CEO's Guide to Restoring the American Dream

by Dave Chase

  So, in response to these shortcomings we now have Health care 2.0. The era of Big Medicine. Large corporate groups buying practices and hospitals, managed care and Obamacare, randomized controlled trials and evidence-based guidelines, EMRs, PQRS, HCAHPS, MACRA, Press Ganey, Lean, Six-Sigma. It is the era of Medicine As Machine…of Medicine As Assembly Line. And we—clinicians and patients—are the cogs in the machinery. Instead of ceding authority to physicians, we cede authority to government, administrators, and faceless algorithms. We more often treat a computer screen than a patient. And the doc isn’t the boss, but neither is the rest of the health care team—nor the patient. We are ALL treated as commodities…raw materials in the factory.

  Health 3.0 Vision

  Dr. Damania goes on to describe Health 3.0 as follows:

  Taking the best aspects of 1.0 (deep sacred relationships, physician autonomy) and the key pieces of 2.0 (technology, evidence, teams, systems thinking), Health 3.0 restores the human relationship at the heart of healing while bolstering it with a team that revolves around the patient while supporting each other as fellow caregivers. What emerges is vastly greater than the sum of the parts.

  Caregivers and patients have the time and space and support to develop deep relationships. Providers hold patients accountable for their health, while empowered patients hold us accountable to be their guides and to know them—and treat them—as unique human beings. Our EHRs bind us and support us, rather than obstruct us. The promise of Big Data is translated to the unique patient in front of us. Our team provides the lift so everything doesn’t fall on one set of shoulders anymore (health coaches, nurses, social workers, lab techs, EVERYONE together). We are evidence-empowered but not evidence-enslaved. We are paid to keep people healthy, not to click boxes while trying to chase an ever-shrinking piece of the health care pie. Our administrators seek to grow the entire pie instead, for the benefit of ALL stakeholders.

  As I’ve shared this framework, I’ve received a couple of questions/comments to the effect of “where’s insurance?” It’s not here as it’s not about who is assuming the financial risk. That varies by country and, even in the U.S., most risk is assumed by employers or various government entities at the state and federal level. The “insurance” companies are largely claims processors (typically only about one-third of the claims insurance companies process are their funds at risk). No matter who carries the risk, we’re bad at purchasing health care and health & wellness services in the U.S. This framework suggests we need to take a fresh look, rather than buying what has been radically underperforming.

  The pyramid graphic below is the start of developing a North Star for how various elements of health and health care interrelate with each other. It’s going to require some verbal explanation of where we’re going with this. The “we” is Dr. Venu Julapalli, Dr. Zubin Damania (aka ZDoggMD), Jonathan Bush, and Dr. Vinay Julapalli. The problem we’re trying to address is how health care is “organized” in a tangled jumble of silos largely organized around medical technologies, not individuals (patients). It’s exacerbated by economic models and information technology that further impair healing. We believe that fostering an ecosystem that is antifragile should be one of the key design points.154 Flawed thinking looks at health care simply as an expense (or, from the perspective of the health care industry, revenue to be maximized). As Churchill states, when health is looked at as an asset, it causes one to optimize for something completely different.

  For those unfamiliar with Nassim Taleb’s book, Antifragile, he introduces the book as follows:

  Some things benefit from shocks; they thrive and grow when exposed to volatility, randomness, disorder, and stressors and love adventure, risk, and uncertainty. Yet, in spite of the ubiquity of the phenomenon, there is no word for the exact opposite of fragile. Let us call it antifragile. Antifragility is beyond resilience or robustness. The resilient resists shocks and stays the same; the antifragile gets better.

  Health care has been unique in that it uses technology as an excuse for costs to go up and productivity to go down. In Health 3.0, a properly organized health ecosystem can benefit from technology rather than helping fuel hyperinflation for all of us, while decreasing productivity and job satisfaction for clinicians.

  Figure 14 is a thumbnail sketch for how the pyramid works. You can also explore an interactive graphic at healthrosetta.org/health30. Each layer represents a level of care or self-care. You want to spend as much of your life as possible in self-care at the bottom of the pyramid.* When you have to move to higher layers, you want to move back down asap.

