health care transformation
Mr./Ms. CEO…some bad news!
Your legion of six sigma black belts has about as much utility in the battle to transform health care as a conventional army does when fighting ISIS. Incremental change predicated upon statistical models is, of course, a needed skill. But the skill we seem to be lacking in health care is bold innovation.
Bold innovation means separating oneself from the pack and doing the unexpected in your market; convincing your Board to take risks rather than playing it safe (such as the intelligent assumption of risk rather than cash-cowing fee-for-service). It’s about hiring people who aren’t merely custodial administrators…but will constantly challenge the status quo looking for a better solution. And leaders who want to be pushed, and I mean really pushed, in their thinking.
Wake up health care…or you may end up like the Department of Defense — increasingly surrounded by asymmetrical threats, and unprepared to deal with them effectively.
What if I told you that there was a panacea to our nation’s health care crisis? Would you burst into laughter, stop reading, or simply conclude that I could not possibly understand the complexity of issues underlying our health system’s dysfunction? After all, everyone knows that there are no silver bullets in real life.
Yet, that’s exactly what I am going to propose – there is a panacea, we are simply choosing not embrace it. Before describing the cure, let’s define the illness.
In the most basic of terms, the U.S. spends far more than any other nation on health care services, yet “enjoys” some of the worst health outcomes. We live shorter lives, have ridiculously high rates of infant mortality, and succumb to a plethora of chronic, yet preventable diseases. Here are a few, quick stats:
“In 2005, nearly half of all adults – 133 million – had at least one chronic illness. In 2009-2010, more than one third (35.7%) of U.S. adults were obese, and 8.3% had diabetes. In 2005-2008, over 30 percent had high blood pressure.”
“Health care spending represented 17.9% of our gross domestic product (GDP) in 2010, and is expected to reach 20 percent by 2020. Three quarters of these costs go to treat chronic diseases, which in many cases are preventable.”
“According to the IOM’s 2012 report…an estimated 80 percent of cases of heart disease and of type-2 diabetes, and 40 percent of cases of cancer, could be prevented by implementing public health interventions that increase physical activity and healthy eating and help reduce tobacco-use and excessive alcohol use.”
We Stand to Save as much as $1.1 trillion annually:
According to a research published by the American Public Health Association, “By investing in prevention and treatment of the most common chronic diseases, the U.S. could decrease treatment costs by $218 billion per year and reduce the economic impact of disease by $1.1 trillion annually.”
Jim Fries’ Contribution:
These are not stunning, new revelations. The July 17, 1980, issue of the New England Journal of Medicine featured a landmark article by Jim Fries, a professor of medicine at Stanford University. The article became one of the most frequently cited scientific references in the emerging field of wellness. Fries focused on the impact of chronic disease, which he described as follows: “Chronic illness now is responsible for more than 80 percent of all deaths and for an even higher fraction of cases of total disability.”
The power of Fries’ article, however, lies in his conclusion: “Disability and lowered quality of life due to the most prevalent chronic diseases are thus inescapably linked with eventual mortality. These chronic diseases are approached most effectively with a strategy of “postponement” rather than cure. If the rate of progression is decreased, then the date of passage through the clinical threshold is postponed; if sufficiently postponed, the symptomatic threshold may not be crossed during a lifetime, and the disease is “prevented.”
Fries is stating that, while we cannot escape the human condition, by taking care of ourselves, we can stay vital, active, and healthy until the very twilight of our life. We can “compress morbidity” – thus reducing the disease burden, costs, and impact on our quality of life.
A Pittance of an Investment in Wellness:
So what level of investment are we making in prevention/wellness? “In 2009, U.S. public health pending amounted to $76.2 billion – only 3.1 percent of the nation’s overall healthcare expenditures of $2.5 trillion.” Granted, the Affordable Care Act (ACA) provides additional funding for prevention/public health initiatives– but a few more billion dollars, though significant, pales by comparison to our burgeoning health care tab that now exceeds $2.8 trillion.
Perhaps even more significantly, ACA may have stifled many embryonic efforts by providers to implement more robust wellness offerings. Like deer in headlights, most providers are responding to ACA by trying to eviscerate costs – not expand wellness programs for which there is little to no direct reimbursement.
Hospitals and the Wellness Sham:
Furthermore, while hospitals and health systems may preach wellness, few offer comprehensive services designed to improve your health and well-being. Rather, they pay lip-service to this essential component of health care – viewing wellness more as a marketing opportunity than a true effort to do everything in their power to minimize unnecessary and costly utilization of their medical services.
There’s no surprise here, since the dominant reimbursement mechanism, fee for service, rewards the provision of medical services – not maximization of the health of a defined population. As a result, we pay a very dear price.
From Sick-care System to a Positive Health System:
It is possible to shift from a sick-care system that doles out interventions to manage the burden of chronic illness to a positive health system, focused on wellness/well-being system, that minimizes unnecessary utilization by focusing on population health. However, it would require tremendous will on the part of numerous constituents to achieve such a powerful transformation.
Far short of transformational change, there are nonetheless small seeds of hope in the form of new, evolving reimbursement and delivery models, such as ACOs and medical homes that stress population health management. Unfortunately, the pace of adoption is glacial. For providers who have been burned in the past by assuming risk for a defined population, there’s little enthusiasm for doing so again.
Our Role in Changing the System:
More than three decades ago, Jim Fries gave us one of the keys to healing American health care…a silver bullet. The question is whether we have the fortitude to change the health care paradigm, as well as accept the personal, stewardship responsibility for our health that is essential to success. If so, there’s a role for each of us to play:
Consumers/patients: We need to understand what it means to be prudent stewards of our health, and the health of our families. It is essential that we understand the role lifestyle choices make in determining our health, and how we might combat risk-factors that imperil our future. For many of us, we will need to have access to resources that will aid in this journey – particularly if we are socio-economically challenged, and thus find lifestyle change all the more difficult. As has been well-demonstrated, the social determinants of health play a profound role in wellness and well-being.
Providers: Health care executives need to take the moral high-ground and do the right things for the communities they serve. One place to begin is with the development of a strategic wellness plan illustrating how wellness initiatives can be integrated into the very fabric of your hospital or health system’s care model. Once developed and implemented, you can then reasonably assert that you do everything possible to minimize unnecessary consumption of health care resources while maximizing the health and well-being of your patients.
Insurers/Payers: There needs to be an unremitting pressure to partner more fully with providers on the assumption of risk for the health and well-being of a defined population…thus accelerating the demise of fee-for-service medicine, and its replacement with a reimbursement mechanism that rewards wellness.
Employers: There needs to be broader adoption and implementation of wellness programs that incorporate proven mechanisms for elevating the health and well-being of an employed population. Such programs will likely involve potent incentives for lifestyle modification by those employees at risk. Expect the providers within your network to make two promises: 1) They will do everything in their power to help keep your employees healthy and out of their health system; 2) when medical care is needed, they will provide the highest value care as measured by agreed upon standards of quality, safety, and costs.
Government: There needs to be dramatically increased spending on proven prevention programs that can be administered at a local, state, or federal level. Furthermore, there need to be greater rewards under governmental reimbursement programs for those providers who embrace risk and demonstrate their ability to reduce the morbidity of a defined population.
Out on a Limb:
Panacea, silver bullet, and transformational change – these are powerful, almost Pollyanna-ish words to use in a serious article about health system change. Yet I’m convinced that this change represents our path to salvation, if we are willing to make the arduous journey.
A blog will never do justice to a proper articulation of the wellness argument, but hopefully it is a start. I welcome your thoughts!