The New Competition: Whats the Goal? Rereading of M. Porter


: 09.09.2008
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: #1   : 23, 2014 12:43 pm     : The New Competition: Whats the Goal? Rereading of M. Porter

The New Competition: Whats the Goal? Rereading of Michael Porter

In any field of human endeavour, the major motivators are adversarial, with an unwillingness to be lagging, and the activity of medical providers is no exception. For what actually do the medical providers compete and patients and how will this change in the future? It is convenient to consider the example of USA as competition in medicine, which has a medical market in its purest form.

I must say that the U.S. health care system has distinctive features that allow it to be described as a kind of anachronism that miraculously survived to this day. Despite the highest medical technology, including technology of business governance and the best in the world scientific basis, the ideology of U.S. health care itself, in my opinion, is almost an exact copy of the system that was brought to America by early European colonists. Historians, if they wish, can recreate the average look of ideology of health care as it was in Europe in the middle of seventeenth and the beginning of eighteenth century, but adjusted to national identities. The only upgrade which the system has undergone during this time between patient and physician now appears as an intermediary: insurance company.

What are these distinguishing features? First, medicine remained relatively closed, a clannish profession, a type of medieval guild. Neither the state nor citizens until very recently were allowed into the guild kitchen, which adopted the technological and marketing solutions. The medical community there still stands apart from the rest of social institutions, largely retaining its medieval liberties.

Second is the method of payment for medical services. The doctor gets education in a closed clannish system for his money and then tries to justify the invested funds, providing services to citizens through business intermediaries, which are insurers and assisting companies. From the point of view of the doctor, his service is economically and fundamentally no different from repairing a TV or car in instalments. The social role of the state in such an ideology only recently attempted to wholly or partially participate in medical payments of citizens, and health care workers all in history made out a bill for their services, for both individual citizens and the state that paid for them. At the stage of the doctors education or the stage of certification or the stage of practice and continuing education, the state does not claim its social interest in the results of the medical community as a whole, preferring to find out detours through educational programmes for potential and current patients and encouraging or fining certain types of businesses, including pharmaceutical, tobacco, alcohol, food companies, etc.

The third feature of the United States is that it continuously receives massive population from all the world, with the majority of the population having no experience of co-financing social insurance projects, or even if such experience is present, it is not compatible with different groups of immigrants. A large proportion of the foreign population leads to the fact that the United States still cannot create a complete system of health insurance for the entire population. For the state with such a structure of population, the risks of health insurance are too big and it is logical to put him into private hands, which by definition can afford to risk much more by artificially restricting the market and limiting itself to the most solvent parts of the population. This unique and permanent social instable routine does not allow the U.S. health system become European, designated for stationary population that is able to articulate their social goals and generate a social umbrella of sufficient size to cover the majority of citizens. Such a health care system by their ideology is still a temporary system that spontaneously arose in the era of the first settlers that are prone to constant changes of residence and is characterised by sharp social, material, and cultural inequalities.

There comes the understanding that this HCS, despite medical advances, as a separate service of a specific physician for a specific patient, starts to break down during the transition to fundamentally new technologies. The U.S. population has begun to notice that the price of such health care is prohibitive, and the accessibility of modern effective treatment is reduced. Medieval way of financing health care has become like a brake, in the sense that even the most advanced technology cannot show its effectiveness for society fully because of their low availability. The public opinion will begin to shift, aimed at greater social responsibility of medicine, at the fact that the population has begun to influence the clannish medical community, not so much in order to control what? doctors make, but for the fact that people could make physicians also implement why? and what for? which in the immediate interests of doctors are not yet included. The book Redefining Healthcare by M. Porter and E. Teisberg is one of the attempts to indicate to the American (and not only!) society some oddities in the health care system that are becoming more visible to the professionals.