  Each pyramid layer has four facets, one for each side of the pyramid.

  1. Optimal way to deliver health services

  2. Optimal way to pay for care

  3. Enabling technology for #1 & #2

  4. Enabling government role for #1 & #2

  Following a given layer (e.g., value-based primary care 3.0) shows how the four facets apply to that layer.

  You read the pyramid from the bottom and at each layer look at the four facets to ensure they are meeting your goals. Thus, you would see that the self-care layer is at the bottom. When you access the health care system next generation primary care is where you should start. In places like Denmark and the best value-based primary care organizations in the U.S., over 90 percent of care can be addressed in a proper primary care setting. Full valued-based primary care includes things like behavioral health, interior work, health coaches, and physical therapy, all enabled by technology like secure messaging, remote monitoring, and other future advances.

  Chapter 14 covers value-based primary care and focuses on high-cost individuals who consume the vast majority of health care spending. For the majority of people who have simpler primary care needs, there are more streamlined, technology-enabled, and cost-effective methods of delivery. For example, Dr. Jay Parkinson has proposed what he calls “Primary Care 3.0” which is optimized for the majority of people with simple medical needs.155

  If an issue can’t be addressed in primary care, you move up to the diagnostic layer (e.g., lab tests) for deeper insight to rule in/out various issues. Then, if you need a prescription, you’d go to the next layer―pharmacy woven into primary care. Organizations such as ChenMed do this well. If a prescription isn’t the answer, you proceed to the next layer for a “professional consultation”. This is a consult between the PCP and an unconflicted specialist. In this context, unconflicted means that the specialist wouldn’t be performing an intervention or procedure, thus removing the profit incentive to overtreat. If an intervention is needed, you proceed to the next layer―intervention via focused care setting with deep experience in the intervention.

  Jonathan Bush, CEO of athenahealth, told me about his own knee surgery and finding that even the highest-volume knee surgeons in Boston only do less than one-third of what they could. They spend the rest of their time doing a bunch marketing they’d rather not do (e.g., be a “team doctor” for a sports team to market themselves). Most would rather spend the majority of their time doing what they do best. If they did, they could drop their unit price.

  Finally, for the unfortunate few who have rare and highly complex conditions, they’d go to a Center of Excellence (CoE) in their condition like the NIH, Mayo, etc. at the top of the pyramid.

  To reiterate, even when at higher levels of the pyramid, the goal is to move back down the pyramid as soon as possible.

  As I developed this framework further, I was interested in getting specialists’ feedback. Relatively speaking, I’ve spent more time with primary care physicians at the base of the pyramid. The most advanced and successful value-based primary care organizations intuitively understand two key issues that drive costs and quality.

  1. Fostering self-care and caregiving by nonprofessional loved ones is essential to optimizing healing and health.

  2. Without a seasoned “ship captain” (the primary care physician), rough medical seas cause patients to needlessly suffer from an un
coordinated health care system.

  Specialists, like any group of humans, have many opinions, but I will share the feedback from Dr. Venu Julapalli on the framework (he has also been writing about the tenets of Health 3.0).156 The following are Dr. Julapalli’s comments, edited for length and clarity.

  I am loving what you guys have come up with.

  1.It starts with self-care at the base. That’s key. It underscores personal responsibility in health, which has been woefully neglected. At the same time, social determinants of health (SDoH) are right at the base, where they belong. I love the pyramid’s government facet, letting it act as the market accelerator, not an overly active market participant without the ability to enable the most effective and efficient system.

  2.It properly puts value-based primary care right near the base. As a specialist, I don’t need to be near the base. I also need to have as few conflicts of interest as possible in my interactions with primary care.

  3.It properly puts the specialist care in focused settings near the top (this position doesn’t make them the most important, just the most focused). This is what Devi Shetty is executing in India and Cayman Islands―high-volume cardiovascular surgery by experts who love what they do, while dropping unit price ridiculously through streamlined operations and economies of scale.157

  4.It appropriately puts Centers of Excellence at the very top―go there for help with rare diagnoses, but keep it limited. We should also never forget the power of the engaged patient, who destroys the most expert doctors when love for life takes over. See this article as an example, “His Doctors Were Stumped. Then He Took Over.”158

  Overall, I love this pyramid framework. Conceptually, it’s honoring much of what I’ve come to believe on health care, health, and healing. You’re distilling what real-life experiences and data have shown works in health care.

