Can You Handle the Truth about Healthcare?

Before I unnecessarily offend those who endure the daily stress of delivering medical care in the US healthcare system... I do value medical care. I have found, however, that medical care is no longer sufficient to address the tsunami of chronic illnesses that has overtaken the US. No amount of money, no number of quality initiatives will fix this until healthcare treats the whole person and accounts for major determinants of health outside the clinic.

The Truth

It is no secret that the US healthcare system is broken, with the most expensive care and the worst outcomes among wealthy nations according to research from the Commonwealth Fund and others. In fact there is disparity even within the US, as the Washington Post highlighted in Our infant mortality rate is a national embarrassment:

The U.S. rate of 6.1 infant deaths per 1,000 live births masks considerable state-level variation. If Alabama were a country, its rate of 8.7 infant deaths per 1,000 would place it slightly behind Lebanon in the world rankings. Mississippi, with its 9.6 deaths, would be somewhere between Botswana and Bahrain.

Medication does not become less effective when it crosses a state line. Physicians do not lose part of their training when they practice in a poverty-stricken zip code. Yet there is evidence of health outcome disparities based on where people live, level of education, race, income, and so on. If we want to fix the US healthcare system then we need to face the truth... the conventional medical care model will not improve health outcomes in the 21st Century like it did in the 20th Century and may actually work against necessary changes.

1) Working Against Necessary Change?

How could those trained and devoted to "healthcare" be an impediment to necessary change to improve healthcare? For years, we have relied on those in the conventional healthcare industry to develop and implement changes that will achieve the desired Triple Aim of improving patient experience, reducing per capita expense, and improving population health. The answer is simple... 86% of the US healthcare expenditure is for chronic disease and the economics of health insurance as well as the current clinical practice model were built for acute illnesses where fairly healthy patients showed up with an acute complaint that could be diagnosed and treated over a short time horizon... not a lingering chronic illness (usually with co-morbidities) that are largely determined by non-clinical factors and lasts years and even decades. Worse... chronic illnesses will continue to grow as the US deals with aging Baby Boomers, an obesity epidemic and other factors.

Physicians have traditionally been the bulwark for fixing any health ailment. When the leading causes of death were rooted in trauma and infection in the early part of the 20th century there was often a clinical treatment that addressed the acute malady in short order, whether a broken bone or an illness like pneumonia. Now physicians are faced with mainly chronic illnesses that cannot be cured through clinical means and usually involve not just the primary care physician but one or more specialists and a myriad of prescriptions.

Unfortunately, many physicians are increasingly subject to quality and efficiency initiatives to measure their performance on these very chronic diseases that are largely due to non-clinical health determinants (more to come on this point). It is not surprising that physician burnout has become such a concern as they struggle to coordinate with other providers, reconcile medications and still treat patients all in a 10 or 15-minute visit, especially when the patient then spends hours every day in a sedentary lifestyle laced with fast food, increasing stress and, potentially, side effects from the pharmaceuticals prescribed in that visit.

Government agencies and entire industries have developed to support physicians in delivering the best healthcare possible through policies, guidelines, pharmaceuticals, medical devices, etc. However, too many of those same actors have now become at least a reactionary impediment and perhaps even self-serving.

We trust academics and scientists to establish guidelines for healthy eating like the Dietary Guidelines for Americans released by the Agriculture and Health and Human Services Departments but learn those guidelines are politicized and that some members of the committee received monies from organizations with an economic interest in the recommendations.

For decades we have relied on new drugs to cure or ameliorate diseases and watched as "the pipeline" continued to produce new therapies for decades. In recent years, however, pharmaceutical CEOs show up on TV news shows to explain why they increased the price of a decades-old life-saving drug hundreds-fold or even thousands-fold while increasing their own pay by millions per year. Sometimes it is not even that apparent as a recent Watchdog Report from the Journal Sentinel titled New and expanded medical definitions create more patients — and a lucrative market for drug firms found numerous examples where new definitions or lowered thresholds fit the criteria of having treatable disorders for millions of potential new patients.

Elected officials from one political party and the support bureaucracy (Federal, state, and local) push for new medical coverage models, payment mechanisms, and more while elected officials from the other political party and their support bureaucracy steadfastly fight against such changes. Where some civil common ground can be found (e.g., the 21st Century Cures Act) it usually results in more funding to medical research but nothing to address the disparities in health outcomes like infant mortality or diabetes among states in the Union.

2) Diverting Resources and Attention

So what is wrong with a focus on medical care and putting trillions of dollars into medical care every year, even if there are a few bad actors? The Network for Excellence in Health Innovation (NEHI) produced a stunning graphic in its 2013 Annual Report Card that highlighted the mismatch between impact of health determinants and share of the national health expenditure. Access to clinical care accounted for just 6% of a person's overall health where roughly 50% of a person's health depended on other determinants like socioeconomic, physical environment and healthy behaviors. However, the lion's share (90%) of healthcare spending went into medical services, leaving 9% for healthy behaviors and 1% for "other". You can find other similar studies in my article Clinical Care ≠ Healthcare.

