CHAPTER 5

Consumers Are Us

There is no average healthcare consumer. As the diversity of consumers shifts, the variety of consumer needs also changes. Because the one-size-fits-all solution was made for the average consumer, it fits some individuals nicely—but it doesn’t fit others at all.

Even though the patient paradigm is shifting, patients do have some common expectations of the healthcare system. These are listed in the Healthcare Consumer Manifesto.

Understanding the New Healthcare Consumer

The new consumer needs and expects different things from the healthcare system depending on their situation. However, they have three demands for healthcare delivery that are consistent—access, convenience, and quality. Ideal delivery is when all three demands can be met. Access plus convenience means getting healthcare at a place that is locally very close, open in the evening and on weekends, and offers a lower cost. Speed clinics, described in the previous chapter, fit the bill for this. If the consumer is seeking convenience and quality, she will pay more and find those demands in concierge care. Demands for high quality and access to care will cost more and likely be located out of town or state. These needs can be met by academic medical centers. The intersection of consumer demands is shown in Figure 5.1.

Figure 5.1  Healthcare delivery consumer demands

There are multiple customer types based on an individual’s circumstances, including health status, familial care, and patterns of obtaining healthcare. So how do you understand the new healthcare consumer?

Individuals perceive healthcare individually—it is unique and personal. Their views of health and healthcare are formed by many factors, including:

• Education

• Culture

• Income

• Encounters with the health system (for themselves or others)

Look at the broad categories of consumers for your business. These consumer segments are grouped and differentiated by behaviors, attitudes, and decision-making processes. Understanding what is important to each consumer segment provides insight into how businesses can adapt to the new consumers in a healthcare system that is focusing on patient-centered care.

The Rise of Electronic Health Records

One major path toward patient-centered care is electronic healthcare records (EHRs). With these, patients can more seamlessly switch doctors, get their medical records, and do more functions online. The National Partnership for Women & Families conducted a survey¹ in 2014 of representative adult consumers in all 50 states who knew that their main doctor was using either an EHR or a paper-based system. The respondents had direct experience with EHRs to answer the questions. The survey revealed the following:

Patients see significant value in EHRs. Of the adults with a main doctor, 80 percent said their doctor uses an EHR system. For all patients, over 85 percent felt an EHR was useful in care delivery, while only 57 percent said paper records were useful. Patients also believed that EHR systems helped doctors and their staffs. For paper record patients, 26 percent stated it would be very valuable to them if their physicians switched from paper to EHRs.

Online access to EHRs rises. Now that the healthcare system is migrating to EHRs and digital data, the consumer’s view of health IT will come from their experience in the doctor’s office, hospital, and online. Their awareness of online access availability to their personal health information has grown from 26 percent in 2011 to 50 percent in 2014.²

Online access sparks desire to improve health. Those who have online access use it—86 percent of people with access use it at least once a year and 55 percent use it three or more times a year. Of those who access their information frequently online, 76 percent report that it motivates them to do something to improve their health.

Consumers want more functionality and features in online access. Patients want the ability to e-mail their providers, schedule appointments, request medication refills, review treatments plans, doctor’s notes, and lab results online.

Consumers trust providers with EHRs with respect to privacy. The more patients experience the benefits of EHRs, the more they trust providers to protect their privacy. The more they trust their privacy is protected, the more they use and benefit from EHRs. Patients believe that EHRs give them more control over how medical information is used and trust the way medical information is handled. In addition, the more patients use EHRs, the more they believe providers are compliant with privacy and confidentiality laws, and that their information is safe.

Online access gains trust for EHRs. Patients with online access to their health information trust their provider significantly more than patients who had EHRs but did not have access to their EHR.

Consumers want to know how their information is collected and used. People are concerned with the safety of their health information. Only 51 percent of patients said their doctors and staff explained “very well” how their information is used.

Different populations prefer and use different health IT functionalities. Hispanic adults were significantly more likely than non-Hispanic Whites to respond that having online access increases their desire to do something about their health. Hispanic, lesbian, gay, bisexual, transgender (LGBT), and Asian American individuals were most likely to say that they would access their personal health and medical information on a mobile device or tablet if they had the capability. Only 29 percent of non-Hispanic Whites would do the same.

