Making sense of the healthcare ecosystem and how technology is enabling people-driven healthTerrence Ryan | 10.21.2019
Healthcare used to be much easier. The “ecosystem” consisted of you—the patient—and your doctor, the provider. If you needed medical attention or required a hospital stay, your doctor was in charge of coordinating your care. Healthcare works best when all stakeholders are aligned around a proactive patient, within an ecosystem that supports success. In an ideal healthcare system interrelated consumer, providers, payers, government agencies, and others work together as a community centered around patient care: our care And with total transparency into costs and shared, open access to the health information we need, healthcare consumer like us can make informed decisions to get the best care for ourselves and our families. Unfortunately, that’s not the world we’ve been living in. Our current healthcare system has grown increasingly complicated over decades of growth, changes, and regulation. And too often there is a disconnect among those who populate it. The key players often have conflicting goals that make it impossible for them to unite to serve each our unique needs, preferences and values. Often, it’s not that they don’t want to work together to provide the best patient care. Our complex healthcare industry simply isn’t set up to enable coordinated care at a reasonable cost that allows patients to call the shots. Calcium is on a mission to change that by taking on our present dysfunctional healthcare system where those who pay for, deliver, and receive healthcare currently operate in siloes that are not aligned with our needs and don’t always put us first.
A lack of transparency is preventing the healthcare system from working the way it shouldHealthcare used to be much easier. The “ecosystem” consisted of you—the patient—and your doctor, the provider. If you needed medical attention or required a hospital stay, your doctor was in charge of coordinating your care and would consult with specialists as needed. All your health information was managed within one practice, whose doctors made decisions based on your complete medical history. You knew the costs up front and paid the doctor directly. For example, back in the 1960s, having a baby would set you back about $200 for the delivery and 10 cents a tablet for pain medication. You knew this because you would get a hand-written bill presented to you directly by your doctor’s desk clerk. Today, the healthcare market is more opaque, to put it mildly. The ecosystem has expanded to include countless other providers – primary and specialty physicians, nurses, and other clinical staff, as well as different hospitals, clinics and labs that deliver care. Our current healthcare ecosystem also includes healthcare organizations like payers—insurance companies that reimburse providers for covered healthcare services—and pharmacies that dispenses and manage the medications prescribed on your behalf. Rounding out the healthcare landscape are healthcare organizations that don’t deal directly with patients, but whose contributions indirectly influence patient outcomes. These include…
- Pharmaceutical companies who make and develop our medications
- Biotechnology companies pushing the boundaries of treatment research
- Medical device companies
- Distributors whose products and services are used to prevent, diagnose, treat and even cure diseases
- Health information technology providers who manage the all-important patient records and data
Transparency could help improve accountability across the ecosystemTransparency about pricing, quality, health and wellness data, appointments, services rendered, results, etc. can benefit each participant in the healthcare industry. Ultimately, transparency can help patients make better decisions that will improve healthcare outcomes and lower costs throughout the healthcare system.
- Smarter decisions. Upfront pricing and health data transparency will also help patients make informed decisions about whether they want to proceed with a healthcare service, if they would like to get a second opinion, or if they would like to shop around for a lower-cost option. The same goes for clinical services.
- Quality control. Information about a facility’s quality of care and outcomes can help consumers make better choices and give providers actionable information they can use to improve.
Benefits to healthcare providersTransparency also offer benefits for providers, as well:
- Fewer missed appointments. Making appointment information will help consumers with their schedules.
- More informed partner. Sharing findings, results and records more readily can help educate patients, for better health decisions.
- Better ratings. The movement for more transparent pricing and consumer reviews and ratings is happening and patients are using it as a yardstick to measure their providers against the competition.
Benefits to healthcare payersFor healthcare payers and insurers, availability of patient data will help identify patterns and trends in healthcare quality and enable them to implement value-based payment models. This could further improve quality and lower costs across the entire healthcare industry. In addition, payers who provide consumers with clear information about what’s covered, who pays for what, how patients can access care and which providers and facilities are in their networks will gain an advantage in cost management. When patients understand upfront how much they will owe out of pocket they are more likely to pay in a timely manner, thus reducing the amount of uncompensated care and administrative cost that the system must absorb. Additionally, the patient/consumer can leverage their own health data as they shop for plans or discounts. By taking advantage of health incentives offered by certain plans and being able to share health and medical data with their payers, the consumer might be able to take advantage of certain discount and health incentives to lower their overall costs.
Benefits to federal, state and local governmentsPrice transparency would allow private payers and policymakers to better understand how Medicare/Medicaid’s purchasing power impacts market pricing. This can open the market up to competition that lowers costs and improves quality of care for the millions on government health plans. As the country’s largest health insurer, the government, can standardize and provide system-wide access to healthcare data that could help drive transparency on many other fronts, to increase competition, lower costs and improve the quality of care for everyone in the healthcare sector.
Benefits to pharmaceutical companiesGetting a better understanding of the costs associated with each stage of their own drug development and manufacturing process would help them secure competitive pricing from their suppliers, and in turn lower costs for consumers. In addition, by improving access to information about the safety and effectiveness of medications, pharma companies would enable payers, providers and patients to choose the best, lowest cost options. Improved affordability means people are less likely to skip doses, or split pills to save money, leading to improved health. And imagine if there were better ways of informing consumers about their medications either through alerts announcing updates and improvements or notifying them that they should see their physician or pharmacist about a timely refill or a possible drug interaction. The benefits seem endless.
Focus on the patientAt the center of all of these is the healthcare consumer. Transparency about costs, quality, and safety from everyone throughout the healthcare sector would help them be better, more empowered consumers. With the information to be accountable, people can make value-driven healthcare decisions that will result in lower costs, more choices, and better outcomes for everyone.
Why isn’t it working today?Consumers, who should be quarterbacking their own healthcare decisions, have no choice but to look on from the sidelines. What’s holding them back? The answer points to what our current system is missing:
- A lack of understanding about how our complex healthcare system works
- A lack of awareness about their rights as far as ownership and access to their health data
- A lack of true data portability so that they can access and share their data within their healthcare ecosystem.