US News carried an article that put the numbers more starkly:

only 3.1 percent of U.S. health spending went to government-administered public health in 2009, according to the U.S. Centers for Medicare and Medicaid's National Health Expenditure Accounts. That works out to $251 per person in public health spending, compared with $8,086 per person in medical care spending.

By 2015 the amount spent for medical care in the US grew to $3.2 trillion or by nearly $2,000 per person to $9,990 vs the $8,086 per person in 2009! It is especially unnerving when we understand there is wide-spread agreement that 30% (or $1 trillion) is unnecessary medical care or even outright waste. Imagine if even a few dollars more had been diverted to non-medical determinants each year.

3) The more things change the more the stay the same

The US is moving from Fee For Service to Value Based Care. This transition was captured largely in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which had broad bi-partisan support (passed the House 392-3 and Senate voted 92-8). MACRA is supposed to reward providers who demonstrate greater value and penalize those providers who do not. There are two tracks, the Alternative Payment Model (APM) which is essentially a risk-sharing arrangement between CMS and the providers and the Merit-based Incentive Payment System (MIPS) for those not part of an APM. So what providers are covered in this new paradigm shift to Value Based Care:

• Starting with the first year, any eligible clinician in an Alternative Payment Model.
• For the first two years under MIPS (2017 & 2018): Physicians, PAs, NPs, Clinical nurse specialists, Certified registered nurse anesthetists.
• Starting in the third year of MIPS (2019): Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians / Nutritional professionals

So... pretty well the same providers who are covered in the current Fee For Service world. The Centers for Medicare & Medicaid Services (CMS) has put together a nice overview of the MACRA Quality Payment Program that shows its four areas to improve quality for those providers not part of an Alternative Payment Model: Cost (10%), Quality (50%, based on six measures), Clinical Practice Improvement Activities (15%), and Advancing Care Information (25%).

So in MACRA healthcare value is better...

• If Medicare claims are in line with other clinicians,
• If clinicians show risk-adjusted performance is better on six chosen clinical measures,
• If clinicians participate in Alternative Payment Models,
• If clinicians use Electronic Healthcare Records.

What about non-clinical health determinants like socio-economic, physical living conditions, lifestyle, etc.? Studies have demonstrated the significant impact of these non-clinical health determinants.

What about complementary providers (e.g., naturopaths, acupuncturists, massage therapists, biofeedback, etc.) Americans are currently engaging many of these practitioners at their own expense, as the National Center for Complementary and Integrative Health found in its 2012 survey:

NPR provided another example where it is easier to get opioids dictated by medical care (and contribute to a national epidemic) than at least exploring less invasive alternatives:

... generally injections and pills are standard treatment, but there are helpful alternatives, things like biofeedback, acupuncture, cognitive behavioral therapy, alternative physical therapies. A big problem she says, though, is even if doctors know of them.... They'll find out the insurance won't cover it, and so they're back to needing drugs.

And just a few days ago, the American College of Physicians published this:

Philadelphia, February 14, 2017 -- The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published today in Annals of Internal Medicine that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation.

MACRA and Value Based Care represent change... but a change that will leave things essentially the same unless the healthcare system embraces the major health determinants, new needs and modalities that accompany chronic illnesses.

4) Separation of Clinic and Lifestyle

In January 2005 NBC News ran a story about a McDonald's restaurant that was located in the food court of the Cleveland Clinic, a hospital system noted for treating heart problems. Hardly something that a physician would recommend to a heart patient. It took over a decade to close that McDonald's in the Cleveland Clinic. A recent Huffington Post article highlights that fast food restaurants are allowed on hospital premises in 15 states, not just nearby but on the premises.

It was only in 2015 that the large drug store chain, CVS, stopped selling cigarettes in its stores... that conveniently allowed patients to pick up a pack of cigarettes (or at least be tempted) while waiting for their prescriptions. Walgreens, on the other hand, still sells cigarettes and you might even be able to buy a bottle of Wild Turkey bourbon whiskey in some states.

Payer organizations like commercial insurers, Medicare and Medicaid also send mixed signals that not only confuse consumers but can incentivize poor behavior, for example covering bariatric surgery but not providing (or making it tremendously difficult) for nutrition counseling. Aetna's CEO, Mark Bertolini, has a profound understanding of health determinants and the value of mindfulness and has even rolled out mindfulness programs to Aetna employees but Aetna has not brought such forward-thinking to the marketplace.

When actors in the conventional healthcare systems (e.g., payers, hospitals, physicians, pharmacies, scientists, policy makers) do not think and act for the whole person they devalue the impact of other determinants on health like fast food, super-sized soft drinks, tobacco and alcohol. What happens in the clinical exam room, the surgery center, the pharmacy, the dentist's chair, the psychologist's office is intimately and inextricably connected to what happens in the grocery store, the workplace (or lack thereof), the bank account, the school, the place of worship, in social relationships, within ourselves, and so much more. Again, we must face the truth... the conventional medical care model will not improve health outcomes in the 21st Century like it did in the 20th Century and may actually work against necessary changes. If we want to influence clinical outcomes and costs then we must treat the whole person and can no longer suffer this divide between Clinic and Lifestyle.