Consumers Want Uberized Healthcare

Five years ago, there was no Uber, AirBNB, or GrubHub. These companies combined the high use of smartphones, unmet customer needs, and a residual workforce to tap into consumers’ demand for near-instant service. Even Amazon, the first online marketplace to guarantee 2-day service for a fee, has upped its game by offering its prime members sameday delivery.

So it should come as no surprise that healthcare has broken into the realm of on-demand. The ecosystem is ripe:

• Smartphones are owned by 71 percent of Americans. Consumers are going to the Internet to research health information and find providers.

• Physicians are moving toward concierge and direct pay practices.

• Consumers lead increasingly busy lives and the average wait time to see a primary care physician is 2.5 weeks. Convenience and accessibility are highly valued.

• Consumers have experienced on-demand services as simple, easy to use, and fees stated up front.

On-demand healthcare services can be divided into those that are fulfilled in-person and those that are fulfilled virtually. There are also companies that deliver medication on-demand, such as Zipdrug and Postmeds. Use of on-demand services, of course, presumes that the consumer is willing and able to pay for them out of pocket. Some consumers will receive reimbursements from their insurance company, but that is not guaranteed. Most walk-in clinics such as CVS say that they accept most insurance. What they can’t tell you is how much insurance will pay and how much you must pay. However, since the cost of the service is posted, the consumer knows what the costs are for the services being provided. In most cases, the fees are in the range of $50 for a telehealth visit, while walk-in establishment charges depend on the number and kind of services provided.

Attracting Consumers

Consumers look for ease and convenience from on-demand services. For healthcare, that means the service must be easier to use and faster than the standard appointment and wait time. This translates into scheduling online appointments quickly, followed by an appointment within 30 minutes or at least the same day. Convenience is a provider coming to the patient either in person, via televisit, or the patient goes to a place that is nearby. It depends on the patient’s problem and perceived urgency. If the problem is a possible child’s ear infection or sore throat, then a telehealth visit within an hour might be acceptable, whereas a picture of a skin lesion sent to a doctor and responded to in a couple of days could also fit the patient’s need.

On-demand is not limited to retail outlets, kiosks, and telehealth. These are simply different modalities of providing health services. Primary care doctors could use the same delivery mechanisms and offer on-demand services. It would mean changing practices to handle virtual telehealth appointments, expanding hours of service, allowing online appointments, and responding to e-mails in a reasonable time period. The advantages for the primary care physician are as follows:

• Meeting the needs of her patients and decreasing the potential of losing existing patients.

• Attracting new patients.

• Decreased work due to efficiencies gained.

The popularity of on-demand services can create gaps in a patient’s EHR unless a record of the visit is sent, preferably electronically, to the patient’s primary care physician. Therefore, it is essential to maintain continuity of the patient’s record and the sharing can be done through a health information exchange or other method that protects the privacy and security of the patient’s data. Patients expect that their data from on-demand encounters are secure, private, and will be transmitted to their primary care physician.

Characteristics of on-demand services include:

• On site—open during weekends and evenings

• Online appointments 24 × 7

• Telehealth visits 24 × 7

• E-mails with photo attachments

• Medication refills

• Transmitting a record of the visit to the patient’s primary care doctor

Consumer Segments or Fragments—The Progressive, the Changeling, and the Indifferent

In the past, healthcare providers had patients. Now with the passage of the Affordable Care Act (ACA), patients are becoming healthcare consumers. This transformation has been triggered by start-ups and nontraditional healthcare businesses that see an opportunity to serve the consumer in ways that they are accustomed to and expect from the current retail environment. However, most healthcare businesses are not consumer oriented or consumer friendly.

There are seven important characteristics of the patient-turned-consumer profile. Current research suggests that the following factors differentiate how consumers make healthcare decisions.

1. Value-oriented. Improving and maintaining health is a priority. Value-oriented doesn’t mean that price is the only factor that people consider when shopping for individual coverage. For individuals who bought health insurance on the federal site, Healthcare.gov, 66 percent could have purchased health plans for $50 per month or less after the premium tax credit according to a Department of Health and Human Services report.³ Only about half purchased the lowest cost plans. Value-oriented consumers are interested in shopping for services and health plans, and they are more willing to consider and use alternative approaches to care such as retail clinics and telehealth.

