Medicine's Innovation Problem

The novel coronavirus exposes health care’s key weakness

Rena Xu

 
 

The tongue-in-cheek adage “tradition unimpeded by progress” has always seemed to contain a kernel of truth when applied to health care. Historically, change has not been our medical system’s strong suit. But as COVID-19 sweeps across the nation, wreaking havoc on society and placing unprecedented strain on healthcare infrastructure, the need for system-wide innovation becomes more critical than ever.

Innovation doesn’t just refer to the race to develop a vaccine, or even the scramble to rig ventilators for multi-patient use, repurpose ships into hospitals, and fashion protective masks out of home supplies, as important as these extraordinary efforts may be. It also applies to more ordinary challenges—challenges that many hospitals were ill-prepared to face even before the current crisis. In overbooked clinics, wait times are long and visits are short. Patients spend hours on the phone trying to get their symptoms triaged, their questions answered, their prescriptions refilled. Frequently, they get routed to the wrong specialists and wait weeks or months for an appointment, only to learn that they really needed to see someone else. In other instances, not knowing where to turn, they seek care in the wrong places—going to the emergency department for non-emergent issues, for instance, or trying to self-diagnose online.

While these challenges pre-dated the pandemic, they will be far more pronounced in a post-COVID world. Many hospitals, quite sensibly, are cancelling non-essential doctors’ visits and procedures to preserve precious capacity. But disease processes don’t halt in a pandemic, and patients with medical issues other than COVID-19—cancer, chronic illness, even so-called elective needs—require attention, too. Our medical system is not prepared to handle this backlog. Put another way: if we are lucky enough to flatten the curve, the next great challenge will be managing the long tail—not just of COVID patients, but of countless others. Doing so successfully will be possible only if we are willing to embrace creative measures, and quickly.

Hospitals and medical practices have been particularly slow to change when it comes to matters of workflow. Capabilities that are commonplace in our day-to-day lives—conducting business virtually, for instance, or making and managing appointments online —are still used tentatively in medicine, or not at all. Telemedicine offers an informative case study. While the technology itself has been around for decades, its use has fallen persistently short of mainstream—at least until recent weeks. Now, adoption of telemedicine is skyrocketing and garnering significant attention. Connecting virtually with a doctor, we’re learning in quarantine, really can be as easy as FaceTiming with family or conducting a business meeting over Zoom. Though far from perfect, such technologies offer opportunities for connecting those who are otherwise kept apart.

This breakthrough is due not only to the novel coronavirus, but also to two important changes made in response to it. The first is in insurance coverage. Previously, under Medicare, only patients in rural areas were eligible for telemedicine coverage, and only if they traveled to designated medical facilities to access the service. Now, the Center for Medicare and Medicaid Services (CMS) has temporarily modified its regulations to reimburse for telemedicine services regardless of where patients are located. An increasing number of states have mandated that private payers reimburse telemedicine services at the same rates they would offer for in-person services—so-called payment parity—and some insurers have expanded telemedicine coverage for their members.

The second change is in physician licensure. As part of their emergency response to the pandemic, the federal government and several states have relaxed restrictions on providers’ ability to practice across state lines. Historically, this has been a major barrier to the adoption of telemedicine. Getting licensed in a single state is hassle enough—start to finish, it took me five months to get licensed as a urologic surgeon in Massachusetts—and requiring separate medical licenses for each state, many doctors long have argued, is as unnecessary as requiring separate drivers’ licenses to cross state borders.

These regulatory modifications are timely, but also belated. It shouldn’t take a pandemic to convince the medical system to support the use of a telephone. Like many, I wonder whether the progress made now will be sustained after the crisis ends—whether this brief experiment in virtual care, much like a free trial, will be enough to catalyze permanent change.

But beyond that, I wonder what other barriers to innovation, regulatory or otherwise, are still in place and don’t need to be. The fact that we are collectively navigating uncharted territory right now presents a unique opportunity to jumpstart other measures that, like the adoption of telemedicine, should have happened long ago.

Opportunities for change abound at virtually every step of the care continuum. We need smarter ways to triage patients—to get them the right evaluations, in the right settings, in the right timeframe. We need more efficient and responsive mechanisms for pairing care supply and demand—so that patients see the appropriate doctors based on their specific medical needs, and providers’ schedules are neither over-booked nor under-filled. We need to divide and conquer medical visits, potentially leveraging virtual pre-visits with non-physician staff to help focus patients’ discussions with their doctors. And we need to scale back bureaucratic tasks so that clinicians can dedicate their time and energy to saving lives. The list goes on.

Many private enterprises already have developed solutions to address these very issues, from Zocdoc’s online appointment scheduling to Kyruus’s algorithmic patient–provider matching. Numerous startups have built tools for symptom triaging, patient education, and care navigation. But health systems themselves have yet to adopt such changes on a meaningful scale. None of these innovations entails particularly groundbreaking technology, but they all require considerable resources and willingness on the part of many—clinicians and administrators alike—to learn new ways of working.

While healthcare workers will play an essential part in executing these changes, they cannot do so without the right regulatory environment and the right leadership from the institutions where they work. This is a pivotal moment in which we need health systems to embrace innovative solutions, policymakers to provide funding and regulatory support, and insurers to allow for progressive reimbursement structures. Before last month, many in the medical field perceived a stark choice: between practicing within the status quo and seeking progress outside of clinical practice. Now, suddenly, that dichotomy seems outdated. It’s time to demand a third option and bring innovation into the core of our medical system, where it is needed most.


Rena Xu (MD, MBA) has written on health care delivery for The New Yorker, The Atlantic, and the New England Journal of Medicine. She is currently a fellow in pediatric urology at Boston Children’s Hospital and a Blavatnik Fellow in Life Science Entrepreneurship at Harvard.

Graphic by Bianca Ibarlucea.

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