In this book in Chapter 8, Health Care Policy and Value-Based Competition. Implications for Government, the authors write:

The fundamental flaw in U.S. health care policy is its lack of focus on patient value. (p. 323)

If there is any overarching perspective that has guided public policy, it is governments version of zero-sum competition: drive down the cost of government programs by policing costs, forcing down prices, and shifting costs to the private sector. (p. 324)

In all of these disparate views, however, there is agreement on one thing: the current system is not working. A fresh approach is clearly needed to address a health care system that is consuming a larger and larger share of public, corporate, and individual resources with questionable results. (p. 326)

Thus, the main words uttered are the current system is not working! I think that it should be clear that a system that does not work could not survive a couple of hundred years, resisting any attempts to reform it. The point is that the system works, but for itself! There is no mechanism that would allow the system to produce the result, which it is expected. If it is more precise, nowadays the American society can begin to understand what exactly is expected from the system. I think that this is what the authors of this book are trying to convey to the reader.

First of all, it would be nice to understand exactly who competes with whom and for what resources? Porter says that medical providers compete for patients money, and its totally logical in a market economy, no more and no waiting. The means of competition are relevant in offering services that are the most appropriate to customers expectations at a reasonable price. Porter says that this competition is counterproductive, because it offers a process, not outcome for the patient. It seems to me that the root of the problem is that the patient and medical provider traditionally understands by the proposed product that there are two different things:

Medical services provider speaking about treatment refers to the chain of process steps, reaching the best possible results for some time and known money.

The patient under treatment refers to the elimination of his medical and social problems to restore his ability to work within a certain time and fit in the available amount for him.
The only factors for which patient and medical provider can come together are the sum and time. If these conditions are met, the transaction is considered concluded. But the results of all medical procedures in general are probabilistic in nature, and the parties understand them differently. For medical providers, the result is a faithfully executed process chain, for the patient, there is restored workability or more years of life, and the first does not necessarily guarantee the second. All the many proposals of Porter in this chapter were reduced in order to force the medical provider to understand the results just as the current patient understands. But there is a huge problem: The patient obtains the explanation about the possible outcome from exactly the medical provider, i.e. someone who is financially interested in his misinformation to ensure maximum sales! Therefore, most of the conclusions of Porter in Chapter 8 focuses on how to organise the information field, which would be correct, impartial, and timely information for the patient about the best possible outcome for his medical condition.
I think that in reality the problem is even more complicated. There is competition among medical providers for patients money thats not all. In fact, all actors compete: medical providers, patients, medical insurers, and governments.

Providers, as already mentioned, compete for money of patients and for now all the available potential patients, not just the population of this state. Limitation of this type of competition serves the cost of moving the patient from the residence to the provider of medical services. We should expect that as the solution of traffic problems and reduce the cost of moving people on the planet; the available pool of patients will increase and competition of this type will increase.

Providers of medical services compete with each other also for the public funding they receive because of governments involvement in paying for medical services for some categories of patients and some socially important disease entities. The purpose of this competition may also get all sorts of preferences: tax, advertising and information, technological, political, personnel, and others, which allow access to new medical technologies and new pools of patients.

In the countries that have HCS, which cannot evenly cover the entire territory of accessible medical service providers, patients compete for the possibility of getting even formal medical care. The advantages of such competition are awareness of patients about the availability of the medical provider, ability to quickly move around the country, and material prosperity, since under such conditions the prices will be unreasonably high.

Patients compete for saving the maximum amount but achieve the desired result (not necessarily the provider from the current state). Under the desired result, they can assume quite different things, depending on the patients understanding of his medical state and possibilities of modern medicine. In this competitive field, patients are divided into multiple pools with different requirements for the final results, depending on many factors: age, education, profession, awareness of its pathology, financial features (both personal finance and financial capabilities of their insurance company), etc. But subconsciously, all patients are well aware of finite resources of any health care system, and that fact encourages competition between them.

Insurers compete, firstly, with each other for money of potential patients, and secondly, they compete with providers of medical services, by absorbing the money not only of current but also of future patients on the distant approaches to hospitals and, thus, reduce the pool of customers who could pay providers directly for services. The fact that there is competition among medical services providers and the insurers for the finite resources of the patient, in my opinion, is insufficiently reflected in the literature.

