy, increasing costs, declining rates of health coverage, and potentially widening health disparities—new approaches are undoubtedly needed. But innovation is often tantamount to small-scale pilot projects or to digital tools mismatched with clinical realities, as seen with the electronic health record and clinician burnout.

How do we get from flashes of health innovation to a steadier flame?

Perhaps we should frame it less as innovation and more as imagination. The late theoretical physicist Richard Feynman, PhD, described imagination and the scientific process thus: “The great difficulty is in trying to imagine something that you have never seen, that is consistent in every detail with what has already been seen, and that is different from what has been thought of; furthermore, it must be definite and not a vague proposition.”

Pursuing novel solutions to the most difficult problems in health—across the domains of care delivery, public health, and government—requires a similar type of imagination.

Care Delivery Transformation
Reimagining how health care is delivered begins with a metamorphosis for primary care. Although primary care is literally the “first point of care” for many patients, it is grappling with competition from convenient care models such as urgent care centers for acute conditions and from new corporate entities (typified by the merger between CVS and Aetna) for chronic conditions. CVS provides thousands of access points that patients may already frequent, while the insurer Aetna changes the incentives such that keeping patients healthy may be a more lucrative proposition. In both cases—for acute and chronic conditions—telehealth could provide a “virtual front door.” Amid these shifting sands, primary care may need to cede some first-contact services for healthier patients while renewing a commitment to the longitudinal relationships at the heart of comprehensive care for more complex patients.

Another health innovation we need is to ensure that this market ferment translates into benefits for low-income people as well as the more affluent. More than 100 million US residents are Medicaid beneficiaries or are uninsured; too often they are both most in need of solutions to their health problems and most likely to be excluded from those solutions. New programs and digital tools do not focus enough on engaging patients—particularly those who are hard to reach. For many such patients, figuring out where they will sleep at night takes precedence over attending a medical appointment during the day, and if they have a phone, it may be out of service near the end of each month. In addition to directly addressing material needs, simple innovations can have an outsize effect for low-income patients—particularly innovations that give back patients some precious time, such as averting multiple in-person visits for patients with diabetes through use of text messaging to titrate insulin doses.

Public Health Priorities
Karen DeSalvo, MD, MSc, and other architects of the Public Health 3.0 model have urged thinking beyond innovation in clinical settings. In this framework, community prevention complements clinical prevention (eg, immunizations and colonoscopies) and treatment by addressing the social, economic, and environmental factors that predispose patients to illness. For instance, Kaiser Permanente recently announced an investment of up to $200 million, joining with mayors and business executives around the country to address housing stability and homelessness, citing their impact on health.

Actionable data is another element of Public Health 3.0. At the individual level, the promise of data science—particularly when applied to cross-sectoral datasets—may be to better identify inflection points in illness trajectories. Wrong-site surgery is considered a sentinel event for a hospital, triggering review and action. In the same way, perhaps eviction or incarceration should be viewed as sentinel events for vulnerable patients. At the macro level, data visualizations like the City Health Dashboard and The State of US Health can help better align resources and interventions with fundamental drivers of health outcomes, such as risk factors for chronic diseases.

Achieving a threshold level of vaccination helps protect a population against an infectious disease. What would promote an analogous “herd immunity” for chronic diseases such as obesity and diabetes? Prevention would have to be reimagined as something not delivered person by person, but instead through changes to our built environment (such as walking-friendly communities) and changes to our approach to healthful behaviors (such as making nutritious food more affordable than junk food). Local, state, and federal government can all foster community prevention, helping generate herd immunity against chronic diseases.

Role of Government
The Department of Veterans Affairs (VA) could be at the vanguard of addressing the social determinants of health. Although the VA system is generally known for delivering health care services, the broader department administers education and vocational rehabilitation benefits, pensions, legal services, home loans, life insurance, and disability compensation. The VA has already made significant strides in reducing homelessness among veterans from 2010 to 2016. A whole-person approach to meeting medical and social needs at scale could serve as an exemplar for other populations.

A major commitment to innovation in the Affordable Care Act was the $10 billion per decade investment in the Center for Medicare and Medicaid Innovation (CMMI). The center has played a catalytic role for payment and delivery system reform, launching 37 new models, including accountable care organizations (ACOs), bundled payments, and primary care initiatives. As CMMI embarks on a new direction, an emphasis on scaling successful models, like the Diabetes Prevention Program, seems appropriate. Scaling involves not just expanding a model to all eligible beneficiaries but also learning how to “transplant” a program that works in one context into another. Particularly for complex innovations, this requires balancing intervention fidelity (to maximize chances of replicating the original success) with intervention adaptability (to maximize chances of adoption in diverse settings).

An area ripe for governmental innovation is addressing high prices for health care services. A recent JAMA study added to evidence that US exceptionalism in health spending is more the result of high prices than of higher utilization of services. One approach to reducing prices in peer high-income countries such as Switzerland and Germany is all-payer global budgeting. By providing a fixed amount of revenue for health systems, all-payer global budgeting curtails price growth. The most recent independent evaluation of hospital global budgeting in Maryland showed a reduction in total expenditures for Medicare beneficiaries, although more research is needed to understand effects for other payers and in other states. The CMMI has supported 2 variations on this concept in Vermont, via an all-payer ACO, and in Pennsylvania, focusing on rural hospitals. Beyond CMMI, additional experiments, such as reference pricing or using the VA formulary to address prescription drug spending, are warranted to address costs.

Of course, government alone cannot turn flashes of innovation into flame. Rising to our health challenges will require reimagined partnerships between the public and private sectors, between patients and clinicians, and between practitioners in health and many other fields that help produce health.

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About the author: Dave A. Chokshi, MD, MSc, is the chief population health officer of New York City Health + Hospitals—the largest municipal health system in the United States. He is a primary care internist at Bellevue Hospital and clinical associate professor of population health and medicine at the New York University School of Medicine. Follow him on Twitter at @davechokshi. Disclaimer: The views expressed in this post do not necessarily reflect the position of NYC Health + Hospitals nor NYU. (Image: NYU Langone Medical Center)

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 



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