Sink or swim: Why we need to reimagine our outdated care delivery model

By Kulleni Gebreyes, M.D., MBA, principal, Deloitte Consulting LLP

Emergency room doctors are a bit like lifeguards at the beach. When a lifeguard spots someone in a life-threatening situation, they dive in and pull the person to shore. As a former ER doctor, I can attest that there is nothing more inspiring or rewarding than intervening in someone’s life when they are in dire need of help. But it can be truly disheartening to witness preventable suffering or avoidable loss of life.

After 10 years in emergency medicine, I was on a first-name basis with several patients. These patients often came to the ER with the same recurring conditions…and my team and I team performed the same invasive and intensive treatments, which would not have been necessary if the patient had received the right upstream interventions.

Case in point: Several of my regular patients suffered from congestive heart failure (CHF)—a chronic illness where fluid can build up in the heart, lungs, and even feet. By the time I saw some of these patients in the ER, they might have gained 20 pounds of fluid and were literally drowning in their own bodies. We would need to intubate them, put them on a ventilator, drain the fluid, and clear their airways. Unless we can get to the root cause of an illness (e.g., poor diet, lack of exercise), or improve how diseases are monitored and managed, patients like these will continue to show up in the ER in distress, and families will mourn preventable deaths and face overwhelming medical expenses.

CHF, asthma, diabetes, and hypertension are all examples of ambulatory care sensitive (ACS) conditions. These are illnesses that typically do not require hospitalization if managed properly. For example, a care team that helps a CHF patient monitor their weight from home might be able to alter the patient’s health trajectory by calibrating medication doses if weight suddenly increases, or by teaching the patient to avoid certain foods. Such interventions will hopefully be part of the health delivery model of the future and will focus holistically on the patient, rather than responding to acute conditions.

What is the care delivery model of the future?

Our existing care models were built around either the location of care (e.g., hospital-based, retail, virtual health), the type of physician (e.g., primary care, specialty care), and the payment model (e.g., fee for service). These models are often misaligned, obsolete, and rife with redundancies and inefficiencies.

In June, Deloitte surveyed 307 US consumers in an effort to understand priorities, preferences, and perceptions about health care. We wanted to find out how they received care today, and how they expected it might be delivered in the future. We expect the health care delivery model of the future will be built around the goals and needs of individuals, populations, and patient cohorts (e.g., people with similar conditions or circumstances). In addition to addressing physical and mental health, the care model of the future can incorporate emotional, spiritual, social, and even financial health (see charts below). The location of care, the type of physician, and the payment model can be designed with services and offerings required to meet the needs and goals of the consumer. In this consumer-centered model, both the location of care and the provider of care could transition away from the traditional medical facilities and hospital campuses. The hospital of the future would then likely become a part of health ecosystem rather than being the primary setting for care. 

As we described in our paper on the future of health, we expect hospitals will be smaller, more specialized, and used for complex surgeries and emergency services. More routine procedures will likely take place in outpatient facilities, physician offices or even in the patient’s home. My colleague Summer Knight recently wrote about the idea of hospital at home, which has increased since the COVID-19 pandemic began. Similarly, some physician practices are reporting that virtual health use has increased by as much as 70%, according to results from the Deloitte 2020 survey of US physicians.

COVID-19 is accelerating change

Health systems are beginning to reinvent themselves in response to the COVID-19 pandemic, which has altered human behavior and accelerated many of the changes that we outlined in our future of health paper a year ago. Consumers have come to expect care delivery to come to them. Adoption of virtual health, for example, is now five years ahead of where we initially thought it would be. It can give patients a level of safety and can create a more seamless care experience.

We will still need emergency rooms and ER doctors in this future care model. But if we could design a care model that provides upstream care that includes education and advocacy, we would potentially reduce the number of people who suffer from an illness and could more effectively support patients. In this model, the care team could put the patient on a path where they don’t need an emergency intervention, saving their lives much less dramatically but more effectively.

Teaching someone to swim (or giving them a lifejacket) before they head to the beach reduces the likelihood that a lifeguard will need to dive in to help. Similarly, a new care model that focuses on wellness, prevention, and addresses the root causes of disease could keep some people from needing emergency services. Instead of relying on ER doctors to save lives, health coaches—like swim coaches—could keep patients from getting in over their heads.

Acknowledgements: Amy Gammelgard, Neal Batra, Ralph Judah, Gaurav Mehta

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