Insurers compete for the number of healthy population that is sufficiently solvent to pay for modern insurance services. The means to attract the customers to the insurer is the price and complete coverage of potential medical and social needs of patients. Limiters for such a competition are the laws of various states while the physical presence of the patient for the contract and the insurance payment is not necessary, and if it were not for these limitations, health insurers would have long operated on the internationalised pools of clients of enormous size; moreover, the contemporary banking services have already allowed that.

Recently, insurers have begun to compete also for the opportunity to save on a denial of service to already sick clients or customers who often get sick. This type of competition arose after the state began to try and force insurers to work also with customers that are unfavourable. In fact, this is just turned out in the previous paragraph, but it should be recalled that it is an important motivator of behaviour of insurers in the market. To combat this phenomenon, Porter offers to create pools of patients at risk and distribute them equally among insurers, thus making the market fairer in relation to insurers. However, to implement this idea, all insurers should be unified and equal in terms of prices and ranges of services provided, otherwise the situation will be unfair to customers. For now can only dreamed of this.

The state competes with other states for the number and quality of current and future patients, for they are the taxpayers, working hands, and parents of future generations of citizens. Resource is the quality of life as well as duration of life that is offered to potential immigrants and their descendants. I want to emphasise that the state is the only player in the market that competes not for money patients, but for the patients themselves. Namely, the current and future patients are the basic value for it. Lets remember this fact.

That is to say, all of these types of competition in health care are aimed at making one or another way to attract and utilise the maximum amount of money of current or future patients. But funds that even the rich elderly citizens that often get sick of a given state can spend on their health and social needs are fairly limited. To broaden the base for competition and, thus, increase their income, market actors began to apply specific techniques:

Customisation of health services, with medicines, serums, and medical devices (including implantable) developed specifically for a particular patient or a small group of patients. Price of the service while dramatically increasing, but the added value created for the customer is rather doubtful. But in the future, with the application of nanotechnologies, the customisation of medical services will become an integral and necessary part of making medical decisions and all medical activities.

Compulsory insurance of the population dramatically increases the amount of funds available for consumption by competitors at the moment, but the problem is that the list of advanced technologies in medicine is clearly expanding faster than the list of medical conditions and methods of treatment that is covered by insurance. Thus, the probability that in certain circumstances and/or combination of diseases the patient will have to pay also for the newest treatment (that is not covered by insurance) is growing, which is the aim of competitors.

There is active fundraising of patients from abroad, both as individual payers for medical services (now we call it medical tourism) and also as customers of transnational medical and social insurers and their alliances. State boundaries at this level of competition do not exist at all, and thus competition in the market of health and social services is no longer locked in their national quarters.

International markets of semi-medical goods and services, including medical assistance, are developing. Special value to competitors represents technologies for lifelong support of a patient, while he cannot switch to another medical service provider for reasons of medical or technical nature.

The use of telemedicine is a means to provide medical service to local or foreign patients without his physical presence, giving a sharp increase in the pool of potential patients which significantly save on travel costs. The market of telemedicine services currently shows one of the most impressive growth curves and promises to be a giant planetary market, as it is almost not influenced by local laws.

Using the high availability of medical information to the end customer in the world today, health care providers purposefully create the fashion for certain medical technologies, causing inexplicable spikes of demand for scientists and developers and then cyclical disappointment in them though. Such information campaigns are a powerful way to create planetary demand for medical technologies effectiveness which has yet to be proven and collect money patients before the publication of the late results of the given medical technology.

As mentioned in the previous sections, the only source of funds, consumption of which is the aim of the players on the medical services market and related markets, is the current and future patient which is now the whole worlds population, while the citizens of more developed countries have more than the less developed ones. The population of economically developed countries is mere titbit simply because the average labour productivity in them is substantially higher, and respectively, the average per capita income is higher. That is, I want to say that for the money, for example, an American or Swedish pensioner now will indirectly fight simultaneously all medical providers in the world, as well as all providers of health and social insurance. The only player in the market, which will be interested not in the consumption of current and future patients money, but in improving its quality with a reasonable increase in its quantity, will be the state. NGOs of patients, even global ones, will fight only for honest business, but no more for matters in general beyond their competence and interests. To expect from them requirements to better organise the HCS or to introduce advanced medical techniques to increase the number of people is as naive as to expect from the mall visitors the claims that the store has requested for additional buyers. The patient is a natural marketer; he knows exactly the fact that if other things being equal, the prices are as low as possible when there are fewer buyers; thats why the population is always sharply opposed to increasing its size at a rate at which this becomes evident.

