The Innovatorís Prescription: A Disruptive Solution for Health Care, Christensen, Grossman and Hwang, McGraw Hill (2008).


It is a commonplace that the U.S. healthcare system is broken, but the discussion often degenerates into a debate about who is responsible. This book takes a different approach, focusing on what is wrong with the healthcare system and needs to change so it can work better.


The proposed solution is to discard the current fee for healthcare service model, in which healthcare providers are systematically paid to treat illness without recompense for fostering welfare, and create a three-track system:


1. Fee for service would continue to apply to diagnostic services, where due to the nature of the patient's condition and the state of medical knowledge -there is a high need for intuitive investigation versus results-based treatment for conditions that are well understood. (The process described brings to mind episodes of House, a TV show in which a brilliant but irascible doctor challenges a team of colleagues to find the problem before the patient dies.)


2. Fee for result would apply for treating conditions that are well understood and have a clearly defined solution --colonoscopies, laser eye surgery, implantation of stents, etc.


3. User networks for patients with chronic conditions/ unhealthy practices to learn how they can help themselves and be motivated to do so.


As is pointed out again and again, disruptive changes will be needed to get from A to B. Thus, hospitals must be redirected to focus on diagnostic services and cede provision of standardized care and wellness coordination to specialized clinics and other agencies. Primary care physicians (the traditional "family doctor") should concentrate on diagnostic services at a lower level rather than acting as "gatekeepers" for referrals to specialists.


Enabling changes in reimbursement rules, health insurance arrangements, and medical record keeping are spelled out in detail.


When the dust settles, there will be fewer hospitals (with the survivors focused on enhanced diagnosis, like the Mayo Clinic), fewer medical specialists (who currently operate in narrow niches, often without a full grasp of a patient's situation), more primary care physicians and nurses with augmented responsibilities, a new model for pharmaceutical companies that focuses on targeted medications for precisely defined conditions versus the development and marketing of "blockbuster" drugs that only help a fraction of the users and require enormously expensive mass clinical trials, and a lot of medical work performed by less highly trained personnel with better diagnostic tools.


Andy Kessler presented an analogous vision in "The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor," Harper Collins (2006). His book is very entertaining, but this one covers the ground in a more disciplined and comprehensive manner. I would recommend "The Innovator's Prescription" for anyone who is seriously concerned about the current healthcare system.


Doctors, hospitals, and other healthcare providers cannot make the needed changes on their own, because they do not control all the levers. Having the government take the lead is said to be problematic, for reasons that are dispassionately stated and I happen to agree with. The authors suggest that the best candidate entities for leading the transition to healthcare in the new mode might be employers that profit from the good health of their employees. Then there is the intriguing possibility of expanding the role of integrated healthcare providers, e.g., Kaiser Permanente.


Let's hope our country chooses the right path.


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