It's been a short (or is it long?) ten years since the September-October 2000 issue of Harvard Business Review published the article "Will Disruptive Innovations Cure Health Care? In that piece, the authors (Clayton Christensen, Richard Bohmer, and John Kenagy) argued that powerful institutions fight simpler alternatives to expensive care because those alternatives threaten their livelihoods. If history is any guide, the authors posited, the health care system can be transformed only by creating new institutions that can capably deliver lower-cost, higher-quality, and more convenient care, rather than attempting a tortuous transformation of existing institutions (read that as acute-care hospitals) that were designed for other purposes. They went on to comment that our major health care institutions have together overshot the level of care actually needed or used by the vast majority of patients. Has much changed during the intervening decade? And, it set me to wondering, should palliative care be considered a disruptive innovation?
James Cleary, MD (palliative care chief at the University of Wisconsin Hospital and Clinics), referred to hospital-based palliative care as a disruptive innovation in a 2008 keynote address to an audience of hospice and palliative care professionals. And as one considers that disruptive innovations "sneak in from below", start by meeting the needs of "less-demanding customers", and enable "less-expensive professionals to do progressively more sophisticated things in less expensive settings", the case sharpens for palliative care as a disruptive innovation.
So why doesn't palliative care always feel like a disruptive innovation? Surely one reason
is that new organizations to do the disrupting have not sprung forth the palliative care sector. That is likely to change soon, as the formation of Accountable Care Organizations (ACOs), encouraged by the health reform bill, reconfigure the delivery models of health care over the next decade. And within the ACOs will emerge Advanced Palliative Care Organizations (APCOs), proven to be successful models for improving delivery of chronic and late-life care because their characteristics encourage processes of care that are:
Timely - delivered to the right patient at the right time (early identification of patients)
Patient-centered - based on the goals and preferences of the patient and family, articulated in goals of care conversations
Beneficial and effective - demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)
Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).
I invite our readers to weigh in. Is palliative care a disruptive innovation? And if so, what steps will best advance its influence within the larger health care system?