Launched globalisation will lead to a more and larger percentage of patients being shared. By analogy with physics, which recognises that all objects in the universe (even the ones that we can not detect) attract each other proportional to their masses and inversely proportional to the square of the distance between them, now we can say that the entire population of the Earth (and even part of it living far beyond civilisation) is indirectly included in the pool of holders of the planetary health system that has formed before our eyes and which tries to regulate the same planetary market of health and insurance services. As an analogy of the mass here, it is the financial ability of the client, but as an analogy of distance, it is the degree of his accessibility for the system. It remains to find out what will be analogous of inertia in such representations. I propose to announce the degree of loyalty a patient has for outdated medical technologies the analogy of inertia, while such a loyalty is a function of his age and degree of financial ability, i.e., to be approximately the same relationship as the inertia and mass in physics. The accessibility, I suggest, is the physical accessibility of the patient (without this it is hard to provide medical and social services) and the accessibility of patients funds to use by the system.

As soon as competitors in the market of health and social services will go global, their competition will get new features, and, in particular, one can easily predict the following:

Competitors will be interested to involve in the system more and more new customers; in the first place, the most affluent customers will be involved, regardless of their place of residence or citizenship. Thus, actors in this market will be indirectly interested in the fact that rich people will as much as numerous, and, in general, it is good.

Competitors will seek to ensure that clients funds are in the form most convenient for consumption of the system, for which they will lobby for changes at the state level. Such changes may lead to a decrease in the degree of client control over the expenditure of his own funds and a view in which they are, and, in general, it is bad.

The process of establishing global medical and social markets will likely try and undergo all the stages double quickly, which passed large-scale machine production in the early twentieth century, with transnational mega-corporations, attempts to monopolise markets, lockouts in the form of mass rejection of support of large groups of patients, strikes by patients in the form of a mass refusal to pay the bills, and other charms of a little-regulated market. Any sudden movements at such a critical market for the population as the health care market is very bad, but for certain groups, it is even catastrophic. The only player at the outset who can lead a new emerging market in the civilised appearance will again be the state.

Advertising on this new market will have features; as opposed to other goods and services, medical service can be tested by the client usually only once. Because the clients usually in such conditions cannot go to a competitor, competition tightens, respectively, and the pressure of advertising on its target audience will increase. The state here will need to intervene to protect the interests of clients in the early stages of market.
It is already seen that a difficult time is expected for the market of health and social services. In fact, it has already begun. Those countries that had begun to use new technologies not just of medicine but integrated chains of various medical and social technologies into one meaningful whole have abruptly pulled ahead in terms of providing additional value to their patients. What is the main additional value?

If you recall the birth of technologies of mass production of goods in the early Middle Ages, the main way to distinguish a quality product from an amateur forgery was the presence of trademark, which confirmed the qualifications of the master and his membership of the guild. Counterfeiting of trademark attracted severe punishment. Thus, the client no longer had to spend time for checking the quality of goods, but it was enough to see the trademark of a standard form. With the complexity of products, the ability of the client to personally evaluate the quality of goods fell, because for this, they needed to have sophisticated skills or create a special situation. How can you check the quality of the gun if you do not shoot out of it a few times? But what if you do not know how or cannot shoot? How can we determine the quality of a fabric, if we not wear it for many years? There is no other way to assess the quality of technologically sophisticated goods as entrusting it with its testing specialist. Thus, the responsibility for quality is automatically transferred from the individual master to the management of the relevant organisation that performs the quality control. What confirms the presence of trademark? It confirms that this master (or the whole team) produces consistently high-quality product. That master was able to get rid of the probabilistic results of the application technology of making this product, and its defects are minimal.

