"Local" Healthcare Isn't What It Used To Be

We live in a world where bigger is better.  Our phones are getting bigger.  Our televisions are getting bigger.  Our biggest companies are getting bigger (at least if they are in tech).  Our cars, especially SUVs, are getting bigger.  Our houses are getting bigger.

And, in healthcare, our hospitals are getting bigger, our physician practices are getting bigger, our health insurers, pharmaceutical companies, and medical device manufacturers are all getting bigger. 

It's time to question whether any of this is good. 

We're seeing it happen with retail malls already.  As has been widely reported, all across the country malls are re-purposing, dying a slow death, or dead already.  With Amazon and other online shopping giving seemingly limitless choices, easy price comparisons, and insanely quick home delivery, why bother to fight the traffic and the crowds, only to trudge through the mall in hopes of finding what you're looking for?

But retail shopping is not quite dead.  We're already seeing the one-time anchor tenants of malls starting to resize, as well as "big box" stores.  They making their existing stores smaller and opening up new, smaller stores.  "Retailers are realizing that they have to downsize stores to save money,” one retail expert told The Washington Post.

Healthcare is finally starting to realize it is, in fact, a retail business, and there is a trend for healthcare to locate in malls, part of the many ways malls are reinventing themselves.  But, of course, healthcare may be too late on this curve too.

Another, and perhaps better, example of how retail is changing was outlined recently in The Wall Street Journal.  Despite the much-ballyhooed increase in urban living, it's not all downtown condos for millennials and empty-nesters.  Millennials, it turns out, like the advantages of urban living but still want homes in the suburbs.  So suburban real estate developers are starting to incorporate retail in alongside new homes. 

"The single biggest challenge is walkability," Steve Patterson of Related Development LLC told WSJ.  People want schools, shopping, restaurants close by.  Another developer, Mark Culwell of Transwestern Development Co., added: "The resident comes home, relaxes a bit and then goes to a store half a block away without having to get back in the car." 

Unless, of course, he/she has to go to the doctor or, even worse, a hospital. 

Along these lines, NEJM Catalyst just published an interesting article by Jennifer Wiley, Nir Harish, and Richard Zane, three physician leaders.  In it, they make the case for "decentralization of health care."  As they say:

The traditional delivery model of a hospital as the “hub” of care, with a single centralized facility providing every facet of disease management and treatment, from specialized surgical cancer care to routine eye exams and chronic blood pressure management, should be questioned

Their argument is based around two key premises.  One is that "in the not-too-distant" future, health care systems will get paid for keeping people healthy.  Procedures like surgeries will go from being "golden gooses" to being an expense.  Having a big building with high fixed costs will be big disadvantage.

The second premise, of course, is that we have so many technologies that allow for more at-home options.  As they describe it, "...an entire industry is increasingly leveraging the power of “mobile health” to connect patients with providers."  E.g., portable electrocardiograms, x-rays, and ultrasounds.

They cite the example of Johns Hopkins' Hospital at Home program that "admits" patients to their own homes, and "are linked to the hospital through remote monitoring technology and receive daily visits from a physician and other caregivers (e.g., nurses, respiratory therapists, and physical therapists)."

A key to this away-from-the-hospital future may be what the authors call "community paramedicine," highly trained paramedics and EMTs whose "ability to deliver specialized tertiary care virtually in a patients’ driveway is changing the landscape of traditional care delivery models."

Finally, they point out a trend towards "microhospitals," whose 20 - 30 beds "rely heavily on virtual consultation and protocol-driven care for patients with specific care needs."  Construction Dive says they have a "big future," noting their convenience factor (although, typically for health care, regulation may prove a barrier). 

A similar trend is happening with nursing homes, such as in the Green House Project, which The New York Times just profiled.  Instead of the big, institutional nursing homes many of us picture, Green House's facilities are smaller and try to suit themselves to residents' preferences rather than vice-versa.  Susan Ryan, senior director for the Green House project, told NYT: "We try very hard to say, ‘This is home for life.'" 

This is not to say that either microhospitals or Green House nursing homes are revolutionizing their industries yet, but they may be pointing the way. 

Imagine suburban housing developments with microhospitals, Green House-type nursing homes, retail clinics, and doctors' offices all located within walking distance, alongside those stores, restaurants, and schools, not to mention all the online options that are and will increasingly be available.  Wouldn't you want to live there?

As long as most of us can remember, people have said "all health care is local."  What that usually meant, though, was "come to us."  Come to our hospital, our office, our facility, mainly because it was the closest to where you lived, and never mind what was available at the next hospital or in the next city, state, or even country. 

Increasingly we're going to see that health care may, indeed, be local, but it's going to mean what we can do in our homes or, at least, within walking distance from our homes.  Health care institutions and professionals who can't adapt to that are going to go the way of malls, dying or having to reinvent themselves. 

"Patient-centered" is a nice slogan, but it can't just be a slogan and it can't just be something that is applied in the usual places of care.  To make it a realty, it means truly centering health care around, and integrating with, where and how people actually live.   

As long as people are local, which even Ray Kurzwell thinks may be at least another thirty years, healthcare will be as well.  But who is giving that care, how, and where: those don't have to be -- and won't be -- "local" in the way they have been.