Book Review

The Innovator's Prescription: A Disruptive Solution for Health Care

N Engl J Med 2009; 360:2038-2039May 7, 2009

Article

The Innovator's Prescription: A Disruptive Solution for Health Care
By Clayton M. Christensen, Jerome H. Grossman, and Jason Hwang. 441 pp., illustrated. New York, McGraw-Hill, 2009. $32.95. ISBN: 978-0-07-159208-6

In Aravind Adiga's novel The White Tiger (New York: Free Press, 2008), the narrator describes his weekly visits to the liquor store. On the wall, in dripping red paint, were the names of hundreds of liquor brands and their prices. But he knew what he wanted. He was there to buy whiskey for his master, who drank only one kind. He had to jostle with dozens of other customers who milled around the counter, yelling to get the store clerk's attention.

MinuteClinic promises a better experience. Founded in Minnesota in 2000, the company has clinics in about 525 retail stores in 24 states and offers to treat medical problems that range from athlete's foot to strep throat in 15 minutes. The company's slogan is “You're sick. We're quick.” It lists a handful of common illnesses, tests, and vaccines along with the associated charges, which are under $100 for most services. Nurse practitioners provide care to patients, and like Adiga's liquor store customers, the patients often walk in knowing what they need.

According to Clayton Christensen and his coauthors, MinuteClinic is disrupting traditional business models by bringing services closer to users at lower cost. Nurse practitioners are delivering care that was formerly the bailiwick of family physicians. The physicians' loss is society's gain — in the form of convenient and affordable care for patients.

Underpinning such innovations are advances in technology that convert “intuitive medicine” to “rules-based care.” Problems that once needed intensive diagnostic work by highly trained physicians can now be handled by assistants who use algorithms that incorporate the expertise of physicians. Patients with diabetes can check their own glucose levels and manage their condition with insulin. Quick tests for strep throat allow nurses to provide care. Primary care physicians, meanwhile, are taking on tasks that previously were performed by specialists. And specialists are encroaching on each other's turf — angioplasty, for example, has enabled cardiologists to displace cardiac surgeons.

Christensen first studied disruptive innovation in the disk-drive industry, a field he selected because a friend described disk-drive companies as the “closest things to fruit flies that the business world will ever see.” Geneticists like to study flies because of their short life span. The rapid rise and decline of waves of disk-drive technology helped Christensen formulate his theory of innovation, which he has applied to fields as diverse as education and telecommunications. Along with his coauthors, Jerome Grossman and Jason Hwang, he intends The Innovator's Prescription to be a road map for health care reformers as they tackle the problems of rising health care costs and poor access to services in the United States.

Physicians often denounce the commercialization of health care. Arnold Relman, former editor-in-chief of the Journal, has said that the U.S. health care system is failing because “we in America have allowed ourselves to believe that healthcare is just another industry, that the provision of medical care is a business, and that medical services are an economic commodity that is best distributed by market forces.”

Christensen and his colleagues believe that such arguments are self-serving — an attempt by physicians to preserve incomes and dysfunctional service models. Their prescription: let people choose the health care they need and use health savings accounts, coupled with high-deductible insurance, to pay for it. They foresee further fragmentation of service delivery and hope that electronic health records will be “the connective tissue that draws and holds together the individual elements of our care.” They urge integrated, fixed-fee providers such as Kaiser Permanente to expand nationwide, to act as orchestrators of health care reform, and to create conditions that allow disruptive innovations — such as the use of lower-cost caregivers — to take root and thrive.

The Innovator's Prescription will delight supporters of consumer-directed health care, will alarm physician associations and proponents of nationalized health care, and will enlighten all.

Karunesh Tuli, M.D., Ph.D.
310 Mockingbird Ln., South Pasadena, CA 91030
karuneshtuli@hotmail.com