As described in the previous section, a university medical diploma at one time served as the trademark that allowed an even completely illiterate patient to easily distinguish a genuine doctor from the quack doctors, but its still not a guarantee of quality service. The current state of the market of health and social services and, in particular, modern management techniques as well as quality control of services pretty much allow the probabilistic nature of medical services results to be overcome, while the patient obtains a new added value of enormous size stable (option: guaranteed) quality of chain of medical services which ends with the best possible outcome. It means quality control in the form of new medical brands come to the fore in the battle for the customer. But the clients due to their incompetence are deprived of the slightest opportunity to personally evaluate the very complex multi-component medical services and look for trademark. What namely does he look for now?

I think that a trademark now and in the foreseeable future will be performing the health systems of countries that were able to organise a continuous quality control of medical services in their territories. It is remarkable that this country does not necessarily have to be developed in the technological and purely medical sense. As always, when you go to a newly created market, competitors are on the same starting position, and past achievements hardly play a role. When Henry Ford applied the new principle of assembling cars, there was no technical innovation in this, but he was able to give the customer totally new quality and quantity of goods, which ultimately changed the whole country.

Thus, the name of the country turns into a trademark that guarantees the quality of medical and social services on the given territories. How long will it last? Probably not for long, because this technology is the so-called open source code, i.e. completely open to imitation. Dissemination of good management decisions in health care among states with political systems that will not prevent such borrowing will be held by historical standards immediately, and then only two brands will remain: a system with quality control and system without quality control. It is logical to expect that the new system will gain instant victory; that is, there will be no appreciable period of the struggle because the old system has no chance to keep the position, but it will not disappear completely, like the cottage industry didnt disappeared with the advent of robotic production lines. A man just likes to do something with their hands, showing his individual skills.

In the new system, the competition will take place already in the form of grinding of managerial techniques, in the struggle for a percent of successful results by reducing unproductive expenditures, for best design of medical services, that is, already semi-medical values, as well as in duration and ubiquity of warranty of achieved results. Solitary handicraft medical providers remain to meet the needs of rare eccentrics who appreciate individual high art of the given physician at risk to get complications.
Next, in Chapter 5 in Implications for Individual Physicians, M. Porter and E. Teisberg wrote (p. 201):

Medical practice must be designed around value for patients, not convenience for physicians. Apparently, the author here implies that the owners of medical institutions (federal government, state governments, local communities, religious structures, and private owners) need some organisational efforts to oppose the doctors (and medics at all) who are trying to get the greatest return and are creating businesses just for this. It is the peculiarity of the United States that all doctors (with rare exceptions) and much of the nurses are self-employed private entrepreneurs, the whole meaning of the activity of which consists of obtaining the highest possible income in the current legislation. For the implementation of this conclusion, the author would have them all as employees that would just change their system of incentives but at the same time, if Im not mistaken, come into conflict with the letter and spirit of the U.S. Constitution, which provides freedom of entrepreneurial activity for all citizens.

I see only one way to realise the authors conclusion: deliberately pushing the patient and the doctor together in the same competitive field, namely, that the patient is able to demand and receive from the doctor the most value for his money he must be a co-owner of medical structures and have a strong direct business mechanism to impact its functioning. The structure of the U.S. health care should be corporatised by patients, and one of the shareholders should be the state (governments at all levels), which also pursues its own, different from the patients, tasks of top-level management.

The business of physicians is addressing medical conditions, not performing a specialty. Physicians must understand what different businesses they are in. Here, authors are trying to force the current physicians to become specialists in one or two diseases, but this situation the medical community is still considered a sign of low professionalism or even degradation. Its not so much a market problem as the problem of physicians psychology. Centuries-old medical tradition involves a large element of universalism in this profession; a couple of hundred years ago, the concept of medical specialisation did not exist, yet the entire medical world was divided into surgeons and therapists. Now, M. Porter offers the next step in the specialisation of medical staff and its division into competing enclaves with various professional and business interests, which would automatically lead to the disappearance of the physicians profession, as we know it currently. The word doctor will remain, but it will mean absolutely different. This has already happened in the past with the profession engineer. Remember the universal engineer Cyrus Smith from the novel Mysterious Island by Jules Verne? And so these universal engineers are long gone, and in terms of contemporaries of Jules Verne, current engineers are not engineers; they are just professionals to develop extremely narrow classes of devices and structures. Market for design has matured and forced engineers to split into narrow specialties. Unlike doctors, engineers were not a clan with centuries-old professional traditions, and so, for them this division was painless. Specialisation of the medical staff in the patients medical conditions is a very painful step for most doctors, but its inevitable, and the authors are probably right. Customers with their money will force doctors to take the next step in their specialisation, not for this, but for the next generation of doctors. Just keep in mind that this specialisation is not the last; there is specialisation in the age of the patients, in their professional profile, on race and genotype, the geography of residence, type of environment and climate, and their combinations.

