Our team has spent many months trying to answer questions about capacity in the health care system: How many health care professionals does any population need – and how many of what type? How does the quantity of available professionals relate to consumer access to care and quality of care? I’ve written about these issues before (Tactical Planning With ‘Supply & Demand’), and there are, of course, no simple answers.
In the process of thinking about these questions, my colleague Dr. Paul Block, the Director of NAFI Center for Integrated Care Innovation and OPEN MINDS advisory board member, sent me an interesting article, The Occasional Case Against Broad Dissemination And Implementation, about how to address part of the capacity issue through a “specialty behavioral telehealth care model.” The authors, Jonathan S. Comer Ph.D. and David H. Barlow Ph.D., of Boston University, define this model as:
…specialty services would be offered in real time through the use of videoconferencing and related technologies, either directly to patients in their homes or to other private locations with Internet access. Generalists confronted with patient presentations for which they have not completed competency training could easily identify credentialed specialists online and make a quality referral, regardless of patients’ geographic proximity to specialty care in their area…In light of current licensing regulations and pending reform, the only geographic limitation would be that at this time providers in most states cannot deliver care to individuals outside of states in which they are licensed…
I don’t disagree with the premise; specialty mental health “clinics” may be housed online instead of “bound” to a facility, leading to more available services, more service opportunities, shorter waitlists, and more cost effective use of resources. But I think the “creative destruction” needed to retool our service delivery system is even greater. Two elements in this retooling are happening simultaneously: the potential of innovation to improve the value of health care investments, and the changes needed in financing to allow those innovations to reach their full potential in the delivery system.
The financing piece is easier. I wrote earlier about the MedPac recommendations for future delivery system financing (see The Future Of ACOs Looks Bundled). While the prospect of moving to that financing system may sound daunting (“when pigs fly” was a phrase used recently by one of my colleagues), I think it is “easy” compared to the remaking of the delivery system that is at hand. In this emerging market, both specialty care and primary care will need to be reinvented.
In this market, “specialty” care will likely be imported via technology and that specialists may become more “specialized,” e.g., the emerging sub-specialty of vascular psychiatry (see Vascular Psychiatry?). I think the reason for this increasing specialization is that so much of specialists’ knowledge will be captured and disseminated via consumer self-service expert systems. For 90% of the population, “specialist” services will likely be delivered using computerized-enabled expert systems that can be accessed directly by consumers or by their health care professional. For mental health, this is the evolution of electronic CBT and other online treatment programs – perhaps in conjunction with highly-trained lay workers like peer support counselors. This is likely for the treatment of what we know as “mild” and “moderate” forms of conditions like depression, anxiety, and post-traumatic stress disorder (PTSD). This will reduce the “volume” of services required from professionals of all types.
Conversely, for acute conditions that threaten life or functionality, consumers aren’t willing to rely on technology – they want a professional with very specialized knowledge. If I get cancer, have a car accident that severs my spine, have an eye injury, experience a major depressive episode, develop a heart blockage, then I want a professional with lots of knowledge and experience in that specific condition – not a generalist and not any kind of self-service therapy.
Managing the on-going care of the 5-10% of the population with multiple chronic conditions and complex support needs presents another issue. I don’t know that the often-proposed solution to get everyone a primary care professional is the answer, because most of those professionals are not prepared for this task. The traditional primary care model that is focused on assessment, prescription, and referral needs an overhaul in-line with our new expectations of medical homes. Currently, the ability of primary health care managers to actually assess, request consultations, develop treatment plans, and manage multiple systems is pretty limited.
So back to the initial question – how many professionals do we need and what type? There are many great resources answering that basic question on its surface:
- Answering The Capacity Question In Your Market
- Trends In Market Size – The Specifics
- Trends In Market Size – The Most Basic Of Market Metrics
- Markets Increasingly “Unlimited” By Geography
- The Strategic Edge – Core Competency Versus Positioning
But, I would argue that we’re at a point of paradigm shift where building models from past experience will leave us unprepared for the future. To quote, Yogi Berra, “The future ain’t what it used to be.”