Barriers

Barriers to what consumers want:

• Health Care Not Consumer Friendly: Consumers want health care that fits their needs. The design of many health businesses, technologies and procedures is inconvenient, embarrassing, and even painful to the patient. The health care system frequently requires patients to alter their behavior to conform to the demands of how care is organized and services are delivered. Consumer centered health services would reorient care to better fit how people live their lives.

• Patients Not Empowered: Consumers want choices about where, when, and how they get their health care as well as what they receive. They want to be active participants in their care. However, the health care system often dictates the time, place and conditions under which care is provided, leaving the patient powerless. Consumer centered health services would recast the patient as a consumer of health care services, not as a passive receiver.

• Complex, Expensive Medicine: Consumers want a more affordable health care product with value they can clearly identify. Their definition of health success is based on how quickly their infection ends or how little their chronic disease interrupts their life. Visiting the doctor by itself does not constitute success (getting the job done). Consumer centered health services would be outcome-driven, focusing technology and procedures on efficacy, convenience and speed in improving patient health.

• Monopolies of Knowledge: Consumers want access to the best care available. But much of care currently is provided by a limited pool of highly trained providers using complex technologies. This puts it out of reach for too many people because of the skill necessary to provide the care and the cost that comes with highly-skilled providers. Consumer centered health services would shift labor and control in ways that everyone would win.

Insights

Insights represent new standards emerging from practical applications that are meant to inspire and guide the innovation process. Note that although the best solutions probably involve more than one insight, in the mosaic below we have chosen to emphasize one specific innovative aspect. If you would like to learn about the multiple innovations behind each solution, please click on each name in the mosaic for a fuller description of each case.

• Democratize Access: Many innovations in health care tend to put specialty services ever further out of financial reach of the uninsured and indigent. Publicly supported services for those who cannot pay are in chronically short supply and tend to focus on primary care for the masses at the expense of costlier specialty needs of the few. Disruptive innovations, by contrast, take advantage of efficiencies that can make health care services more affordable and available to a broader population.

• Simplify through Technologies: Many innovations in health care involve technology that introduces additional costs as well as complexity, making health care even less accessible. Disruptive innovations, by contrast, use technology to simplify an existing treatment or diagnostic process.

• Center Consumer in Business Model: Many innovations in health care organize services in ways that are at the expense of the consumer or ignore the consumer altogether, Disruptive innovations, by contrast, are designed to do the job that consumers want done.

• Push Work Down the Chain of Command: Many innovations in health care require ever more specialized training and use sophisticated and expensive technology. Disruptive innovations, by contrast, delegate skills and enable the technologies and procedures to be used by non-specialists or even by patients themselves, creating real value throughout the system.

  
  

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  Short Descriptions of Mosaic Cases

  1.   Revamped nursing homes as structured small group residences to promote independent living for elderly people

     
     Organization: Green House
     Location: USA
     Website: www.greenhouseproject.com
     Mosaic Insight: Democratize Access
     Mosaic Barrier: Patients Not Empowered

     The Green House Project is creating a new way of living for people who need long-term care by replacing traditional institutional facilities with family-size homes of 10 residents or fewer, each with private bedrooms and baths around a common area.

     Developed by geratrician William H.Thomas and driven by the principle of healthy human development, the Green Houses promote independent living for senior residents. Staff members blend the roles of caregiver, homemaker and friend. Called "shahbaz" ("powerful falcon" in Farsi), they are certified nurse's aides who train an additional 200 hours in first aid, cooking, listening, team building and other skills. In a reversal of typical nursing home hierarchy, shahbaz manage the household, supported by nurses and therapists. Costs are kept low, savings coming from streamlining jobs, shifting resources and keeping overheads down. Monthly fees are on par with the national average monthly fee in a nursing home and Medicaid covers the cost for 90 percent of the residents.

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  2.   Cataract surgery for the poor: high patient volume reduces per-patient cost and improves patient outcomes

     
     Organization: Aravind Eye Hospital
     Location: India
     Website: www.aravind.org
     Mosaic Insight: Democratize Access
     Mosaic Barrier: Complex, Expensive Medicine

     Aravind Eye Hospital, a WHO Collaborating Centre for Prevention of Blindness, provides a range of eye care services from primary to tertiary eye care through its network of five eye hospitals with a combined bed capacity of 3,500.

     Aravind is not merely a chain of hospitals; its supplies and resources reach the unreached through structured community outreach programs, a center for manufacturing eye care supplies/consumables, development of well trained human resources, active promotion of evidence based eye care through a dedicated research institute, an international eye bank, and a postgraduate institute of ophthalmology.

     Aravind's mission to eliminate needless blindness maintains its commitment in providing high quality, compassionate eye care to all those in need, using the multi-tiered pricing approach. One of the key factors for its effectiveness is in adopting appropriate systems and processes that provide affordable eye care services either at subsidized or no cost.

