For many years, credentialed experts have acted as gatekeepers for specialized knowledge and service. Attorneys have been gatekeepers for the legal system, universities for higher education, publishers for information and scholars for research findings. These experts have shaped available services, granted access to those services and plotted the course for consumers to navigate the services. In some cases, the gatekeeper’s standing is enforced by law and regulation. In most cases, the gatekeepers are involved in managing the flow of funds.
Control is a core purpose of the expertise model. For nontraditional competitors, the expertise model creates a high barrier by defining the rules and playing field. The more entrenched the traditional model — for example, the university system or the legal system — the higher those barriers to entry.
For consumers, the presence of the expertise model promises a certain level of quality and consistency. The expertise model, however, limits access to alternative models and price points that might be more suited to individual situations and preferences.
There is no better example of an entrenched expertise model than the U.S. health care system. Intensive training, credentialing and specialization establish who has the necessary expertise. Rules and regulations establish who can treat which conditions. Physician gatekeepers largely control access to the system. Physicians and provider organizations structure the care process, which is applied in a similar fashion to everyone. Regulations limit new competitors and limit consumer access to alternative models.
Enter the internet
If a core concept of the expertise model is control, a core concept of the internet is freedom. The internet taps into the deep desire among people for freedom of choice and their resistance to forces that would constrain choice. The internet largely ignores the playing field established by the expertise model, and where a regulatory barrier exists, internet-based companies push ahead and dare regulators to keep up.
The result is unprecedented choice and opportunity to contribute to a worldwide pool of knowledge and services.
The internet rewards organizations that help people tap into the most desired aspects of this collectivity — shopping, information sharing, social interaction — with the greatest convenience. That is the basis of the radical business models of internet giants like Amazon, Google and Facebook.
For many consumers in the internet era, the limitations imposed by the expertise model can be annoying, or even philosophically or economically unacceptable.
Encyclopedia Britannica and Wikipedia are a good example of this dynamic. In the past, if you wanted quick access to concise, accurate and vetted information, you used the Encyclopedia Britannica. It had 100 full-time editors and more than 4,000 contributors. The final print edition, published in 2013, had 40,000 articles. The business model was sales to institutions and individuals.
In contrast, Wikipedia was launched in 2001. About 140,000 people contributed during just a recent 30-day period. More than 30 million people are registered users with the ability to contribute. Access is free. Currently, the English Wikipedia has more than 5 million articles. If Wikipedia were to be in print, it would contain 2,423 volumes the size of each Encyclopedia Britannica volume. Wikipedia is the sixth most popular website in the world. Such is the awesome strength of the social collective powered by the internet.
Of course, consumers still have options for getting expert-generated and expert-vetted content, also through internet sources. In certain situations, that type of content is required. For everyday use, however, Wikipedia serves an extremely broad audience with diverse and sufficiently trustworthy information.
Health care’s expertise model
Similarly, the needs and wants of health care consumers are not monolithic but depend on individual preferences and situations. For example, in the case of critical illness or injury, a high level of expertise is extremely desirable. In some situations, patients may not be in a position to do anything but put themselves in the hands of experts. And some patients by disposition prefer to play a more dependent role.
A serious vulnerability of health care’s expertise model, however, lies in applying it more or less uniformly to all consumers and situations. When a baby has an ear infection in the middle of the night, a working parent wants a rapid diagnosis and prescription; that parent wants the baby to get better but also wants to avoid having to miss work the next day for a lengthy doctor’s office visit. A working mother of two likely would desire a very different approach to prenatal care than a first-time mother. Often these consumer “wants” are in direct conflict with health care’s traditional expertise model.
The entrenched nature of the expertise model also has led to deficiencies in customer service: the need to make appointments by phone, hard-to-understand bills, inconvenient hours, difficult-to-access information and repetitive paperwork.
The expertise model also can fall short in results. The U.S. ranks 11th out of 11 developed nations in healthy lives, cost-related access, equity and efficiency, and sixth out of 11 in care coordination, according to the Commonwealth Fund.
Attacks on the model
The practices of health care’s expertise model have long been frustrating for the public. Now, for consumers steeped in the internet, these practices are less and less acceptable. And what is not acceptable for consumers creates opportunity for companies and institutions that can use the power and ethic of the internet era to offer a more contemporary style of health care.
Retail clinics, urgent-care chains and freestanding diagnostic centers provide longer hours, more-convenient locations, shorter waiting times and lower prices. New primary care models provide online scheduling, caregiver communication via email and text, online access to medical records, and the ability to contribute to the health record through remote monitoring. Online tools allow consumers to compare quality ratings, and the availability and prices of providers, and to schedule appointments. And telehealth truly embodies the possibilities of the internet by transcending the limits of physical facilities and connecting patients with providers via video, phone, online messaging and text any time and in any location for routine, chronic and even critical conditions.
The entrenched nature of the traditional health care expertise model may have slowed the attack of the internet economy, but that attack is gaining speed every day.
A new point of view
For health care leaders, the erosion of the expertise model presents the need for a fundamentally new point of view about the value and strategies of a provider organization.
A value proposition that may currently focus on the expertise and reputation to diagnose, treat and cure will need to be reoriented to focus on understanding and helping consumers on their own terms.
Strategies aimed at advancing clinical excellence, technological capability or operational efficiency will need to be recast from the consumer’s perspective. That will mean developing new care models designed for the distinct needs of individuals and communities. It will mean using technology to create an array of access points for information and care. It will mean developing convenient, online functionality for scheduling appointments, communicating with caregivers, comparing providers, viewing health records and other basic consumer needs. And it will mean recognizing that delivering on these strategies will be a collective effort — one that taps the insights of patients, families, providers and employers, that taps the knowledge and skill of researchers and vendors, and that integrates an range of community resources.
The expertise model is not just an entrenched care structure but also an entrenched mindset. For health care providers to succeed in the internet economy, they will need to look at every facet of design and operations not with the mindset that "the experts know best" but with the goal of organizing the most effective resources to meet needs as defined both by the providers' communities and by the increasingly demanding internet economy.
Kenneth Kaufman is chair of Kaufman, Hall & Associates LLC in Skokie, Ill.