A New Hope

In my core, I am a problem solver who knits together talented people to make a bigger impact. Whether developing and running global infrastructure for a multi-billion dollar enterprise or working in a start-up with a shoestring budget and a whiteboard of ideas, I relish the opportunity to make things better with others. To me, the current dysfunctional healthcare system is just another opportunity to work with great people to make something better. I welcome thoughtful input and offers to collaborate from others who want to engage in this change and also from organizations that are serious about real healthcare transformation.

Innovation

If you look at Google Trends for the search term "healthcare innovation" there is a noticeable uptick in the number of searches starting in 2012. For the past five years there have been billions of dollars invested in Electronic Healthcare Records (EHR), telemedicine, Revenue Cycle Management (RCM), Population Health Management (PHM), Patient Centered Medical Homes (PCMH), Accountable Care Organization (ACOs), and so many others. All these "innovations" promised to revolutionize or at least improve some part of the Triple Aim. At best, all have had a marginal impact. Why?

These innovations have either failed to deliver or had a limited impact because they are incremental improvements that remain focused within the silo of medical care. EHRs? Most physicians hate them and interoperability among provider organizations is years away. PCMH? Lukewarm adoption and results. ACOs and other Advanced Payment Models (under MACRA)? Most providers are still not part of an ACO or APM and will therefore be subject to the MIPS track of MACRA... in other words, lukewarm adoption and unclear results. And the soundtrack is similar for other innovations primarily because they all focus on improving some dimension of medical care. One of my favorites is the focus on "care coordination" which touches on the whole alphabet soup of MACRA, EHR, PCMH, ACO, PMH but usually means coordinating medical care among specialists, primary care, and perhaps pharmacies and lab orders while ignoring the determinants that have a larger impact on health.

Adjacent Markets

What if we treated non-clinical determinants of health like nutrition, social relationships, mindfulness and so on as "adjacent markets". Instead of diminishing returns for investments focused on innovation in medical care like the previous paragraphs, what if entrepreneurial spirits inside and outside of the clinical care model began to leverage those clinical assets for adjacent markets? I don't mean things prevented by Stark's Law like investing in radiology practices or even a hospital-sponsored gym. I mean a consumer experience rooted in medical care but a whole person approach that fully encompasses all health determinants.

For those inside the medical care industry this is almost the opposite of a Deloitte article, Unlock assets from adjacent markets. For those outside the medical care industry, it is pretty much in line with the Deloitte article. The question of whether those in the medical care industry leverage their existing assets or let organizations outside medical care move first and realize all the benefit is one of timing.

Healthcare Not Medical Care

One of the profound insights I gained at Wharton was in David Schmittlein's marketing class which is also repeated in the Deloitte article: “People don’t want to buy a quarter-inch drill. They want a quarter-inch hole!" For our purposes-- people don't want to be patients, they want to be "healthy, wealthy, and wise" (credit to Ben Franklin).

For those organizations focused on medical care this means cannibalizing revenue, for example, by helping consumers avoid heart disease through a more holistic approach that incorporates adjacent markets (e.g., complementary therapies, "food prescriptions", financial consulting, social/support networks, job assistance, etc.) instead of treating the condition with stents after the patient has deteriorated and must be rescued. This is a very difficult conversation to have with medical care administrators and staff (and probably a much easier conversation with payer organizations who would like to reduce expensive medical procedures). For those organizations outside the medical care industry, this means offering an alternative to becoming a patient through a holistic platform that accommodates personal choice. However, getting paid for such a platform is very difficult in a population that sees anything healthcare-related as an insurance question... if it isn't covered then it isn't done. Fortunately, this mentality is starting to change as Health Savings Accounts (HSA) give consumers more discretion over healthcare choices (including the ability to invest those HSA funds and grow for financial security).

Summary

The conventional medical care model will not improve health outcomes in the 21st Century like it did in the 20th Century and may actually work against necessary changes. All evidence points to a dire need to address non-clinical health determinants as part of healthcare. Open-minded intrapreneurs and entrepreneurs can create holistic services to address healthcare for the whole person, preventing and potentially reversing many chronic illnesses and health disparities that plague the US but must be willing to shoulder risk and buck decades of medical-centric thinking. To do this, we must:

1. Bring focus to non-clinical health determinants.
2. Understand that the health challenges today are around chronic illnesses, no longer acute care issues.
3. Be willing to invest in and adopt new business models that incorporate non-clinical determinants as adjacent markets for a holistic approach to healthcare.

Be Well!

-Tim

Tim Perry, MPA, MS, CPHIMS, PCMH CCE, CISSP is a visionary Chief Information Officer who has a deep passion for transforming and improving healthcare. Tim is blessed with a wonderful wife and two inspiring children. Tim has practiced Taiji Chuan for over 15 years and enjoys cooking wholesome (and easy) meals.