When the U.S. military returned from the longest conflict in its history, it did not return to a world at peace. The world was, and remains, turbulent and complex. Global peace and security, and U.S. national interests, demand a force that is ready, healthy and on the job where it matters and when it matters worldwide. So, who is this force, and what is health to them?

The vast majority of men and women serving in uniform today were born after 1986. They are Millennial, Gen X, Y or, soon, Z generations. They are also more highly trained, specialized and educated than any force in the nation’s history. Further, these men and women comprise the less than one-third of high-school graduates who are even eligible to join the military, and the less than 1 percent of the nation who choose to do so. Therefore, every person is critical to the mission.

According to the World Health Organization (WHO), health “is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.” This definition seems to make two implicit, yet unstated, assumptions: 1.) everyone considers their health to be a priority and 2.) health is the purview of medical. Yet, these new generations and their preferences are fundamentally changing how healthcare is delivered and, with that, causing health professionals to question whether the two unstated assumptions underlying the WHO definition are still valid.

As a baby boomer and now healthcare professional, I often reflect on what shaped my healthcare choices and those of my parents. It is clear that we value care by well-trained professionals (the degrees on the physician’s wall were important to us), care that is high quality and care that is safe. Those expectations generated an entire industry dedicated to ensuring these things. Board certification, Joint Commission and any number of regulatory professional organizations are geared toward ensuring expectations were met.

Yet, today’s generation serving in uniform, and their peers in the civilian sector, have very different expectations fueled in part by the success of practices put in place to meet baby boomer expectations.

Issues they considered important in healthcare choices — professional training, quality and safety – are all assumed to be in place by Millennials. These things do not enter into their thinking. It is much like eating in a local restaurant. People assume they can eat there and not get food poisoning without seeing the sanitation card or knowing where the chef was trained. Regulatory oversight and success in ensuring expectations were met have likewise allowed healthcare to become a commodity. Everyone needs healthcare, but where a person obtains it, and from whom, does not matter much.

What drives healthcare choice today are three factors: convenience, experience of care and, increasingly, technology. That reality is going to fundamentally challenge a national system of care that is hospital and clinic-centric and also incentivized by fee-for-service. While the latter does not necessarily apply to military healthcare, the former is relevant because it has a clinic and hospital-centric system of healthcare. The military provides the best healthcare the nation can offer, but a person must come to the hospital or clinic to get it. This is at odds with a generation of young warfighters that value convenience, instant gratification, experience and, as digital natives, technology. Let us look at each of these factors and see how each challenges unstated assumptions of the WHO definition of health, as well as some potential considerations for the future.

Convenience. “Come into my ER, the wait time is only five minutes.” Of all factors, convenience most influences healthcare choices today. This reality has spawned an entire industry dedicated to healthcare on demand, integrating services into people’s daily lives. Major retailers are rushing to put primary care clinics in their stores. This explosion of urgent care centers has not occurred because of the need for more urgent care. It has occurred because of its ability to cater to convenience and to charge more for care delivered in an urgent care versus primary care location. Retailers are increasing the ante by offering shopping discounts and incentives above and beyond traditional tools, such as expanded hours and walk-in operations.

When the majority of what goes into a primary care clinic does not need to be addressed by a physician, and demands of daily life are increasing, it can be very alluring to seek more convenient options for care. Yet, when this happens, care becomes fragmented and preventive or anticipatory services are not always rendered. As it is, a typical patient spends less than 1 percent of their year with a healthcare professional. What little time healthcare providers had is becoming fragmented and focus has shifted from prevention to acute care. So what if this occurs? Just as we live in a world of turbulence and threats, so too we live in a world filled with health threats.

The national obesity epidemic (just super-size it), related rise in diabetes, decline in physical activity, worsening sleep habits, opioid epidemic and other examples point to a society filled with threats to health. And service members are not immune. Military health touch points are limited and increasingly fragmented. It is crippled by a lack of incentives toward health, and adolescent thinking that health consequences are somewhere in the misty future and not a concern today. Healthcare providers are not going to change the desire for convenience. They can, however, mitigate risk from fragmentation while implementing effective incentives. To assume medical can do this alone is foolhardy. Let us be honest with ourselves. Health is not a priority for this generation until they get sick. And any path to sustained health will not succeed if only centered on medical.

Experience of Care. As a culture, Americans value experiences. Millennials place a premium on experiences over tangible goods. As such, the experience plays heavily into their decision-making. The healthcare industry is not immune. Investments in concierge services, gourmet dining, experience coordinators, interior design, peace gardens and feng shui all point to this reality. One need only look at healthcare organization websites and what they showcase to appreciate this reality. Yet, none of these perks or services increase care outcomes or health.

Worse, with increasing healthcare commoditization, people are increasingly confusing the experience of care with the quality of care. Yet, this focus on experience over substance of care is creating “haves” and “have nots” in healthcare. The Federal sector cannot, and should not, use tax dollars for valet parking or feng shui consultants. Congress has limited options to thank an all-volunteer force, and one way they do so is by expanding access to civilian healthcare options for eligible beneficiaries. These beneficiaries are, like most Americans, enthralled by trappings of the experience, mistakenly confusing experience with quality.

