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How splitting the bill impacts disruptive innovations in healthcare

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Sep 8, 2016

In healthcare, it is very difficult for a patient to be overserved by the functionality of a diagnostic or therapeutic procedure (distinct from overtreatment and unnecessary care). If two tests are viable and covered by insurance, rarely would a patient prefer an important diagnostic test that is correct 85% of the time to one correct 95% of the time, regardless of the actual price. The price-insensitivity inherent in a third-party payment system makes it easier for patients to afford the current best option instead of an inferior one, because their out-of-pocket payment is similar either way. This is a case of moral hazard, where patients and physicians are less likely to guard against risk because they are protected from its consequences.

An analogous example of moral hazard from the restaurant industry is when a table of 10 pools the bill and splits the total evenly among each member of the group. If I prefer the $35 steak entrée instead of the potentially disruptive $25 chicken entrée (lower cost, high in protein, less fat, albeit less flavor), but I’m only willing to pay $28 for the steak, I am not likely to pay for it individually as it is $7 over my budget. However, when I pool the price as a part of the 10 person group, the $10 dollar difference in price is split evenly among the 10 members ($1 per member). As a result, the effective price of the steak entrée is a much more tempting $26 – an easy buy at $2 under my $28 budget. Thus, my choosing to purchase the cheaper and inferior option is less likely when pooling the bill.

A similar system of pooling risk is the norm in our healthcare system, as insurers pool premiums and use the premiums collected to purchase healthcare goods and services on behalf of their members. This seems good for patients, as it is easier to afford the best available treatment at the price of a marginal out-of-pocket payment as opposed to the actual cost. However, this creates a problem for potentially disruptive innovations. Disruptive technologies begin as cheaper and lower quality solutions that improve with sustaining innovations. Over time, they upend incumbent technologies when they meet the qualities demanded by mainstream consumers. The question then arises: How can disruptive innovations gain a foothold market in an industry such as healthcare where inferior goods and services are so readily disregarded in the first place?

One strategy becomes clear, and has positive implications for healthcare access, as one understands the difference between low-end and new-market disruptions.

Limits on low-end disruption in healthcare

A low-end disruptive good or service competes against an incumbent, seeking to gain a foothold market among customers who are overserved. Overserved customers are those willing to sacrifice some of the top-of-the-line performance demanded by high-end consumers, for a product that performs the same job with a less unsettling price tag. While many disruptive products lack the sophistication or quality of an incumbent, the disruptive product may better meet the needs valued by low-end consumers with features like portability, simplicity, or low maintenance costs.

An example of low-end disruption from the automobile manufacturing industry is Toyota and their sequence of vehicles’ market ascension in the United States (the Corona, Corolla, and Camry). Toyota’s innovative production processes allowed them to price their simplistic and dependable vehicles at a lower price point. Ultimately, they grew to compete for market share among the likes of Ford and GM as they moved up-market (eventually reaching higher-end customers with the Avalon model and Lexus line of vehicles).

The restaurant example above demonstrates just one of the ways in which the deck is stacked against low-end disruptive innovations attempting to gain a foothold market in healthcare, as pooling risk through a third party minimizes the cost advantage an inferior but potentially disruptive good or service may have over incumbents. Thus, low-end and potentially disruptive options that may actually cost less than incumbent options appear no more affordable to patients, despite advantages in actual cost. This decoupling of price and affordability combined with low-end market-entry regulation by the FDA makes low-end disruption an improbable feat in healthcare, and is a force pushing innovators to pursue costly sustaining innovations upon incumbent technologies as opposed to disruptions.

The potential of new-market innovation in healthcare

On the other hand, new-market disruptive products and services compete against nonconsumption, as opposed to incumbents. Nonconsumers are those who have not historically purchased the incumbent good or service. In healthcare, common nonconsumers for a typical procedure are those in health plans lacking coverage for the procedure and those who have a pre-existing condition or circumstance preventing them from utilizing the procedure. Thus, new-market innovations in healthcare should help patients make progress against the same health condition as the incumbent good or service, but reach patients in circumstances that prevent them from utilizing the incumbent technology.

In our restaurant analogy, this strategy would entail focusing efforts to sell the chicken dish at a different table with customers in different circumstances (a new market, so to speak). For example, a group who does not eat red meat for any number of potential reasons (moral, religious, or health) would gladly opt for the chicken entrée as an alternative source of protein and sustenance over the steak entrée. This foothold market, bound by different circumstances, outside of the mainstream, is where innovative chefs can gain feedback and work to improve their product by adding new spices or pairing the chicken with different sides in an effort to eventually catch the eye of mainstream steak entrée purchasers and convert them into chicken entrée purchasers.

