Restructuring the U.S. healthcare delivery system

Pharmacy and retail blockbuster chains, having already embarked on retail and express clinics, are now proposing partnerships with commercial insurers to expand their reach, improve their bottom line, and reposition themselves as the new “front door” of primary care (for example, the proposed purchase of Aetna by CVS Health and of Humana by Walmart).  At the same time, commercial insurers see pharmacy and retail blockbuster chains as avenues to continue their diligent advances in diversification. If we don’t act soon, these strange bedfellows will dictate the future structure of the U.S. healthcare delivery system itself.

Expanding access to local primary care sounds good on paper – healthcare will be just around the corner for each patient. But there are potential drawbacks to these acquisitions that need to be understood and addressed. For example:

• Do we want to have pharmacy/insurer monoliths wield power to steer patients to specific facilities and providers for care, services and medications?  Beyond primary care, patients need access to specialty care and care coordination across the continuum of healthcare services. Except for the small number of proposed mergers that involve multispecialty provider groups (for example, the proposed acquisition of DaVita by Optum) is this on the companies’ radar?  If so, what are their proposals for a comprehensive delivery system of care?
• Will we be fracturing an already dwindling provider supply?  It is doubtful that economies of scale will be realized by placing one or two clinicians in a retail pharmacy and replicating this model over tens of thousands of sites as they compete on every corner. Primary care clinicians may become an even more endangered species than they already are, with many seeing only a handful of patients per day. What are these companies’ plans to ensure an adequate number of primary care clinicians over a broad geographic area?

These are just some of the many questions that need to be addressed now, while these acquisitions are still in the proposal stage. We need to move the conversation from the   financing arrangements and scale of these proposed acquisitions to the impact they could have on patient access and the structure and provision of healthcare delivery throughout the country.

We do need disruptive innovation in the healthcare market. But that disruption should apply to the very structure of the U.S. healthcare delivery system itself and how to address patient access and healthier communities.

Picture a new, regionally-based structural model where the defined patient cohort consists of the people living and working in a specific area. Where is the best place for these individuals to receive their care, what providers are needed for that care, how can we expand access while reducing cost of care, how can we integrate care into the lives of individuals as they work and live and play? 

What would an innovative healthcare delivery system look like? It could include some or all of the following:

• Patients living or working within a defined region receive care from a designated healthcare delivery system.
• Patients receive primary care services locally and specialty care services regionally. The most complex procedures are performed in a few, well-established centers of excellence located throughout the country.
• The regional healthcare delivery system is incented to improve and/or maintain population health and wellness; financial incentives and/or subsidies are paid to the systems themselves (rather than to patients or commercial insurers).
• Patients purchase health insurance directly from the regional healthcare delivery systems, thereby effectively integrating the financing and delivery of healthcare and thus aligning incentives.

This option essentially reinforces the accountable care organization concept, but expands it to defined regions of coordinated care, services and technologies.    

We need to change the national debate from the financing of healthcare alone (whether to tweak, change or overthrow the Affordable Care Act involving its slippery slope of subsidies) to construct the best system of care delivery to advance patient access, value and population health.

Before we have a new marketplace designed and led by the pharmacy chains and commercial insurers, let’s work to restructure the delivery system to include all services, not simply primary care, before it is too late. By disrupting and innovating our delivery system we may expand patient access, improve quality, and reduce total cost of care, while improving the health and wellness of Americans.

Deborah Walker Keegan, PhD, is president of Medical Practice Dimensions, Inc., a healthcare business consulting firm based in Asheville, N.C.