This book prescribes an innovative and disruptive solution to avert the threat of rising healthcare costs. The authors identify the reasons why healthcare is in a ‘terminal illness‘, citing stark statistics of spiralling healthcare budgets. The book proffers wide ranging suggestions to control health spending, recommendations which would completely restructure healthcare, and drastically alter the relationship of medical practitioners and their patients.
The authors assert that the major cause of escalating healthcare spending is the intuitive nature of medical practice. Imprecise medical diagnostic and therapeutic processes put a heavy burden on health budgets, a huge cost which the authors argue will inevitably fall when precision medicine gains ascendancy (page 43-50). This transformation will enable the making of diagnoses by cause rather than by pattern recognition (pages 151-152), and result in standardised and personalised treatments (page xxii and 42). The authors observe how molecular and genetic techniques are already fine tuning the diagnostic accuracy of infectious diseases and blood disorders. They illustrate how precision medicine is already enabling better prediction of treatment response with examples of chronic myeloid leukaemia (CML) to imatinib, and HER2-positive breast cancer to trastuzumab (page 50).
The authors explore the requirements for transiting from intuitive to precision practice. At the centre of these are disruptive technologies, innovations which convert complex, intuitive tasks into routine, rule-based processes. The authors demonstrate how this ‘commoditization of expertise’ reduces costs by enabling lesser skilled personnel carry out more activities. The authors give several examples of such disruptive technologies in other industries such as the microprocessor, MP3 , and YouTube (page xxi, xxxv). They point out that disruptive technologies are typically pioneered by start-ups, and rejected by the established order (who inevitably become victims of the disruption). Characteristically, the disruptions set in suddenly, and they completely replace the old system (pages xlvi-xlvii).
What will disruptive innovation imply for medicine? One prediction is the disruption of professions, a ‘natural and necessary step’ in making healthcare more affordable and accessible (page 111). This, for example, will result in nurse practitioners and physician assistants assuming ‘increasing levels of responsibility in patient care’, taking over tasks currently carried out by physicians (pages 65 and 357). General practitioners, on the other hand, will disrupt hospital specialists, aided by online expert systems such as Sermo and SimulConsult (pages 25 and 125). As technology reduces the need for invasive surgery, the authors expect procedures will shift away from surgeons to internists, as has already happened with angioplasty (page 65). Other changes include the decentralisation of medical investigations because cheaper and simpler technologies will enable point-of-care diagnostics and in-office imaging (page xl).
A major healthcare consequence of disruptive technologies will be the carving apart of hospitals, structures which have ‘conflated fundamentally different business models whose metrics of output, value, and payment are incompatible with one another’ (page xxi). The authors expect hospitals to be split into three types of independent disruptive business models which they call solution shops, value-adding process businesses, and facilitated networks (page xxvii). The book examines how these will reduce the huge cost of running hospitals, citing examples of health institutions which are already operating according to these models such as Shouldice Hospital for abdominal hernias (pages 23, 83) and the National Jewish Medical Centre for lung diseases (page 80). Beyond hospitals, the book predicts disruption to influence the healthcare reimbursement system, the pharmaceutical supply chain, the clinical trials and drug development processes, research funding, and health care regulation.
Of great importance is the book’s prediction that disruption will result in a greater involvement of patients in their healthcare. Patient involvement is already central to the management of many chronic diseases such as diabetes, heart failure, coronary artery disease, asthma, and depression, all examples of the shifting responsibility of care from physicians to patients (page 122 and 149). The book explores this exhaustively, making recommendations such as applying facilitated networks more widely to patient care, with illustrative examples of Alcoholics Anonymous and the Restless Legs Syndrome Foundation (pages 165-166).
The book spells out, in blunt terms, the crisis facing healthcare. It outlines how this can be effectively, but radically, solved. The authors comprehensively analysed the current state of healthcare across the spectrum of medical practice. Their arguments are as compelling as their writing is lucid and down-to-earth. They predict the inevitable disruption that will come with the evolution to precision medicine, and they make innumerable helpful and detailed prescriptions. The book is quite long, the introduction alone taking up 50 pages. This is partly because the authors repeatedly make their points, a practice that helps to simplify what is clearly a complex subject.
This is probably the most important book predicting the future of medicine. It focuses on current problems, and offers solutions that have been universally effective in other industries. Healthcare practitioners should be aware of the message of the book, and I highly recommend it to all doctors.
Publisher, Place, Year: McGraw Hill, New York, 2009
Number of Chapters: 11
Number of Pages: 441
Star Rating: 5