A few years ago (likely when the idea of paying for “bundles” of care came into fashion) somebody introduced the concept of patients and healthcare delivery systems interfacing in an “episodic” fashion.

Roughly speaking, the idea was that patients interact with the healthcare system for defined periods of time as they become sick and that these “episodes” are interspersed by periods of wellness (or relative wellness as in the case of stable chronic disease). When they get sick, patients enter and then move between elements of care— say, between providers, hospitals and pharmacies— until they are discharged home to await the next episode of illness.

Slide1
Patients have a baseline of “wellness” interspersed by periods where they become ill and enter the healthcare system for “episodes” of care

You can plot out patient interaction with the healthcare system over time.  Patient forays into the healthcare system can be spikes– brief and simple such as a single visit for a sprained ankle, for example.  Other times, in cases of more severe illness, patients enter the system and require more and longer care of various kinds.  

My observation has been that, partly depending on their level of sophistication and size, various healthcare systems are focusing their efforts at vastly different parts of the graph.

The smallest simplest healthcare providers (say independent doctor’s offices) are focused on delivering “visits” of care.  They are trying to optimize their systems to move patients into and out of the office.

More sophisticated systems, including most large and  integrated healthcare systems spend their days linking various visits of care to provide a coordinated approach to an episode of illness—by, say, optimizing the interfaces between the various resources needed to care for a heart attack: for example, the various doctors, ED, lab, rehab therapy, pharmacy and the like under one electronic record.

Most of us in healthcare delivery are spending our days doing this kind of work, but my impression is that the most entrepreneurial and innovative health companies are focussed on a whole other area of the graph. I’m referring to CVS, Apple, Walgreens and American Well, for example. 

Slide2They’ve staked claim to the valleys between episodes of illness—the blank-canvas 95% of the time that patients spend generally well.  Their strategy isn’t integration of care, but the medicalization of relative wellness.

You can see this phenomenon in the growth of retail and urgent care clinics (evaluating and reassuring patients with poison ivy, rashes and colds previously managed at home); in the growth of do-it-yourself testing at pharmacies (at home DNA sequencing and drug screens) and in the rise of apps, including physiologic and activity monitors.

It’s an interesting trend: on one hand, prevention and wellness live in the valleys between episodes of care and there is enormous opportunity to improve health and reduce healthcare costs by focusing on improving prevention and lifestyle modification.   On the other, we’re witnessing the stimulation of demand for healthcare, often for issues which– in our parent’s age– were managed through basic self-care, restraint and common sense.  It’s something to watch.