2. Connected. An emerging character of the patient-turned-consumer is her ability to connect online to her health record, providers, and insurance options (cost, provider network). The connected individual also does research online on conditions, illnesses, and treatments. A connected individual has the tools to look up quality and compare prices. Maternity consumers are indicative of a group that is young, healthy, and connected online. However, many patients are still influenced by their doctor’s recommendation on care choices even if they do research in advance.

3. Activism. Activism ranges from proactive to reactive. Proactive consumers have a heightened interest in prevention and wellness. They are conscientious, knowledgeable, open to new ideas, and define for themselves what health looks like, instead of a doctor defining it for them. The proactive consumer is conscientious about health, does not have chronic conditions, and has a focus on healthy eating and exercise. The reactive consumer is one who acts and decides his health and wellness du jour. She will not see a physician on a regular basis, most likely does not have a main doctor, and touches the healthcare system when she is sick or has an emergency.

4. Insured. The uninsured usually don’t seek preventive care and get care only when they are ill. Insured consumers are privately insured (employer-sponsored or individually insured) or publically insured⁴ by Medicare or Medicaid. In general, the insured consumer seeks both preventive and illness care. However, their consumption is also dependent upon their out-of-pocket costs. With high deductible plans, the insured consumer is trying to be mindful about how much they pay for nonemergency services. The Medicaid eligible purchase and receive subsidies for insurance plans purchased on the marketplace exchanges. Plans at the bronze and silver levels on the exchanges have high deductibles and lower premiums. Individuals with richer benefit plans, most often from employers, have less out-of-pocket costs and may do less shopping for healthcare services. Individuals who have to pay for their care until they reach their high deductible are more sensitive to prices. Price sensitivity also means they may be more willing to see healthcare professionals other than a physician, or a physician via video, if it costs less.

5. Health Status. While many people self-report as having good or excellent health, their use of healthcare is more dependent upon whether they have a chronic or serious illness, take prescription medications, and were hospitalized within the last year. The best health status is an individual who has none of these. Each of these factors moves her one notch away from health. Self-reporting of good or excellent health is more likely to mean that any health issues are under control or are being well managed, and that the individual feels well.

6. Engagement. Patient engagement ranges from passive to active. Passive consumers will follow their doctor’s recommendations for treatment and providers. They won’t ask many questions or look up information about treatment alternatives, quality of providers, or cost. They are comfortable with having the main source of input of health information come from their doctor, someone with whom they have a long-term relationship. Healthcare resources are important input, but not the only sources of information; they may ask their friends and family for advice and recommendations to make smart, well-informed health decisions. Actively engaged consumers are independent and want to make their own decisions about care and treatment. They want even more information and more than what the doctor tells them. They exercise initiative to seek information on staying as healthy as possible, are curious about their genetic makeup, and will weigh the pros and cons of new treatments, participate in research studies, and contribute their data. Engaged consumers are also more likely to seek second opinions, evidence-based treatments, read reviews from other patients on treatments and providers, and comparison shop for quality and cost in care and will shop for health plans. Engaged consumers are the group that is likely to use nontraditional modalities of care such as retail clinics and telehealth. The more engaged also exhibit more interest in monitoring their health by using apps to track their diet and fitness.

7. Income. A higher level of income is associated with the freedom to make more choices in healthcare, especially in wellness and fitness. Individuals who are insured through Medicaid or receive subsidies or credit when self-purchasing on the public insurance exchanges may not seek care as often, or delay care, if they have high deductible plans because their disposable income is smaller. The individuals with lower income will consider plans with narrower networks and lower premiums. At higher incomes, consumers may be interested in paying more for additional ancillary benefits such as dental or vision. Higher income also allows these consumers to try new offerings such as using their DNA to find out what are the best ways to stay healthy. They are also more likely to pay for out-of-pocket services like speed clinics or concierge care.

What Type of Profile Is Your Customer?

To create profiles of the new consumers, the seven factors above are combined based on consumer needs at various times in their lives. The most common types of consumers are shown in Figure 5.2.

