Managing across conflicting business models

Recall that over the past few weeks, we’ve been sharing our framework for thinking through the path forward for traditional health systems, as they look to drive value for consumers. We began by describing today’s typical health system as “Event Health”, built around a fee-for-service model of delivering discrete, single-serve interactions with patients. We then proposed the concept of “Episode Health”, which would ask the health system to play a coordinating role, curating and managing a range of care interactions to address broader episodic needs. Finally, last week we shared our vision for Member Health, in which the system would re-orient around the goal of building long-term, loyalty-based relationships with consumers, helping them manage health over time. In this broader conception, the health system would “curate” a network of providers of episodes, and events within those episodes, and ensure that the consumer (and their information) moves seamlessly across care interactions.

As we mentioned earlier, most successful health systems will play a combination of these roles at the same time, pursuing strategies that allow them to manage episodes while moving closer to a risk-based model that gives them the ability to create a member value proposition for consumers. As the graphic below illustrates, however, that pluralistic approach will create some important tensions for the health system.

Episode Health is fundamentally a fee-for-service approach—these systems will become specialists in delivering specific episodes (e.g., joint replacement), and will seek to drive increased volume through their model. That may not be an ideal outcome on the Member Health side of the business, however, where more episode volume could mean lower profitability, given the capitation-like incentives of “owning lives”. That’s a tension that faces every health system with its own health plan—even systems that have been pursuing both strategies for years still find it challenging to manage across conflicting incentive models. (Witness Intermountain Healthcare, long a pioneer of the Member Health model, which is in the midst of a structural overhaul to allow it to better manage across the two businesses.)

Recognizing the tensions inherent in shifting away from Event Health toward more comprehensive approaches is critical for organizations looking to make the leap forward. Health systems run the risk of being doomed by their own success if they don’t take steps to realign operating structures, administrative and clinical incentive schemes, and even market-facing branding to navigate the complexity inherent in running parallel business models.


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