This November, as the weather started to turn toward winter, EUA invited The Advisory Board to give their “State of the Union” presentation to our healthcare clients, as well as our entire group of healthcare design professionals. Ethan Brosowsky, Senior Director of Educational Service for The Advisory Board, presented the material, and I moderated a discussion session afterward. Here are a few actionable ideas from our conversation.
Beware the Disruptors
Top of mind for many people in our industry is the risk of disruption, and Ethan dug into this topic right away. As an example, he offered a range of possible near- and long-term strategies for Amazon, including: “next-generation retail pharmacy,” based on its acquisition of PillPack; “global healthcare logistics specialist” with the ability to drive down costs on medical supplies and devices through scale and efficiency; “consumer-focused technology platform,” leveraging the technology behind Alexa to manage patient EHR data; and even “primary care operator,” with the physical assets to set up retail clinics in Whole Foods stores and the technology to provide telemedicine services.
Alongside potential threats from Amazon, Google, Apple, Uber, and others, two other external forces are putting pressure on our industry: payment reform, at both the federal and state levels, and increased activism among employers searching for ways to control their costs. (Stay tuned, for example, for results of the Amazon-Berkshire Hathaway-JPMorganhealth venture, led by Atul Gawande, which aims to reduce costs for 1.2 million employees and could be an incubator for scalable strategies.) Incumbents are racing to adjust their cost structures in response, in many cases through mergers and acquisitions. Ethan highlighted four important “mega-mergers” from the past year: Cigna-Express Scripts, CVS-Aetna, Walmart-Humana and Optum-DaVita. The unifying themes among these are the increase in retail healthcare footprints, integration of pharmacy benefits, and partnerships between healthcare providers and insurers; in short, the rise of the hospital-less integrated delivery network as a strategy to provide affordability and convenience.
Invest in Alternative Care Sites
As I was talking with clients before the start of Ethan’s presentation, a guest of ours who offers administrative consulting services to physicians said to me (perhaps anticipating the discussion above): “Hospitals will be obsolete in 10 years.” This statement may have been slightly provocative in terms of the proposed timeline, but the underlying sentiment is not new. Surprisingly, after laying out the case for the hospital-less IDN, Ethan went on to say: “The Advisory Board is betting on hospitals.” Had I heard that right? Didn’t that contradict everything that went before?
As we unpacked this during our discussion, I came to interpret Ethan’s statement to mean “betting on hospital systems.” We talked about the opportunities in the new landscape for high performers and how they can turn the following risks into upsides:
- Systems who own an extensive primary care network, and have no partnerships with existing convenient care providers, can leverage this capability into low-cost alternative sites of care for at-risk patients
- Those who own a multispecialty network, and have no partnerships with existing competitors, could become the efficient specialist referral of choice for payers
- Organizations who have invested heavily in acute care sites, rather than alternative sites, could work toward becoming the low-cost acute care provider of choice
- Those who have yet to differentiate their acute care offerings on the basis of quality or unique services could also work toward becoming the low-cost acute care provider of choice, or build a truly differentiated clinical service
The bottom line, I believe, is that incumbent health systems have the clinical expertise that the disruptors lack and can leverage this expertise to their advantage. Of course, a combination of the above strategies with continued investment in alternative care sites, as well as continued exploration of potential partnerships and operating agreements, is likely the best recipe for success. At EUA, we are seeing most of our clients move quickly to develop their ambulatory service lines. Our recent off-campus projects include Ambulatory Surgery Centers, Cancer Care, Physical Therapy, Diagnostic Imaging, Urgent Care, and Primary and Specialty Care clinics.
Respond to Evolving Physician Needs
We wrapped up our session with a discussion of physician engagement, a topic a little closer to home for many of our client executives. Ethan cited research that found that 90 to 95% of graduating medical students have no desire to be independent physicians; entrepreneurialism may be giving way to a desire to focus on patient care rather than managerial duties in an era of increased administrative complexity. This is good news for systems looking to build their group of employed physicians, but it also means that systems must actively recruit and compete for talent. Gawande’s recent piece in the New Yorker on physician frustrations with adopting EHRs is a great and relevant read. He describes physician burnout as having reached "epidemic levels" and notes that EHR may be a major contributing factor.
We believe that good design can be a recruitment tool – but what do doctors really want in a facility? At EUA, we believe it’s important to go directly to physicians to seek their input on critical design decisions, especially those that impact their interactions with their patients. Based on Gawande’s piece, as well as our own observations, it seems that physicians want a place that enables them to see patients efficiently when they’re in clinic, and one that facilitates face-to-face interaction when discussing the patient’s care plan.
In our recent designs for primary and specialty care clinics, we have explored many options for increasing efficiency, as well as facilitating face-to-face interactions in the exam room. At the Wisconsin Institute of Urology, we used a full-scale mock-up to test a variety of furniture, equipment, and IT configurations with the physicians and nurses. The team eventually settled on a layout that achieved their goals of clear wayfinding, minimizing staff footsteps, and optimizing the patient experience during their encounter.
That’s a lot to reflect on for the past year, and we know that 2019 will bring more challenges. I hope you have a relaxing holiday season, and I look forward to picking up the conversation in the new year!
Paul Stefanski, RA, LEED AP, EDAC