Figure 5.2  New healthcare consumer profiles

The Progressive: proactive, highly connected, insured—These individuals want to know more about maintaining and improving their health, even though they are healthy. They put effort into staying informed about the latest trends of healthy eating, exercise, and do extensive research when illness hits. They are interested in alternative products and services to find out more about their genetics from companies, such as Helix and GenebyGene. They are also interested in customized health recommendations and precision medicine because they will do research on its efficacy and make their own judgment as to whether these products or services are valuable for their situation. This individual will shop online to find the highest quality, but not necessarily the lowest cost.

The Changeling: insured, value-oriented, not healthy, lower income—An individual’s health status determines whether or not she is value oriented and insured. Someone with a chronic or serious condition is more likely to be covered by health insurance simply because they want to have the ability to seek care when it is needed. However, their income level and out-of-pocket costs in their insurance plan affect their behavior. Individuals with illnesses that require ongoing prescription medication are highly sensitive to the cost of their medication and will look for plans that keep their payments low. The value-oriented factor for the lower-income consumer means that she will first consider the necessity and priority for care, and then shop for care to keep out-of-pocket costs to a minimum.

This combination individual is most likely a mobile user who seeks information and convenient care for self and family so as not to lose work time, and is open to alternative care delivery modes as long as his costs are not higher. This consumer can be convinced with high value, but decisions tend to be based on conditions at a moment in time rather than long term.

The Indifferent: uninsured, reactive, lower income, passive engagement—These individuals will be young and have lower income. Being uninsured means they are unconcerned about their health. In general, they will not have a chronic or serious illness. While they may have some interest in fitness and diet, they are not willing to spend money or time to become more knowledgeable and don’t look for healthcare or health information online. Their healthcare is reactive in nature and low priority, so there is little or no planning involved.

This group will be the least interested in using new and innovative types of care and products because their awareness is low. Even if they are connected online, they are not looking for healthcare or fitness information. Being the least informed, they would benefit the most from education that pops up at sites that they frequent online.

Consumer Diversity and the Health Disparities Gap

An increase in consumer diversity has led to increased disparities in healthcare when it comes to race, ethnicity, language, gender identity, sexual orientation, socioeconomic status, and disability status. With the EHR Meaningful Use Incentive program, adoption of health information technology has increased greatly among providers and created a foundation of EHRs nationwide.

However, the design and usability of technology to address the needs of diverse healthcare consumers has not changed. Mark Savage, director of Policy for the National Partnership of Women & Families, talks about the importance of reducing healthcare disparities: “People developing health IT need to build for people who do not look or think like themselves,” he says. “Without looking at the broader perspective or patient’s perspective, they will miss an opportunity to incorporate universal design. Instead, they end up building in barriers. It is a systemic problem in interoperability. Providers want to build an interface that works with their particular system—but it prevents them from exchanging with unaffiliated organizations that also have responsibility for the care of their patients because they’re different systems.”

Access to their own health information and improving communication between providers and patients will contribute to closing the gap in healthcare disparities. A 2013 report⁵ by the Consumer Partnership for eHealth recommended an action plan for leveraging the EHR Incentive Program to reduce health disparities in three identified areas:

1. Data collection and use to identify disparities. EHRs need to record factors relevant to health, such as sexual orientation, gender identity, occupation, disability, environmental factors, caregiver presence, race, ethnicity, and language. For example, research data show 47 percent Hispanics own smartphones and 49 percent of non-Hispanic Blacks compared with 42 percent non-Hispanic Whites. Smartphones apps are a growing source of patient-generated data and are an access point for underserved populations.

2. Language, literacy, and communication. The patient’s preferred language should be available on websites, in education material, media, and other patient tools. Culturally and linguistically appropriate information is important in the bidirectional exchange between providers and patients and their families.

3. Care coordination and planning. Health IT can be used to connect and coordinate efforts of people, providers, and community resources. Technology can make necessary information readily available and actionable, connect everyone who has a role in an individual’s care plan, and provide a shared platform for the ongoing maintenance and management of an individual’s care.

