The healthcare industry is ripe for disruption and transformation. According to McKinsey & Company, U.S. pharma is “in a state of flux.” Seismic shifts are happening, from significant merger and acquisition (M&A) activity to pharmacy store closures to changes in strategic partnerships between major health insurers and pharmacy benefit managers (PBMs), and the seemingly inevitable entry of Amazon into the market. Moreover, the healthcare ecosystem continues to face challenges as it attempts to comply with regulations like HIPAA and HITECH.
During this period of change, McKinsey’s research establishes three imperatives for healthcare businesses to consider. The first is to pursue business models that deliver a lower total cost of care for consumers and employers. The second involves leveraging data aggregation and big data analytics to generate insights and create value, and the third is to put the consumer at the center of everything by creating innovative ways to bring more consumer-driven insights and actions into the business.
The growth in digital health indicates that many businesses are acting on these imperatives and are finding commercial success. The digital health sector currently is estimated at $86.4 billion and is predicted to grow by almost 30 percent year-over-year through 2025. But with such a vast and complex industry like healthcare, it is challenging to appreciate the realities of digital disruption without drilling down into specific sub-sectors and profiling some of the disruptors that are in the process of altering their landscapes.
Following are some examples of how the “value pool” is shifting in this industry, resulting in cost savings for patients through the elimination of waste.
Pharmacy benefit management value pool shifts by removing inefficiencies
Pharmacy benefit management (PBM) includes third-party administrators for prescription drug programs at insurance companies, businesses, self-insured employers and government health plans. PBMs have a vast market valuation of $368 billion, as of 2018, within the U.S. healthcare system and an expected annual growth forecast of more than 9 percent.
Despite the size of the market, however, many PBMs do not have the technical sophistication to flourish in the digital world, which has given rise to companies such as RxSense. Previously a PBM, RxSense pivoted to meet the real-time needs of customers by providing a business-to-business (B2B) digital platform for the whole PBM industry. Its goal is to bypass problems with legacy PBM systems, including a lack of innovation, inefficiencies, inflexibility and challenges around accuracy and transparency.
The next step beyond digitization for players such as RxSense will be the application of artificial intelligence (AI) and machine learning technologies to further increase administrative efficiency, drive down costs and, ultimately, improve clinical outcomes.
There’s no shortage of news stories and think pieces outlining the ways regulations have hurt healthcare in the U.S., from spending to physician burnout. (Notably, there’s also no shortage of stories claiming the opposite.) Regardless of this debate around benefits vs. protections, there are a few non-negotiables–like doing everything possible to prevent a breach. Patients are entrusting organizations with their health data in way that they don’t understand and failure to protect their data can lead to clear and direct harm (via embarrassment, or identity theft–healthcare records are considerably more valuable than credit card numbers, or discriminatory practices from employers).
As a result, many engineering and IT departments in the healthcare industry accept a reduced level of function and service in order to avoid costly penalties. Unfortunately, this also harms their customers because of reductions in the effective level of care.
New, smaller and more agile healthcare companies are encountering these legacy environments. For example, they may only be able to get a “data dump” every week (or month) from partners, and many of the organizations they partner with are exporting data in formats that are expensive to work with, like retro formats from ’70’s and ’80’s mainframes.
This is a problem in an era where customer service has become the crux of any business. The healthcare providers that don’t change because of the regulatory risk will not be able to build a quality consumer product, even for internal platforms. And internal products have to be consumer grade, now, as well. We’ve talked with doctors who changed jobs because their hospital adopted a medical record system that was bad.
The truth is that newer technologies can allow healthcare systems to do both, but fear of transition and possible compliance violations are holding progress back. And that’s why, in 2018, we can get a probe to Pluto but we can’t send over health records within minutes of a patient’s request. To scale a new infrastructure and workflow for the largest healthcare systems is a huge project, so changes with clear benefits–like DevOps practices, iterable software development and a constant release schedule–are met with resistance. Here are three ways healthcare systems can start digging themselves out of this:
#1: De-silo. Most have heard this advice, but acting on it is different for every organization. At a high level, most healthcare IT departments have a compliance group, an infrastructure group, a security group and a product engineering group, all working independently of each other. The compliance group (usually lawyers and analysts who often lack technical expertise), need ongoing conversations with engineering and security so that the latter understands the compliance requirements. In return, those teams can help the compliance group understand trade-offs, what’s realistic, anticipated roadblocks, etc.
Security teams tend to develop their own compliance controls internally and often don’t tie back their controls to actual regulation and policy. The infrastructure engineering teams are concerned with implementing compliance and also care that the system is always available to customers. The product engineering team wants to build something of value that keeps customers safe and meets their needs. All of these different priorities require complex tradeoffs, making it unsurprising that systems don’t fulfill customer expectations. To de-silo here, compliance teams should act as consultants to product teams and help them understand the compliance requirements. Additionally, consider merging the defensive security and infrastructure teams into a single team with a safety and availability mandate; high-quality infrastructure and high quality security end up at the same place.