Patient value comes from expertise, experience, and volume in particular medical conditions. Physicians must choose those medical conditions in which they will participate and achieve true excellence, rather than try to do a little of everything. I think the authors here are offering to split the proposal on market sectors before the splitting of demand happens. One can imagine a situation where a man in the late nineteenth century, wanting to buy a car, asks: Do you want sports car, SUV, or family coupe? The client does not understand the question and says that he just wants to drive. In another situation, a customer comes into the store, just knowing that he needs a coffee mill. But at the entrance, he meets the manager who has a psychologist diploma. He stares into the customers eyes and says that he, as a professional, believes that he needs a meat grinder. And the customer humbly agrees to pay for the meat grinder. Does this not remind you of our health care facilities? Before starting to compete for clients at the level of medical conditions, a doctor must undertake the set of measures, sometimes on the verge of detective investigation, in defining this medical condition. In such a situation, the narrow specialist is unproductive, especially if you have to differentiate a dozen fundamentally different medical conditions. Even now, in the presence of medical specialists universal in its field, the complex differential diagnosis often turns into a long process with nonzero probability of failure. How can the diagnostic process be built in the world where the doctors are divided and compete at the level of medical conditions, i.e. separate disease entities or its narrow groups? All of these specialists may take time in the diagnostic process as a sequential bypass, which is critical for timely assistance. Apparently, the diagnostics, as a form of medical practice, will have to be separated and excluded from the general field of competition, otherwise collusion between the narrow specialists and group that diagnoses medical conditions may happen. Do you remember the aforementioned manager that offered the meat grinder? Can anyone believe that he offered it unselfishly?

Another problem is the problem of full coverage of medical conditions. The fact is that they are clearly not equivalent in terms of complexity, time required for diagnosis, and treatment. In addition, they are very different in the effectiveness of therapeutic measures and the percentage of successful outcomes. What happens if the doctors in some area or the country will en masse specialise in the direction of the easiest medical conditions in terms of business? Who will do the treatment of labour-intensive and rare medical conditions? Who in such circumstances would impose on doctors the treatment of conditions that are unfavourable to them? Now such a covering happens because of the universality of physicians within their specialty; that is, after treating some unfavourable patient, the doctor immediately goes to the next favourable patient and makes up for lost profits. The imposition of such patients happens at the moment of splitting of the general medical field into narrow specialisations. If the doctors will determine the areas in which they are most effective on their own, it is almost guaranteed that all the areas that are uncomfortable for the treatment of medical conditions would be left out. Even if a doctor tries to specialise in such medical conditions, he will inevitably lose in the competition for the customer, because after developing the individual patients with this pathology in his area, he will be forced to become a nomad in search of casual patients. Shipping patients to the narrow-specialised doctors will be several times more expensive than conventional wholesale delivery of goods to remote residence places this is a feature of the market of health and social services, where not the goods are transported but namely the customers themselves.

Health care value is maximised by an integrated team, not individuals acting and thinking as free agents. Physicians must know what team or teams they are part of, and ensure that these are functioning as teams. It seems to me that this phrase of the authors slightly exaggerates the situation. Certainly, service that is provided by a team will generally be fuller and better than the same provided by the single specialist. The question is: How it will affect the price of such services? Whether the entire cost of such integrated medical services will be approved by the patient as a thing he really needed and as exactly what he expected? The value of medical services for the patient is a complex set of factors such as quality of service, its price, the time needed for providing the service, his psychological comfort, waiting time, confidentiality, and much and much more. Do we not get the situation where by improving the quality of care we reduce other components of its value? I think that it will be better to stick to the principle of reasonable sufficiency.