     From its inception in 1976, Aravind has screened 21.7 million outpatients and performed around 2.8 million sight restoring surgeries. Its high volume of surgery makes it the largest eye care provider in the world. The Aravind model is being replicated globally through Lions Aravind Institute of Community Ophthalmology (LAICO), Asia's first eye care training and capacity building institute.

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  3.   User groups of physicians focus on minimally invasive angiography

     
     Organization: Angio Clubs
     Location: USA
     Mosaic Insight: Simplify through Technologies
     Mosaic Barrier: Complex, Expensive Medicine

     The establishment of the angio clubs fulfilled in part the need for members to share information and to learn from each other. They were important as a means for members to educate and alert each other to the incidence and nature of complications.

     Frank discussions at the angio clubs played a critical role in the early development and acceptance of angiography as a safe diagnostic method. Soon it became obvious that geographic expansion of the city-based angio clubs would bring more angiographers together to share the latest advances in the new field. This led to the organization of regional meetings.

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  4.   Unites caregivers in "clubhouses" for people with motor disorders, letting patients make the decisions

     
     Project Leader: Pedro Chaná
     Organization: Center for the Study of Motor Disorders (CETRAM)
     Location: Chile
     Mosaic Insight: Center Consumer in Business Model
     Mosaic Barrier: Patients Not Empowered

     Pedro Chaná, a medical doctor and an Ashoka Fellow, has evolved a health delivery model that empowers patients with chronic motor disorders by putting them in a one-on-one, inclusionary partnership with doctors that topples the top-down doctor-patient relationship. Together, through a network of "clubhouses," they work out treatment and rehabilitation, thereby democratizing medical professionals' approach to long-term care that forces doctors to become highly sensitive and caring of the individual needs of patients. In a total overhauling of the traditional system, the doctor is no longer the singular expert and patients are no longer subservient recipients of treatment.

     The patients and their families are encouraged to educate themselves about the illness and treatment options and to make informed, consensual choices along with their doctor. Moreover, now clubhouse members are able to demand and receive medical attention from a whole range of specialists like neurologists, psychiatrists and occupational therapists-something that would have been unthinkable earlier.

     Through Chaná's Center for the Study of Motor Disorders (CETRAM), patients associations are also collectively buying expensive drugs at cost price and procuring unavailable drugs and selling them through CETRAM clubhouses at 30 percent less than the market rate. All patients have equal access to quality treatment and payment is determined by the financial situation of the patient.

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  5.   Retail-based clinics where physician assistants provide walk-ins

     
     Organization: Minute Clinics
     Location: USA
     Website: www.minuteclinic.com
     Mosaic Insight: Center Consumer in Business Model
     Mosaic Barrier: Complex, Expensive Medicine

     Located in mini-malls and discount stores and sporting catchy slogans such as "You're Sick, We're Quick," a new wave of retail health clinics is transforming the American health care landscape by offering quick, convenient diagnosis and prescriptions for a range of common illnesses.

     Well-laid down protocols ensure swift, accurate care thereby reducing inappropriate use of hospital emergency facilties for basic medical services. For the un- and under-insured, the clinics offer an alternative route to access primary care services. The retail clinic model relies on low prices, quick throughput of patients, minimal staff, and propriety software systems that can reliably manage selective medical diagnoses and information of a short list of simple procedures. Most are staffed with non-physician practitioners (typically physician's assistants or nurse practitioners) who provide basic medical care, including writing prescriptions, for a limited number of conditions.

     Visits take approximately 15 minutes. Patients with significant or unusual medical concerns are referred to outside physicians.

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  6.   Organized group insurance for the self-employed that costs 30% to 40% less

     
     Organization: Working Today
     Location: USA
     Website: www.workingtoday.org
     Mosaic Insight: Center Consumer in Business Model
     Mosaic Barrier: Monopolies of Knowledge

     In the prevalent employer-centered benefits model of workplace USA, Working Today is creating safety nets for the rapidly expanding army of independent workers through a portable benefits delivery system with benefits linked to the individual rather than the employer.

     Working Today's members work in industries ranging from media and technology to domestic childcare-and due to their non-traditional employment arrangements, they do not have access to employer-based benefits, such as health insurance. It enables independent workers who previously remained unisured or severely underinsured to access group-rate health insurance plans in New York State priced at less than one-third of the average price in the individual market. Thus, by pooling risk and uniting interests, it has eliminated the costly barriers to insurance for the self-employed.

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  7.   Tiered pricing that provides low-cost glasses through high-volume, cost-efficient specialty clinics

     
     Project Leader: Rebeca Villalobos
     Organization: Asociación de Servicios Médicos para el Bien Social (ASEMBIS)
     Location: Costa Rica
     Website: www.asembiscr.com
     Mosaic Insight: Push Work Down the Chain of Command
     Mosaic Barrier: Health Care Not Consumer Friendly

     Rebeca Villalobos has developed a participatory system of eyecare that enables Costa Ricans of all classes to access affordable medical services ranging from basic vision tests to sophisticated surgical procedures. By reconceptualizing the field of eyecare, this Ashoka Fellow is ensuring the affordability of vision care for even the poorest.