Getting the healthcare system to work for the underserved population means it can likely work for everyone. Help is on the way, courtesy the 2015 edition of the Health Information Technology Certification Criteria Final Rule from the Office of the National Coordinator. This edition added the following certification criteria specifically aimed at increasing support of diverse consumers:

Certification criteria	What the functionality supports
Documentation of social, psychological, and behavioral data (e.g., education level, stress, depression, alcohol use, sexual orientation and gender identity)	Allow providers and other stakeholders to better understand how these data can affect health, reduce disparities, and improve patient care and health equity
Exchange of sensitive health information (data segmentation for privacy)	Allow for the exchange of sensitive health information (e.g., behavioral health, substance abuse, and genetic), in accordance with federal and state privacy laws, for more coordinated and efficient care across the continuum
Accessibility of health IT	More transparency on the accessibility standards used in developing health IT
More granular recording and exchange of patient race and ethnicity	Allow providers to better understand health disparities based on race and ethnicity, and improve patient care and health equity

The new criteria will gather data that can be used to identify health disparities based on various individual characteristics.

How are insurance companies addressing disparities? UnitedHealthcare Group’s vice president for Latino Solutions Russ Bennett says they are employing a variety of techniques.

The United Health Foundation’s 2015 America’s Health Rankings Report shows that the rates for illnesses such as diabetes, hypertension and obesity remain serious concerns for Hispanic Americans. Finding effective ways of communicating with Hispanic audiences, using innovative, bilingual tools through a wide variety of platforms, can help bridge the gap.

UnitedHealthcare provides employers with language-appropriate and culturally-sensitive information for distribution among Hispanic employees. Offering bilingual (English-Spanish) content on our member websites also facilitates Spanish-preference members a better understanding of their benefits and healthcare options.

Our UHClatino.com website houses health and wellbeing content, such as animated “fotonovelas,” to help address the language barrier in the U.S. Hispanic communities at large. UnitedHealth Group’s online Just Plain Clear English-Spanish Glossary defines thousands of healthcare terms in plain, clear language to help make informed healthcare decisions.

Creative Solutions to Serve the Underserved—The NEMS Story

North East Medical Services (NEMS) in San Francisco is developing a totally different tact to tackle disparities. NEMS is one of the nation’s largest community clinics serving underserved Asian populations in its 10 Bay Area locations. The majority of its patients are low income or uninsured. The growing need for healthcare for diverse populations is demonstrated by the growth of NEMS from 23,000 patients eight years ago to 65,000 patients, and from two to 10 clinics. Over 90 percent of their patients are Asian. The recent expansion of Medicaid added more patients to their clinics.

NEMS provides culturally sensitive and linguistically competent healthcare through the skills of multilingual and cultural staff. Their model of staff hiring has been to bring onboard those of the same culture and who speak the language of their patients. This eliminates the need for cultural and language training, which is difficult because certified translators must pass difficult written and verbal tests that prove they are able to translate medical terminology.

Patients are afraid to go for treatment because they don’t speak English, and going through a translator can be very uncomfortable. This can cause disparities, according to NEMS CEO Eddie Chan: “Some patients use the AT&T call line as stop gap measure for translation and it doesn’t work that well,” he says, referring to the service that provides translations for callers. “Patients are never very comfortable. Disparity here is the inability to get good treatment for whatever diagnosis they have. Language and cultural barriers in our population are huge.”

Some of the health disparities that characterize NEMS patients include increased rates of diabetes and hepatitis B. In fact, 1 in 10 Asians is infected with hepatitis, compared with 1 in 1000 in the general population. The incidence of hepatitis B and liver cancer constitutes the greatest health disparity that exists between Asian and Pacific Islanders (APIs) and the general U.S. population. APIs have the highest incidence of liver cancer of any race or ethnic group. The Centers for Disease Control and Prevention (CDC) Statistics & Surveillance shows that many die as early as 30 years old from this disease.

Because mothers can transmit hepatitis B during pregnancy to their unborn child, many individuals who are at risk need to be screened, including those born in the United States. The good news is that hepatitis B is preventable with a vaccine, and that early detection will prevent HBV from spreading.

Screening tests for hepatitis B are not included in routine physical examination blood tests and must be requested, but many patients don’t know to ask for it. It is also often misdiagnosed. Educating the Asian population about screening is important because it is a silent killer—people feel fine until symptoms appear and liver disease is advanced. Compared to HIV, Hepatitis B is 100 times more infectious.

NEMS is using technology to break down these kinds of language barriers. For NEMS, the typical model doctor is someone who speaks the Asian language of their patients and is part of the same culture as the patients. However, the increase in number of patients has caused them to hire outside of this model. They now hire doctors who speak only English and don’t speak the language of their patients. The English monolingual doctor requires a medical assistant to be in the room to translate during the visit.