Another problem is that narrow specialists belonging to different teams specialising in different medical conditions can and likely will compete with each other for the client because of the fact that they remain free agents in the market. The most valuable professionals become a bone of contention between the teams, which will lead to the fact that every team wants to have its own exclusive narrow specialist. The market of medical education will respond as it is accepted in the market: will start overproduction of narrow specialists compared with today; that is, if the number of doctors will be more, then their income will decrease. Thus, the application of such a principle can make the doctors oppose such changes.

Physicians rarely have full control over the value delivered to patients, but are part of care cycles. They need to know what care cycles they are involved in, and how to integrate care with both upstream and downstream entities to ensure good patient results. The authors here, in my opinion, want to entrust the doctors with the role of system integrators who develop and maintain the interface for a smooth and predictable interaction between professionals that make up the team and in between teams. I believe that the narrow specialist cannot be a system integrator in this case, as he will try to do administrative functions not intended for him, and even at the level at which he found himself. The more narrow specialist is the physician, the less he will be fit for the role of system integrator. This is a specific task of higher level management.

Physicians have no right to provide care without demonstrating good results. Results should be made available to patients, other providers, and health plans as soon as measurement is reliable. Requiring is absolutely reasonable, but we will need to precisely define the words good results; other health care workers may be subjected to targeted harassment, which is a type of competition under the banner of increasing value to the patient. First of all, we should understand they have to measure the results achieved by a physician or as a team relative to what or whom. Can we now compare the results of the example of Turkish and American cardio surgeons? Would it not be that after this Turkey would immediately close all cardiac clinics and stop all attempts to establish this type of specialised care? Is it fair to Turkish patients? Is it an acceptable comparison of the results of a specialised private cardiac clinic somewhere in New York City with the results of a small university clinic of the same profile somewhere in the outback USA? And how do we assess the value of such care for the health of the patients from the provinces, if it turns out that for this added value, they have to travel across the country to New York City and get it in a private clinic for a much higher price?

Physician referrals should be based on excellent patient results, together with the ability of referred providers to share information and integrate care across the entities involved in the care cycle. Translating this requirement of the authors in ordinary language, we can say that the doctor should do analytical work to determine the degree of openness of the work of their colleagues (by what criteria?), the accuracy of this information (by what means and powers?), to build a registry of achievements (only now on a global scale), knowing which care cycles his colleagues of other specialties are involved in and what is the degree of integration of his colleagues in these care cycles. Does it not seem to you that this activity, to say the least, is unusual for a doctor? From my perspective, this work is the power of a group of specialists, analysts, marketers, and system integrators, organised into a kind of national office with the prospect of transformation into a global organisation for the control of the quality of care. To require this from private practitioners, it means to try and discourage him from professional development, time for which does not remain.

Electronic records and the ability to exchange and share information are indispensable to excellent medical practice. Physicians will limit effectiveness unless they wholeheartedly embrace IT. The question about the form of reports he sends to the doctors in regulatory agencies and to his colleagues is only a matter of speedy decision-making in the health care field. Exchange of information happens anyway and management decisions will be made anyway, but in todays world, it is critical, namely, the speed of the decision-making process. Avoiding the use of the fastest ways to share information is just as amazing as the attempts to control the country through the mails, which are carried in postal stagecoaches on the condition that you have a valid airmail and phone. The fact that many doctors do not use the electronic methods of information exchange is the result of the fact that in a professional environment there is no public demand for results in fast information integration of this environment because these results are not needed by doctors, so they do not increase their income and social status. This question is not for a doctor; it is a question to a state which does not expect (as opposed to patients) a significant improvement in the quality of medical services by introducing more rapid ways of information exchange.

