From One-To-One To One-To-Many: Rethinking Health Care Relationships In The Digital Age

April 6, 2020 – For centuries, the dominant form of medical care has been based on a one-to-one relationship between a physician and an individual patient: The patient presents with an illness, and a physician diagnoses the ailment and prescribes treatment. In contrast, with a one-to-many model of care, a health care professional can manage a group of patients using remote monitoring tools and patient-generated data, and identify those requiring in-the-moment care. One-to-many care can take multiple forms, but a core concept is management by exception, in which patient data is tracked and reviewed regularly and the provider only intervenes on patients who need attention at any given moment.

Why Now?
Care delivery in the US often involves multiple clinicians, and managed care is creating an even more complex maze for patients to navigate. In addition to a set of health care providers, it’s not uncommon for patients to have nurse case managers, behavioral health specialists, and pharmacists recommended by the payer and even the employer. The average Medicare patient sees two primary care physicians and five specialists per year, not including nurses and ancillary staff; those numbers are even higher for those with multiple chronic conditions. Perhaps not surprisingly, chronically ill patients who experience greater care fragmentation have lower quality of care and higher rates of preventable hospitalizations.

Today’s prevailing one-to-one model is not only complex and dangerous for patients, it is also unaffordable and unsustainable. A key driver of rising health care costs in the US is declining labor productivity—the output of visits, tests, treatments, and surgeries per cost—as more and more health professionals are required to care for the same patients. By 2020, we will have more people older than age 60 than younger than age 5, which will only place greater demands on an already constrained health care workforce and heighten the urgency to identify new models of care.

The Promise Of One-To-Many
Three recent developments suggest that a one-to-many care model offers promise. First are efforts to create payment mechanisms that support greater accountability for a population of patients, such as accountable care organizations and other value-based care models.

Second is growing evidence that patients respond well to group models of care, particularly for chronic conditions driven by individual behaviors, in which group social support can improve engagement and accountability. Thus, one-to-many models that leverage peers and community resources can be more cost efficient and more effective.

Third is the widespread availability of smartphones and connected devices, which create myriad opportunities to automate and task shift administrative and low-value services. For example, routine tasks can successfully be completed via technology, allowing health care providers to focus on human interactions with their patients.

There is already considerable evidence of the promise of one-to-many care. Remote monitoring programs—in which patients transmit their health data to a dedicated telemonitoring nurse overseeing many, sometimes hundreds of patients—have been shown to reduce six-month mortality in congestive heart failure patients. The Diabetes Prevention Program, which demonstrated that one-on-one intensive health coaching could prevent up to 58 percent of cases of type 2 diabetes, has been effectively applied to a group class model in the community setting and a virtual, group health coaching app.

How To Shift The Model
What are some examples of technologies that can be used to move to a one-to-many model? The most tangible is remote monitoring of chronic illness, discussed above. To conceive of others, we only need to look at how services are delivered in virtually every other sector.

What are some examples of technologies that can be used to move to a one-to-many model? The most tangible is remote monitoring of chronic illness, discussed above. To conceive of others, we only need to look at how services are delivered in virtually every other sector.

• Chatbots are now used as the mode of initial contact to help businesses better serve their customers. These “conversational agents” include a mix of natural language processing, machine learning, and live operators to enhance and customize a consumer’s experience. As their ability to triage humans improves, one can easily envision chatbots used in health care delivery.
• Social robots, physical devices that often have a humanoid appearance, are getting more sophisticated and able to perform basic care functions (medication or medical appointment reminders) and can provide needed social support. Particularly for our aging population, social robots can help to address issues of isolation and loneliness, which have been shown to increase risks for a variety of physical and mental conditions, and even death.
• Artificial intelligence may paradoxically strengthen doctor-patient relationships and build trust by automating tasks that distract physicians from patients, such as documentation and coding, and eliminating low-value services that further fragment care. For example, image recognition may soon enable primary care physicians to screen for diabetic retinopathy themselves, limiting referrals to ophthalmologists only for screen-positive patients.

In addition to the adoption of telehealth strategies and broader applications of emerging technologies, other changes will be required to support a shift to a one-to-many care model, including:

• Payment models, including innovative value-based and shared risk models, are still largely organized around individual physician services or individual patients, perpetuating the one-to-one model.
• New reimbursement codes that allow clinicians to document work performed in the context of a one-to-many care delivery model are off to a slow start. The American Medical Association’s new virtual health CPT codes will require wider adoption by private payers.
• Rather than presenting technology as a new way of delivering care, medical students are still taught to do everything themselves (patient history, physical exam, lab interpretation, counseling, follow up). More efforts, such as the Association of American Medical Colleges’ work to integrate telehealth competencies into medical training, are needed if we aim to change the care paradigm for the next generation of physicians.
• Finally, key to any wide-scale health care transformation is clinical workflow. Physicians, by nature, find it hard to delegate clinical tasks; and electronic health records (EHRs) are largely seen as a barrier to changing clinical workflow. As physicians gain more comfort with team-based care, and EHRs more readily connect with other technologies and share data with outside parties, the EHR will become a tool for physicians to manage populations and provide one-to-many care.
• One-to-many care models must be tailored to the right clinical and social circumstances, but, in many contexts, one-to-one care will always be required. For example, many patients with complex needs will still be managed by multiple specialists, and face-to-face interactions with their providers will be necessary.
• While physicians have traditionally provided in-person care to one patient at a time, they have long considered themselves as serving defined groups of patients and communities. With the right set of technologies, delivery models, and policy changes, one-to-many care offers an opportunity for physicians to embrace their dual roles as individual healers and public health-minded leaders.

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