In addition, they are looking toward telehealth video to more efficiently use translators, including the creation of a centralized bank of translators in a call center. When a translator is needed during an office visit, she will appear on a video screen in the room with the doctor and patient. Eventually, doctors will be on call 24-hours, seven-days-a-week providing video telehealth services to patients instead of going into the ER, saving time and costs.

NEMS is also dipping directly into a pool of physician resources in China and Hong Kong as another way to meet the needs of their patients. Chan has plans for a residency program that brings in trained medical students who will practice with underserved populations once they complete the training. He is working with medical schools in China and Hong Kong to create a package that includes housing, internship, residency, and a fast-track path to get credentialing and licensed by the California Medical Board. Chan is also meeting with congressional leaders to lift funding caps on graduate medical education and local, state, and national organizations to fund the development of new programs directed toward the underserved population. Once a hospital partner is selected, the program will go through an accreditation process with Accreditation Council for Graduate Medical Education. The NEMS clinics will provide the on-site locations for training the residents. Four residents will begin the program in 2018, which will eventually grow to 12 residents per year.

Customer Service is Not an Option

As we’ve discussed, the business of healthcare isn’t used to having a consumer. In the past, healthcare providers had patients who didn’t really have any choices beyond selecting their primary care doctor, who was the gatekeeper to all other providers. Today, the patient is more consumer-like and behaves like a consumer in other industries. New and nontraditional healthcare businesses have focused on customer satisfaction because they aren’t weighed down by the models of the past.

What does that mean for traditional healthcare providers? They need to adapt and provide good, if not exceptional, customer service. Here are some guidelines for treating the healthcare consumer:

• Treat the healthcare consumer like a customer. Just like any retail business, good customer service is essential in order to survive because there is a lot of competition.

• Great customer service. Customer expectations are set by non-healthcare industries. Being better than other healthcare competitors is not enough. Healthcare customer service should strive to be as good as companies outside of healthcare, such as Apple, Nordstrom, Amazon, and Zappos.

• Educate and inform. There are many new services and products today that did not exist a few years ago. This includes online services for employers, employees, and individuals. With so many products, consumers are looking for ones that will be the most useful to them. Present real examples of how the product is used so the buyer learns the benefits, and use as many details as possible.

• Explain Charges in Advance. Someone who has never had an elective procedure before doesn’t know how they are billed pre- and post-surgery and could easily be surprised with multiple invoices and amounts. The explanation of benefits (EOB) letters are worthless because they often present many reasons to explain a charge and the patient has to guess the one that applies to him. Before the procedure, explain when charges will be billed and estimate their cost. The best improvement and advice is to make the EOBs understandable.

The Patient Paradigm Shifts

The new healthcare consumer is influencing healthcare and driving the direction of the way services are provided. The new consumer is more interested in being proactive in their well-being and will look for ways to carry on with their active lives and keep from becoming ill.

Today’s healthcare consumers are looking for:

• Value and quality in selecting healthcare providers.

• Delivery of care to suit their lives when and where it is needed.

• Convenience from a healthcare system that offers online appointment scheduling, prescription renewal, telehealth appointments, office visits without waiting.

• Availability of healthcare information online.

• Integration of personal data from biosensors, fitness tracking devices, and genomics to create a holistic health record.

• Health and life care in addition to sick care.

Traditional visits to the doctor by an ill patient are characterized by the questions: “What’s wrong with me? How do I get better? How do I pay?” The visit is a very fast transaction and when it is finished, they disengage with the health system. There is little or no time for discussion about other things in life that affect a person’s health.

The trend is away from the paternalistic doctor–patient relationship to one where the consumer has more control creates a peer relationship between the patient and providers, who become partners in health. This is happening even when a patient isn’t sick: Healthy individuals want their providers to focus on their long-term health at their annual check-ups. Baby-boomers who are healthy are asking the question, “What can I be doing better to stay healthy as I age?”

New Mindset and Behavior

The old consumer wanted to get better faster when she was sick. The new consumer has a different mindset. She wants to feel good as much as possible, for as long as possible, and to minimize the number of days where she can’t carry out her daily plans. She wants to actively participate in maintaining her family’s health, and is more likely to opt for preventive measures such as flu shots. She is more likely to go to the doctor armed with research on something that affects a family member and to ask questions regarding diagnosis and treatment. This is a mindset shift from sick care to well care, shown in Figure 5.3.

