Is Trickle-Up  Innovation a Way out of the Health Care Swamp?

Reverse innovation or trickle-up innovation is a term referring to an innovation seen first, or likely to be used first, in the developing world before spreading to the industrialized world… Reverse innovation refers broadly to the process whereby goods developed as inexpensive models to meet the needs of developing nations, such as battery-operated medical instruments in countries with limited infrastructure, are then repackaged as low-cost innovative goods for Western buyers.

Wikipedia

August 10, 2012 -  The word “trickle” is trickling into the language of  politics and health care .  Liberals use “trickle-down” economics” to denounce  Romney economics.  Conservatives counter with “trickle-down government,” as in “You didn’t  build that” to criticize Obamacare.

Now there’s a new kid on the trickle block – “trickle-up innovation” to describe how simple innovations developed at the grass-roots level in the U.S. and in developing nations  can save on costs while getting the job done that needs to be done to preserve and improve health.

This approach is clearly outlined in the summer 2012m issue of The Stanford Social Innovation Review.   The United States spends far more money on health care than any other country, yet Americans are not  among  healthiest  people in the industrialized world. Simply spending more money is not the answer.

What’s needed is a creative new approach, such as the one outlined by MacArthur Genius Grant winners Rebecca Onie and Paul Farmer, along with coauthor Heidi Behforouz, in “Realigning Health with Care: Lessons in Delivering More With Less,” the cover article in the summer issue of Stanford Social Innovation Review. Onie is founder of Health Leads, Inc, which allows physicians to “prescribe” access to social services, and Farmer is a legendary figure in improving health outcomes in Haiti and other third world countries.

Here are excerpts from the article:

Realigning Health with Care

“The misalignment between the expansive goal of “health” and a cramped definition of “care” has cost the United States untold lives and treasure. Yet realignment is in reach: Through expanding the scope of health care, the place where it is delivered, and the workforce that provides it, the US health care system could significantly improve health outcomes and reduce inefficiencies.

·         Everyone knows the US health care system is in crisis. We spend far more on health care than any other nation—a breathtaking $2.6 trillion annually, according to a 2011 report by the Kaiser Family Foundation. The US Department of Health and Human Services estimates that health care expenditures will be 25 percent of US GDP by 2025, twice what many developed countries currently expend.

·         Models of health care delivery that improve patient outcomes while cutting costs are cropping up with increasing frequency. Further, in the last 20 years, public, private, and philanthropic entities have invested billions of dollars learning how to build health care systems despite extreme resource constraints, too few doctors, and overwhelming poverty. Some of these models have been pioneered in the United States; many come from other countries.

·         Indeed, the innovation we need is right in front of us. In his 2009 best-seller The Checklist Manifesto, surgeon and journalist Atul Gawande eloquently argues that medical “innovation” is less about discovering new interventions than it is about properly executing the ones we already have. 

·         In the developing world, health care providers must adapt to limited financial resources, scarce health care professionals, underdeveloped health infrastructure, and widespread poverty—all in settings with huge burdens of preventable and treatable diseases that too often go untreated.

·         What is being delivered when we say “health care”In the United States, we usually mean medicines, diagnostic tests, and hospital services. We rarely include basic necessities, such as food, housing, or heat, even when their absence leads to ill health.

·         Most care, in countries rich and poor, is delivered outside the formal health system—in homes and communities. Caregiving is for the most part the preserve of families and intimate friends, and of the afflicted person herself or himself Health providers can leverage such local networks of care by integrating health care into patients’ daily lives, and locating health resources where (and when) patients are most likely and able to access them. Moving health resources from clinics—often remote from patients in distance and culture—into homes and communities, or alternatively, bringing critical social resources—which are themselves instrumental to the efficacy of medical care—into hospitals and clinics, can improve access to and quality of health care. 

·         Widening conceptions of product and place demands also widening the definition of health care provider. Nontraditional medical workers are critical to health systems, especially those in resource-constrained environments. They are less encumbered by competing clinical care priorities, possess firsthand understanding of patient culture, community, and experience, and are often more aware of nonmedical local resources that may improve patient care.

·         US health professionals, in contrast, tend to take one of two (largely ineffective) approaches. Most often.health care providers bracket patients’social needs, deeming issues like hunger, poor housing, and indebtedness beyond the scope of short patient-doctor visits. Some primary care clinicians do try to address patients’ basic social needs. But they quickly become overloaded, and addressing such needs crowds out other key modalities of their clinical practice.

·         Practicing at the “bottom” of one’s license can be expensive for taxpayers, is draining (or demoralizing) for clinicians, and causes patients to wait longer to get timely and effective care. Task shifting—or task sharing, to be more precise—can reduce such inefficiencies. Although evolving financial incentives in the US health care system, including increased risk sharing between insurers.

·         Health Leads  (A Boston-based health care organization conceived anf founded by Rebecca Onie)  widens the frame of health care, broadening the health care product to include connections to basic resources like food and housing; broadening the health care place by using hospital waiting rooms to make resource connections; and broadening the health care provider, by integrating college volunteers into the health care team. 

·         Located in primary care and prenatal clinics in six US cities, Health Leads empowers doctors, nurses, and other health care providers to ask the previously un-askable questions: Are you running out of food at the end of month? Do you have safe housing? These providers can then write “prescriptions” for food, housing, heating assistance, or other basic resources, just as they would for medication. The patients take their prescriptions to the clinic waiting room, where Health Leads’ 1,000-member corps of college volunteers works side by side with them to secure these resources. The volunteers’assistance is often as straightforward—but critical—as tracking down an agency phone number, completing a benefits application, or bridging language barriers. 

·         The United States is poised for a primary health care transformation. The health care system is in crisis, driven chiefly by escalating costs, suboptimal health outcomes, scarce primary care resources, and rising poverty. At the same time, thanks to grassroots innovation—and, in some cases, US-based funding—a growing number of health providers around the globe have learned to deliver high quality health care at low cost. Now we need to align our resources in the United States to bring this knowledge fully to bear in saving dollars and lives.

·         And the time is, indeed, now. The dual, market-driven imperatives to cut costs and improve outcomes—and the inevitable shift away from fee-for-service reimbursement to shared risk between payers and providers—create an unprecedented receptiveness to new approaches in care delivery. The United States has a window of opportunity to seize this fluidity in the sector to broaden the health care product, place, and provider and thereby expand access, improve outcomes, and cut costs. This approach demands, as Gawande says, that we innovate by properly executing the solutions we already have—and that the private, philanthropic, and public sectors invest in these evidence-based models of health care delivery.

·         Poverty and poor health are linked, or that health resources are more likely to be used if they are offered conveniently to the recipients, or that a goal as complex and ambitious as “health” can be effectively pursued only with a multidisciplinary team of workers. The challenge is implementing these insights effectively and on a large enough scale to reap the synergies they promise.

·         But what’s new is this: The US health care system has reached a tipping point. Reform is in the air across the sector, with primary care especially positioned for transformation. “Never let a good crisis go to waste,” said Winston Churchill. The practices of countries that have improved health despite scarce resources are ready for adoption and adaptation. And the US health care ecosystem, including public, private, and philanthropic resources, is ripe to leverage this crisis to implement solutions that will improve it.

“Health” is a bold, expansive aspiration. Let’s make sure that what we call “health care” is broad enough to get the job done.

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