If you ran a fancy restaurant, would you want the chef also to clean dishes and mop the floor? Of course not. You’d hire others to do these things and let the chef focus on producing delicious food. This simple idea — that one should match the skill level of the individual to the skill requirements of a task — has influenced how many businesses operate. That’s why lawyers are helped by paralegals, professors by teaching assistants, and chefs by sous chefs.
Task shifting of this kind moves routine tasks requiring lower skills away from high-skilled professionals. It must be done judiciously, because if a person is less qualified than a task requires, it will hurt quality and may add to costs if rework becomes necessary. On the other hand, if a person is overqualified for a task, it will increase cost and, counter-intuitively, may lower quality if the person is not as engaged in the task as someone with the right skills. In other words, we want to match perfectly each person’s skills and tasks.
The task shifting logic also applies to health care. For years, nurse practitioners and physician assistants have taken on tasks that doctors once performed. This has saved money, of course, but it has also improved quality, because doctors and paramedics perform tasks that best fit their expertise. However, based on our research in India, we believe there’s a lot more room for task shifting in U.S. health care. Some Indian hospitals have pushed the envelope on task shifting because of intense pressure to make the most of the country’s very limited supply of doctors and specialists, while maintaining quality and keeping costs low. Through a process we’ve termed “reverse innovation” these practices can be brought to other countries, including the United States, where health care costs are out of control. Three task-shifting ideas from India are worth considering.
Create new job categories. The Indian exemplar hospitals we studied have taken task-shifting to new heights by creating entirely new categories of low-cost health-care workers. For instance, when Dr. Govindaswamy founded Aravind Eye Care hospital in south India, he had plenty of patients but too few ophthalmologists and optometrists to treat them. His solution was to hire village women with high-school diplomas and train them for two years to work as “midlevel ophthalmic paramedics.” Over time, these paramedics have made up two-thirds of Aravind’s workforce and perform tasks such as admitting patients, maintaining medical records, counseling patients — and assisting doctors in surgery.
Each Aravind surgeon, for example, has help from six paramedics in the clinical domain and four assistants for administrative and support services. Paramedics go to villages, screen patients, transport them back to the hub hospital, measure their vitals, have tests performed, prepare the patients for surgery, deliver postsurgical care in the ward, transport them back to the village, and provide follow- up care. In addition to being inexpensive, the paramedics bring skills such as cultural competency, loyalty to the organization, strong work ethic, and the ability to connect more deeply with patients and families whose socioeconomic background is similar to their own. The surgeon performs only the actual procedure, which is a small but vital fragment of time to which all other tasks contribute. Aravind’s doctors do what only they can do — diagnose patients and perform surgeries. They are 4-6 times as productive as U.S. surgeons are, not because they are overworked but because of rational task shifting and clever process design.
Similarly, unable to lure trained personnel to work in India’s countryside, LV Prasad Eye Institute has developed a team of vision technicians to perform basic eye tests in villages and small towns. They are not trained optometrists but are skilled enough to screen patients who should be seen by optometrists or ophthalmologists in one of LV Prasad’s secondary care centers. Thus, people get basic eye care close to where they live and only when necessary do they travel to a bigger town to be seen by a more skilled professional.
Upskill employees. At the same time, Indian hospitals also strive to raise the skill level of their employees. At the high end of the skill spectrum, for instance, HCG Oncology has developed a new category of “onconurses” who are better trained than normal nurses to assist doctors in chemotherapy and radiation treatments. Likewise, Narayana Health, a multi-specialty hospital, encourages nurses to advance to the higher-skilled position of “nurse intensivist,” akin to a nurse practitioner in the United States. Narayana Health also encourages general physicians to become specialists, and specialists to become super specialists. Similarly, LV Prasad’s vision technicians who work in villages and small towns have the option of enrolling at its optometry school to become optometrists. Indeed, one such person rose to become an optometrist and later obtained a PhD in ophthalmology.
Encourage patient self-service. An extreme form of task-shifting is self-service, in which patients or their family members take over tasks traditionally performed by hospital staff. For example, Narayana Health encourages family members to provide post-ICU care for patients after undergoing a four-hour audio-and-video curriculum developed with Stanford University. This kind of self-service care backed by training reduces staffing costs and allows for more-personalized care for the patient, while also ensuring continuity and uniformity of care when the patient goes home, thereby reducing postsurgical complications and readmissions. LifeSpring Hospitals, a maternity center, provides an extra bed next to the new mother so that a family member can stay and help care for her. These practices encourage patients and their families to take ownership of health and disease management.
On all these fronts, U.S. hospitals could do more. Instead of embracing the kinds of task-shifting we saw in India, U.S. hospitals’ cost reduction programs typically start with cuts in low-cost staff jobs, forcing doctors to spend more time on simple, routine tasks such as transcription, logistics, and billing. At Mayo Clinic, for example, doctors reportedly spend more than half their time on nonmedical matters. This is exactly the wrong kind of task shifting, and it has led to physician dissatisfaction and burnout. Similarly, U.S. hospitals fail to tap patients as a resource for improving health care (and, incidentally, lowering cost).
America’s health care industry and regulators should take a second look at the scope for task shifting. The impetus for such experimentation needn’t come just from Washington DC, it could also come from individual states. Task shifting could create thousands of new jobs across the industry, while improving care and lowering overall cost. Companies like Iora Health and Caremore, which have shifted aspects of patient care from doctors and nurses to health coaches, are already saving millions of dollars in avoided hospital and ER visits, tests, and procedures. These organizations have shown the way; others should follow their example.
Vijay Govindarajan is the Coxe Distinguished Professor of Management at Dartmouth’s Tuck School of Business. He is a coauthor, with Ravi Ramamurti, of Reverse Innovation in Health Care: How to Make Value-Based Delivery Work (Harvard Business Review Press, 2018).
Ravi Ramamurti is the University Distinguished Professor of International Business and Strategy and the director of the Center for Emerging Markets at Northeastern’s D’Amore-McKim School of Business. He is a coauthor, with Vijay Govindarajan, of Reverse Innovation in Health Care: How to Make Value-Based Delivery Work (Harvard Business Review Press, 2018).
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