This change, from transaction-oriented to building a long-term relationship, is not just limited to patients younger than 50 years. One example is about a woman, Mary, in her 70s who is having symptoms such as fatigue. Before an appointment with her physician, she looks up her symptoms, and tells the doctor that she thought she might have a thyroid problem. Her doctor replies that what she was experiencing was most likely to age. She goes home, does more extensive research, goes back to the doctor, and insists that he give her the thyroid test. When she gets it, the test comes back positive for a hypothyroid condition.

Patients don’t want their doctors to be wrong, but they do want them to listen. A common complaint among patients is that the doctor spends less than 10 minutes with them, only addresses the problem that triggered the visit, and don’t get a chance to discuss anything else that is going on with their health or their lives.

Figure 5.3  Shift from sick care to well care

The age of highly individualized medicine has arrived and the new consumer wants care that is personalized. That means the usual trial and error approach will recede. Precision medicine is the newest kind of disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person. Mapping a person’s genomic profile is the first step in precision medicine. Researchers and doctors can determine biomarkers and variances for potential diseases, determine the best treatment to achieve an optimal outcome with minimal adverse effects. Precision medicine has been effectively demonstrated in treating cancer where the tumor’s genetics are also used to determine the ideal treatment for the patient.

Companies are catering to the desire for personalized health. Arivale is a company that wants to provide individuals with “a scientific path to optimize wellness and aid in avoiding diseases based on an individual’s data and behaviors.” Although the program is personalized, Arivale does not expect each person to interpret the data, so a personal coach is assigned to assist members. For example, instead of giving generic advice like eating more vegetables, the specific advice might be “based on your DNA and lab work, you are best suited for a Mediterranean diet.”

Companies providing precision health don’t review or report on clinical genetic tests, such as the gene carrier status of breast cancer and other diseases. That falls in the purview of 23andMe and Gene2Gene, which are genetic services that analyze an individual’s DNA. While 23andMe provides FDA-approved reports directly to the consumer on carrier status, ancestry, traits and wellness, consumers must request a clinician to order clinical genetic tests for Gene2Gene.

The consumer can drill down into detail about behaviors and life style that is precisely recommended for their body and family history. The data from fitness and health devices will provide the means to monitor and measure their efforts on a daily, weekly, and monthly basis.

The Demands

Convenience means more than geographic proximity. It reflects the best way for the consumer to seek care, advice, and treatment. That care may be delivered via telehealth, telephone call, or a health professional at the corner clinic. One example of innovative ways to increase convenience is the Veterans Health Administration, which makes use of smartphones to adjust prosthetics and cochlear implants. With this ability, there is no need to drive to the VA hospital, which can often be two to three hours away.

In some situations, convenience may be having a doctor come to the patient’s home. Convenience means that there is more than one way to receive care. In the future, going to a doctor’s office will fade as new methods become more prominent.

People can be told how important it is to have healthy behaviors, diet, and exercise, but the critical factor is ease of access, ease of availability, and ease of use. If doing something is easy to use and you can interact with it often, the higher the likelihood it will get done. In addition to that, if the behavior is rewarded or fun, the chances are that the activity will get done more often, and repetition leads to a change in habits. Apps that track exercise and diet make it easy to track the goals on a daily, weekly, and monthly basis that an individual sets. To make it more exciting, the apps will also connect you virtually with other people online that you can compete with and get encouragement.

Shopping is becoming easier for consumers with easy-to-use tools such as Castlight and ZocDoc that offer built-in quality transparency to choose a provider using reviews and ratings, and narrowing specifically by location, specialty, and insurance.

Shoppers are also looking at options such as medical tourism.

Next-Generation Models

The new consumer’s goal is to stay healthy, and avoid sick-care treatment and expensive hospitalizations. Prevention will become increasingly effective as the healthcare system integrates diet, nutrition, and mental health, which allows the patient and ecosystem more control over health to avoid risk factors such as high blood pressure, obesity, alcohol dependency, and smoking to improve overall individual health.