New-market disruption is the path of less resistance for new and potentially disruptive technologies in healthcare today, as the decoupling of cost and affordability in third party payment models leave low-end disruption an unlikely feat. For an in-depth look into how a disruptive technology can use a new-market strategy to gain a foothold market in healthcare, stay tuned for my blog next week.

Ryan Marling

As a Research Associate at the Christensen Institute, Ryan works on Jobs-to-Be-Done case research as it pertains to healthcare. He’s also currently co-chair of the HealthIMPACT committee within Boston Young Healthcare Professionals.

  • Michael Devonas

    Great article!! You’ve described really well why low end disruptions will be challenging in healthcare. However, I think the key here is defining what kind of nonconsumption, because it seems to me that not all of it is equal. The FDA / CMS and other regulatory bodies’ reach is large, and pretty much covers anything that deems to have medicinal or health advisory impact (see FDA’s ban on 23andme’s DNA testing kit). Even folks in circumstances who are currently don’t consume or are dramatically underserved due to failure of the autocratic pricing system fall within their regulatory oversight and the self-same barriers will apply. So, it begs the question as to what those new market circumstances in fact are. The argument could be made that the entire “sick care” industry will make low end disruption very difficult, absent maybe the most commoditized of services (see vaccines) or lower cost AND lower risk procedures (angioplasty vs. open heart surgery). I would rule out therapeutics almost across the board (in part because the way they are priced today rewards almost exclusively sustaining innovation), while diagnostics likely have a better shot. Two possible places to look are: the wellness or real “health care” industry focused on disease prevention and general well being (diet, exercise, etc.) and “reverse innovation” or the idea that impoverished countries have a higher tolerance for disruptive type innovations in the true absence of any options. Finding places where technological core allows for simpler, worse on traditional metrics but better along a disruptive performance trajectory is probably the key. Defining jobs to be done that originate in those places prior to crossing over into consumption of the “sick care” industry when the struggle reaches a certain magnitude might make the most sense … It spends a lot of time / energy in nonconsumption outside regulatory / coverage control before becoming a job that requires a high cost product that is highly regulated and undergone a lot of sustaining innovation to solve, so targeting it beforehand with new technology cores / business models as we traditionally understand disruptive innovation to function could in theory work better. Finally, the ACA seems to have created a “retreat” of coverage from basic services by health insurers (the logical result of increasing the strain of moral hazard, as you’ve written, by requiring coverage of pre-existing conditions, preventative screening, etc.) and so this may create more nonconsumption space than previous plan design had allowed for, excepting the still present pressure of the FDA around most services. But some may escape it.

    • Ryan Marling

      Thanks for the thoughtful response! A lot of food for thought in there. You’re right on that it is the business model of our ‘sick care’ delivery system that makes low-end disruption very difficult. Even in some cases of lower cost AND lower risk innovations it can be difficult for providers to adopt a new innovation due to how entrenched value networks typically are for provider systems and how high switching costs can be in such interdependent and overhead intensive institutions. Adoption for many of these providers are also dependent on an outside entity, being the payer, and a lot of financial risk based on the provider’s ability to coordinate (or plead) with the payer in a way to squeeze meaningful profit out of the lower cost procedure.
      You make great points about the FDA as they ultimately are the gatekeepers of the low-end of the market, and are not likely to let what one would consider a ‘low-end’ product through. Not only that but low-end products (typically earning small margins) are overlooked as not likely to quickly overcome the financial barrier to market entry.
      Job-To-Be-Done research as you mentioned is needed to identify these new markets. My article takes advantage of jobs already identified by the ‘sick care’ system, and targets those who’s job isn’t being met. To take advantage of other areas of nonconsumption, delivery systems’ business models need to ultimately change.
      I think the research can still be done on jobs in the U.S. as opposed to other countries, as the findings would likely be that reactive solutions are being used to satisfy jobs instead of proactive solutions. Its likely best to hold the pressures of circumstance in which the jobs arise as constant as possible (think about how different the milkshake job would look if the case took place in a country that predominately commuted on 2 wheeled bikes and motorcycles as opposed to 4 wheeled cars), albeit some individual jobs are universal and cross country borders and income gaps. The idea of skipping the generation of ‘sick care’ in these countries is still very intriguing!