Physicians must seek out partnerships and relationships with excellent providers in their areas of practice in order to access knowledge and improve the integration of patient care. I believe this point is the most controversial. The main competitor of the modern doctor is his colleague, coinciding with specialisation and servicing the same pool of patients. Can you imagine the car corporation, which, referring to marketing research to improve the quality and after sales service of manufactured vehicles, suddenly began to build integration with other car corporations which were in the same market segment? And most importantly, will it open its technological developments for the greater integration for counterparts? Such processes in the business are called as mergers and acquisitions, and such things happen, as a rule, not voluntarily. In fact, the authors proposed to begin the process of creating corporations or medical cartels, which would virtually monopolise the local market of medical services for selected medical conditions. Firstly, such a practice is forbidden by antitrust law in many countries, and secondly, the first thing that happens after such a monopoly is the rapid rise in prices for treatment of above-mentioned medical conditions. The customer and his insurance company, as I indicated above, are practically deprived of the opportunity to try a particular medical service from different providers (as is observed in the production of ordinary goods and services); thus, they immediately become dependent on the producer of medical services closest to them, from which the customer will not be able to escape (as opposed to an insurance company that can change the provider). Thus, the only victims of such a market of medical conditions that is super-monopolised and artificially divided into small sectors will be patients.

Summing up, I agree with the basic provisions of M. Porter and E. Teisberg, where the general directions of changes in the future health care are shown correctly, in particular, the fact that the market of health and social services will be mature and divided into sectors within each medical specialty. The division will be based on medical conditions which are the most suitable for organisations of full cycle business processes with quality control to deal with the probabilistic nature of the medical service results. Following the segmentation of demand, segmentation of proposal will be logical; that is, the professional field of doctors and nurses in the next generation will begin to specialise in the treatment of medical conditions, a list of which will dictate the market. Next to this, the market of medical education will start to be segmented, which will produce much more narrow specialists than even today, but they will call them physicians like before.

At the same time, the complex processes of extrusion of private insurers out of health care businesses and increasing the shifting of social insurance functions to the state and its subdivisions will take place. The state will more clearly show their social interest in the quality of health services and their cost and start with those medical conditions that are the first to come to the form of individual market segments with reliable quality control. After a while, the state will start to standardise the form in which current and future patients keep their funds in order to enable the health system to use them immediately, without lengthy procedures and delays. It is unlikely that this will be a special mega-community foundation; most likely it will be a new form of money, something like a virtual cash equivalent. Health insurance as a form of business in developed countries pretty quickly wanes, and this kind of competition will disappear in the near future. Market actors of health care and social services will more realistically envision the essence of the processes and predict the consequences of their activities in the medium and long term.

Patients for more effective control of the business chains and the quality of treatment will stimulate the processes of corporatisation of medical institutions and with the participation of the state force medical staff to implement a quality control system even for those medical conditions that are not quite suitable for this purpose in terms of medical business, achieving the highest coverage of the market and overcoming the resistance of conservative physicians with compensations and benefits. Patient in these circumstances will consider an attempt to treat him without quality control as an attempt to premeditated murder. States acting as the brands of health care systems will directly and openly compete with each other for complete coverage of medical conditions in the new quality control system, and the competition can lead to a kind of expansion; that is, more medically developed countries will provide assistance to people with certain medical conditions also not on its territory. In fact, this process has already begun. Providers of medical services will start to compete not so for the money of patients but more so for the mere fact of its existence in the system of quality control. Rare medical conditions and physicians who treat them will not fall into the new system; thus, they will be marginalised in the public consciousness of the next generation of patients, because they will look like artisans.

Managing the medical and social processes as a type of business with strict quality control and predictable results will be a very profitable service, as demanded by individual medical providers and entire states. We can predict an explosion of interest in new methods of quality control in medicine and marketing of health and social care services that are currently in the budding stage. At some stage, such management services will appear far more expensive than the actual treatment of medical conditions. Patients in the system in which the highest possible quality is guaranteed will compete for the opportunity to save their virtual money in choosing the right provider, which will offer the most comprehensive medical services for longer life of the customer and high quality of his life. At a certain stage of development of such a market, a new kind of competition for the new critical indicator will arise extra years of life for patients and their more numerous progeny.
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