The new model for consumers has technology as its foundation, continuously updated data on consumers, experience from real-life cases that can predict the needs of individuals for improving their health and lives, and uses an IBM Watson-like intelligence to diagnose and recommend the best interventions for acute circumstances. Instead of a primary care doctor as the gateway for care, this will morph into an intelligent health or iHealth team of healthcare professionals. The team members will be tailored to individuals or families and composed of a combination of the following:

• physicians

• healthcare professionals—for example, nurse practitioners, physician assistants, nurses

• health coaches for holistic perspective (includes nutrition and fitness)

• genetic advisors

• home care professionals

• pharmacists

• psychiatric professional

• palliative care experts

• legal and financial advisors

• social worker

• monitoring centers of patients with remote monitoring or sensors

Depending on the need of the patient, many parts of the team may be virtual, which allows the model to be scaled. Looking ahead, health insurers will offer plans that allow the consumer to pick from a menu list of providers, such as free Teladoc appointments, discounted prices at CVS in-store clinics, and specialty health coaches.

The Team’s Electronic Black Bag

The doctor’s modern digital black bag will have all the tools shared by a team of caregivers. The bag will connect all team members seamlessly wherever they are, so that they can communicate with the patient and about the patient. It will contain the patient’s health and lifestyle record, genetic data, predictive models that can be used on individual patient data, information about telehealth capability, and access and convenience preferences.

Hyper-data and predictive modeling will allow health teams to create personalized care plans for individuals. The appropriate care team members see or call on the consumer patient according to a customized care plan, which includes real-time sensor data since the last visit.

A Changing Health Ecosystem

In the past, geography was a limitation of the healthcare ecosystem. The digitization of health data and increasingly widespread implementation of EHRs has eliminated that barrier. Today, many services can be delivered across the nation and around the world.

Businesses new to healthcare—but with experience in customer needs and service—will form the new ecosystem. The current healthcare businesses need to adapt to the new consumer-centric model to become a relevant part of the new ecosystem. In the future, the majority of primary care for healthy individuals and families will not take place in physician offices, but at retail clinics in places like Walgreens, CVS, Walmart, and Target. There is no need to wait on the telephone to make an appointment for two or more weeks out and wait again at the doctor’s office, when an online appointment at a retail clinic in the neighborhood can be made from a smartphone or by calling HealthTap or Teladoc for an appointment to consult with a physician within 15 minutes for $49. The choice for busy mobile families seems easy. Consumer engagement will come as a natural by-product of personalized health and wellness care. The more personalized care gets, the more engaged the consumer will become.

This kind of personalized care is evident in a new type of clinic such as the BRCA clinic at the University of California, San Francisco. The specialized clinic will treat patients who have the BRCA1 and BRCA2 genes, inherited mutations that cause ovarian and breast cancers and also increase the risk of pancreatic, prostate, and other cancers that affect both men and women. This new type of clinic is built around a hereditary mutation and has the advantage of coordinated care and input from multiple specialists. Unlike general cancer treatment that is organized around different departments for each type of cancer, the BRCA clinic will treat all BRCA-positive patients, with or without cancer. The clinic will offer genetic counseling, imaging, and appointments with surgeons, oncologists, and other specialists across many disciplines.

Changes to healthcare are happening steadily. The stream of new technologies, the actively engaged consumer, and the willingness to share data to improve cost, quality, and outcomes will allow the U.S. healthcare system to become one of the best in the world.

References

ASPE Issue Brief. March 10, 2015. “Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report.” https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-2015-open-enrollment-period-march-enrollment-report

Leveraging Meaningful Use to Reduce Health Disparaities: An Action Plan. August 2013. “Consumer Partnership for eHealth.” www.nationalpartnership.org/research-library/health-care/HIT/leveraging-meaningful-use-to.pdf

National Partnership for Women & Families. December 2014. “Engaging Patients and Families: How Consumers Value and Use Health IT.” www.nationalpartnership.org/issues/health/HIT/patients-speak.html

¹ National Partnership for Women & Families (2014).

² National Partnership for Women & Families (2014).

³ ASPE Issue Brief (2015).

⁴ About 4% are publically insured through Tricare, VA, and Indian Health Service.

⁵ Leveraging Meaningful Use to Reduce Health Disparaities: An Action Plan (2013).