by Yaneer Bar-Yam
Step I: Separate Simple Care

Healthcare work may be divided into two types: simple care, which is the same for many people, and complex care, which is different for each individual.

Simple care includes preventive services, such as health screenings, vaccinations, and healthy-habits counseling sessions. Complex care includes the individualized diagnosis and design of treatment.

Physicians are specially trained to diagnose and treat complex medical conditions. Nonetheless, one finds that physicians and their offices are typically responsible for simple, standard care in addition to complex, individualized care.

That poses a problem. Asking the same organizational structure to provide mass-applicable preventive care and complex individual care is like asking an expert violin craftsman to provide all the chairs for a new concert hall. The mismatch between the organization and the task leads to ineffectiveness and inefficiency.

Ironically, instead of streamlining the delivery of high-volume simple services, most cost-reduction efforts to date have tried to make complex tasks simpler and faster. Industrial-style efficiency is poorly applicable to doctors' diagnoses and treatment of individual patients, however. Trying to speed and simplify doctors' work assembly-line style reduces doctors' time to make complex decisions, which is not a good idea if we want doctors to be careful and make the best decisions possible. At the same time, many healthy patients are receiving insufficient preventive care, since doctors are being asked to provide many of these services. The volume of preventive care needed is too great for the current system to handle it effectively.

What can be done? The solution is to separate the tasks. Let doctors perform the complex tasks that they do well, and delegate preventive-care tasks such as vaccinations to an organization suited for simple, repetitive tasks.

In many hospitals and doctors’ offices, simpler tasks such as drawing blood and taking x-rays are performed by professionals trained for these specific, frequent tasks. This idea can be applied much more broadly.

We can improve the healthcare system dramatically by separating the simple services that many healthy people need even further, delegating them not just to different individuals but to different organizations.

We are beginning to see this concept in programs that make flu shots available in supermarkets and airports, and in the growing number of “retail clinics.”

Since retail outlets at malls and supermarkets serve many people with similar needs, “retail clinics” make sense; they provide routine and preventive care such as health screenings, vaccinations, and dissemination of public health information. These clinics have the additional advantage of locating preventive services where healthy people frequently go, rather than requiring them to make less convenient trips to their physician’s office.

CVS is installing MinuteClinics in its pharmacies. Walmart has such clinics at over 50 locations and is planning thousands. These clinics, originally developed to provide routine treatment for minor problems such as strep infections, now also offer preventive services, including vaccinations, cholesterol and other tests, and school physicals.

What is the payback in widespread retail clinics?

To be sure, a retail setting offers convenience and efficiency in implementing preventive care via large volume, simplicity, and a focus on healthy people. Whenever a large number of similar tasks are to be performed, the medical system is well-served by moving such care from physicians’ offices or hospitals to the retail setting.

Besides easing the burden on doctors—freeing them for complex tasks for which their time is now too limited—the separating-out of mass care from individual care would streamline high-volume processes. This would address the excess costs that arise when the performer and the task don’t match.

More people would gain access to routine care due to the convenience of location and avoidance of the need to make appointments, travel to the doctor, and wait.

What is clear is that making preventive healthcare more accessible can reduce illness, further easing the burden on the medical system. It is time for the medical and insurance communities to embrace this solution.

Next: Step II: Empower team competition.

For Further Reading

1. Y. Bar-Yam, Improving the effectiveness of health care and public health: a multi-scale complex systems analysis. American Journal of Public Health 96, 459-466 (2006).

2. Y. Bar-Yam, Making Things Work: Solving Complex Problems in a Complex World 239 (NECSI Knowledge Press, Cambridge, MA, 2005).

3. J. Lambreaw, “A Wellness Trust to prioritize disease prevention” (Brookings Institution Discussion Paper 2007-04 (2007).

4. J. Groopman, How Doctors Think (Houghton Mifflin, New York, 2007).

5. H. Baskas, “More airports adding flu shots for fliers,” USA Today, October 15, 2008.

6. K. Yarnall, K. Pollak, T. Ostbye, K. Krause, J. Michener, Primary care: Is there enough time for prevention? Am J Pub Health 93, 635-641 (2003).

7. M. K. Scott, Health care in the express lane: the emergence of retail clinics (California Healthcare Foundation, Oakland, 2006).

8. R. Bohmer, The rise of in-store clinics — threat or opportunity? NEJM. 356, 765-768 (2007).

9. U.S. Preventive Services Task Force Guide to Clinical Preventive Services (Publication 07-05100, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, 2007).

10. Y. Bar-Yam, Multiscale variety in complex systems. Complexity 9, 37-45 (2004).

11. M. Maciosek, A. Coffield, N. Edwards, T. Flottemesch, M. Goodman, L. Solberg, Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 31, 52-61 (2006).

12. Promoting healthy lifestyles. (American Medical Association, Chicago, IL, 2008).

13. A. Mehrotra, H. Liu, J.L. Adams, M.C. Wang, J.R. Lave, N.M. Thygeson, L. I. Solberg, E.A. McGlynn, Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Ann Intern Med. 151, 321-328 (2009).

14. R. Rudavsky, C.E. Pollack, A. Mehrotra, The geographic distribution, ownership, prices, and scope of practice at retail clinics. Ann Intern Med. 151, 315-320 (2009).

15. M. Thygeson, K.A. Van Vorst, M.V. Maciosek, L. Solberg, Use and costs of care in retail clinics versus traditional care sites. Health Affairs 27, 1283-1292 (2008).

16. A. Mehrotra, M.C. Wang, J.R. Lave, J.L. Adams, E.A. McGlynn, Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits. Health Affairs 27, 1272-1282 (2008).

17. Deloitte Center for Health Solutions, Retail Clinics. Facts, Trends, and Implications; Update and Implications (Washington, DC, 2008 & 2009)

Writing and Editing Credits

Yaneer Bar-Yam with Shlomiya Bar-Yam and Nancy Cohen

Image Credits

Mall: photo of Lakeside Mall, Macomb County, Michigan

Vaccination: "Boy Receives Vaccination" James Gathany, Centers for Disease Control and Prevention

Formatting Credits

Alex M. Rutherford, Andreas Gros, and Taeer Bar-Yam


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