When patients make healthcare choices based on who offers valet parking, society runs the risk of care becoming fragmented. The concept of brand loyalty (or forced loyalty), on which military healthcare depended for decades, to obtain and keep patients has been replaced by allegiance to healthcare organizations with the best food, best parking and most spacious interiors. When this occurs, beyond care fragmentation, the military loses visibility and relevance over the health of the force, at a time when it needs that force healthy and on the job.

This challenge is not unique to the healthcare industry. The retail industry is a good example of where segmentation based on experience has occurred. Companies who failed to recognize that reality or tried to outspend their competition on experiential trappings are no longer in business. Those that recognized brand loyalty was the only possible strategy, and aggressively pursued this approach, thrived. What will help create loyalty in patients? Forced loyalty is a thing of the past as individuals have more choices than ever before. Therefore, we have to rely on voluntary loyalty. What factors influence that? Does anyone know?

Technology. “Is there an app for that?” Almost all service members wearing a uniform today possess a smart phone. They are digital natives; they have always known the internet and have always been “connected.” Because of its ubiquity and familiarity, the internet has evolved for this generation into being the primary source of information and communication in their lives. Healthcare is not immune to this trend. Thousands of health-related apps exist in the iTunes store today. Most of them are free. Yet, it is unclear how many have been subject to rigorous quality control or information verification. This is particularly concerning at a time when the volume of medical knowledge is growing at an exponential rate.

Nonetheless, these apps, not the healthcare provider, are the primary source of medical information, and they influence healthcare choices today. Further, most apps are kept only if they are perceived to have value to the user. It becomes difficult, if not impossible, to systematically and deliberately provide age, gender and situationally appropriate medical information and guidance in this environment.

What drives healthcare information is perceived value and ease-of-use, not demonstrated efficacy or accuracy. Significant generational differences also exist in how information is received, processed and used. This has been a major factor in the “stickiness” of apps and whether or not they are retained and used. Madison Avenue learned this long ago and uses it to their advantage in targeting population segments to sell their goods and services. Again, healthcare is not immune to this phenomenon. The days of the “one size fits all” website or app are gone. Careful population segmentation will be critical to delivering effective healthcare information and services in this virtual environment of the future.

Careful design, followed by ongoing refresh informed by feedback and analysis, will be essential to maintaining “stickiness” and, from that, relevance. This will require military medicine to segment its population, to identify and prioritize health messages and services that each segment requires or desires, then explore how best to provide information in a virtual format. The design and presentation layer for each population segment must be done by a member of that cohort and then, instead of “one size fits all” feedback strategies, each segment will require its own feedback strategy and assessment to guide further development and sustained “stickiness.”

The most successful features of apps will be integrated into other apps being used by that segment for other services or information in their lives. Perhaps, it is worth considering partnering with the private sector for app development and presentation. Just as this generation wants healthcare to integrate and not intrude in their lives, so too they want the same thing in their virtual lives. They do not want healthcare set aside on its own with separate apps they have to seek separately. Healthcare is not their top priority, and they do not live medical-centric lives. We must re-think our approach.

What is the way forward? It is clear that convenience, experience of care and technology are here to stay, and the expectations of this and subsequent generations will not change as healthcare becomes increasingly commoditized. The military must adjust or it risks losing visibility, influence and relevance over the health of the force at a time when it needs that force healthy and on the job. A fundamentally different approach to healthcare is required. One that, if done well, can help make the most of the less than 1 percent of time we have direct influence over the lives of our patients.

To recap what I propose:

1. Effectively Incentivize Primary Prevention. This cannot be a “one size fits all” approach. Each segment will have its own effective incentives that can successfully modify behavior. Behavioral analysts know what they are and can help tie them to prevention strategies.
2. Drive Healthcare Out of Dedicated Brick and Mortar. Integrate health into people’s lives, not intrude on it. This will involve partnerships and novel use of care extenders. Why can’t we do house calls, and why can’t they be more than just about medical? Linking those visits with other non-medical, but necessary, services will better integrate healthcare into people’s lives and increase participation. They will have “skin in the game” when it is easy to get healthcare information and services, and when it is relevant to priorities in their lives.
3. Center Care Around What the Patient Wants, Not What the Healthcare Provider Believes They Need. Healthcare is the only remaining industry where the customer is not the one calling the shots; and we pay a price through reduced compliance. Compliance increases, and outcomes improve, if the patient decides the outcome goals and those goals are relevant to their lives.
4. Develop Brand Loyalty. This is the only way to keep people in a commodity industry, as healthcare has become. This will require effort to identify what factors drive loyalty. Then, develop strategies to exploit those factors and get our patients to choose us when they have more choices than ever.
5. Segment the Population and Develop a Strategy for Virtual Healthcare for Each Segment, including information presentation, refresh and focusing on “stickiness” to maintain interest and relevance, targeting prioritized areas of healthcare need to requests.

Success depends on getting this right. There are those in the profession who will be offended that they are no longer the “oracle of all things medical” to whom supplicants gratefully wait to see and hunger for every morsel of medical wisdom they impart. Welcome to working in a commodity profession. As former U.S. Secretary of Veterans Affairs Eric Shinseki once said, “If you don’t like change; you’ll like irrelevance less.” But, with great change comes great opportunity, if we do it right. Our patients and nation are depending on us to do it right!