     Her program incorporates large-scale diagnosis, low-cost glasses, high-volume, and cost-efficient specialty clinics to detect and correct vision and health problems on a huge scale. Thus far, over 1,900,000 patients have benefited from the intervention.

     Villalobos plans on adapting her model of participatory vision treatment to other health fields, including hearing and dental care, where citizen-based initiatives and community partnerships could substantially reduce the incidence of preventable illness in Costa Rica and around Latin America. ASEMBIS started in 1991 with a total capital of $700, and it has taken them four years to attain self sustainability.

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  8.   Web-based company reviews doctor and hospital bills for consumers

     
     Organization: My Medical Control
     Location: USA
     Website: www.mymedicalcontrol.com
     Mosaic Insight: Push Work Down the Chain of Command
     Mosaic Barrier: Patients Not Empowered

     Web-based company My Medical Control (MMC) is ensuring that consumers no longer remain helpless victims of the arbitrary opacity in medical care pricing by reviewing doctor and hospital bills for clients to ascertain they are being charged a fair price.

     It is estimated that overall out-of-pocket medical expenses for consumers will rise more than five percent every year. Already, over 12 percent of working-age adults have out-of-pocket medical costs greater than five percent of their annual household income. MMC reviews that part of the consumer's bills are not covered by their insurance plans. It compares the medical claim or bill against a sophisticated medical claim reimbursement database (their "fair-pricing" database) to ensure that the consumer is being "charged" what the provider generally "accepts" for the same or similar services. If there is a discrepancy between the "charged" amount and the generally "accepted" amount, the Company intervenes with the medical provider on behalf of the consumer, and attempts to settle the bill for the more "reasonable" amount. If successful in settling the consumers' claim for less, MMC charges a professional service fee that is a small percentage of the saved amount. If it cannot save the consumer money or judge the claim to be "fair and reasonable", there is no charge. The turn-around time for the service (from submission to result) is a quick 15 minutes.

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  9.   Creates alternatives to expensive medical equipment for neonatal care

     
     Project Leader: Dr. Jose Americo Silva Fontes
     Location: Brazil
     Mosaic Insight: Push Work Down the Chain of Command
     Mosaic Barrier: Complex, Expensive Medicine

     With "humanizing, simplifying, and preventative" as his credo, pediatrician Jose Americo Silva Fontes, is providing affordable, high-quality neo-natal care in Brazil's resource-strapped public hospitals.

     Fontes, an Ashoka Fellow, replaces costly hi-tech equipment with inexpensive, everyday household and hospital items modified to turn them into lifesaving devices. Tupperware containers and glass water bottles morph into oxygen hoods for babies; phototherapy units are constructed from track lighting, cotton netting, and dimmer switches; a pacifier with a eardropper inside allows a baby with clogged nasal passage to draw in air. At the hospitals, he works with nurses and mothers to train them to apply his principles to the care of the children. Hospitals, clinics, and even families are thus able to have the benefits normally thought possible only from equipment (usually imported) that costs many times more.

     Fontes has now created a foundation to continue developing and distributing new low cost equipment across Brazil and internationally.

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  10.   Monetizes motherhood, certifying mothers to become paid home-health care workers

      
      Project Leader: Krzysztof Liszcz
      Location: Poland
      Mosaic Insight: Push Work Down the Chain of Command
      Mosaic Barrier: Monopolies of Knowledge

      Ashoka Fellow Krzysztof Liszcz, a doctor of medicine, has developed a home-based program of care for children with cerebral palsy wherein mothers are trained to function as their own children's caregivers. His program reduces state expenditures in half while certifying the mothers so that they can earn money with their new skills. The para-professional therapist mothers not only earn salaries while tending to their children, but are also provided with insurance and a pension after twenty years.

      Liszcz's training methods are geared to accelerate the development of these children's cognitive and motor skills, sorely missing in Poland's overburdened and bureaucratic institutions that are unable to help the children realize their full potential. The program also addresses the challenges of economic hardship that inevitably arise in a scenario where one parent of such children (usually the mother) is pressed to opt out of the job market so as to do unremunerated care-giving work at home. Or, conversely, financial necessity forces parents to institutionalize their children in the full knowledge that the three 40-minute physical therapy sessions per week per child that the state provides is inadequate for the child's development.

      At the core of his program are regional Self-Support Circles that bring together families, professionals and volunteers who collaborate to provide each group of families with counseling, peer support, child care and training. This system is designed to provide options and tools to parents that make them independent of the traditional institutional medical care system.

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