  I will conclude with a quote highlighting how we need a major overhaul. Simply shifting who pays is just moving deck chairs on the Titanic. Metaphorically, we’re all on the same ship. Dr. Otis Brawley, chief medical officer for the American Cancer Society said, “I have seen enough to conclude that no incident of failure in American medicine should be dismissed as an aberration. Failure is the system.”

  _____________________

  * Note that self-care is necessary at all levels. However, it starts at the foundation. The pyramid is a holarchy. This just means it incorporates hierarchies that both transcend and include levels. They work like 3D concentric circles, rather than rungs on a ladder. Imagine looking at the pyramid from the top. You will have concentric boxes, with self-care transcending and including them all.

  Appendix F

  Health 3.0 Vision

  Implications for Providers, Government, and Startups

  In the Health 3.0 Vision appendix, we laid out the failings of Health care 1.0 and 2.0 that have primed us for Health 3.0. Despite these failings, we should keep the positive and necessary elements. It’s hard to argue that it’s not an especially challenging time for nearly anyone in health care. We have epidemic levels of burnout amongst doctors,159 only 20 percent of physicians report being engaged,160 health care organizations are struggling to keep up with every-changing reimbursement and quality rules, and well-intentioned government initiatives continue to inadvertently slow rapid-pace innovation. Without a common vision and framework of what Health 3.0 should look like, we’ll remain where we are, failing to activate the full potential from our collective passion, resources, and efforts. Even eight Olympic-caliber rowers can’t make headway without a common goal and view of the course ahead.

  In Health 3.0, the fragmented, uncoordinated health care jumble we know today must be replaced with a unified interplay of these four key elements.

  1. Health & wellness services

  2. Health & wellness services purchasing practices

  3. Technology embedded throughout health care

  4. The role of government

  Health care is frequently a jumble of uncoordinated silos organized around medical technology, rather than people. This has led to a suboptimal experience for both patients and clinicians. This is often made worse by incentives that run counter to optimizing health outcomes.

  The Health 3.0 framework has high-level implications for the following key audiences.

  Health Care Provider Organizations

  Major trends are making the care delivery elements of Health 3.0 a once-in-a-career opportunity (or threat). Just in the U.S. experts expect $1 trillion of annual revenue to shift from one set of health care players to another over the next decade.161 This is a byproduct of the transition to purchasing health care with accountability baked in. Here are three ways health care provider organizations can advance and thrive in a Health 3.0 world.

  1. Sell Health Services Conveniently & Be Accountable for The Value You Deliver

  Various new primary care models such as onsite/near-site clinics and direct primary care have significantly expanded their scope of services (remote monitoring, health coaching, etc.). The top performers readily put their fees at risk (e.g., Vera Whole Health, Privia, Iora Health, etc.). Medicare Advantage programs are taking off like wildfire, with the top performers delivering care far differently than in volume-driven models. If you’re a health care provider, this is the future!

  We expect Medicare Advantage to continue to grow and Medicaid Advantage to follow closely behind. This can’t be dismissed as fringe when two early adopter organizations (CareMore and HealthCare Partners) were acquired for over $5 billion and there has been over $1.2 billion invested in next generation primary care models in the past couple of years.162 Sadly, we hear of too many organizations trying to foolishly cling to fee-for service and even enacting anti-competitive practices such as threatening doctors in their communities who don’t refer to them (e.g., blocking data and patient flows).163 Our message to you, is don’t be scared, be brave. Be among the early organizations that figure out and master how to thrive in the inevitable future.

  2. Millennials, They’re a Comin’

  If you thought boomers were a big deal, millennials dwarf them and are transforming markets. This has already had a devastating impact on a local oligopolistic market (newspapers) similar to health care.164 In another area of health, Big Food and Big Soda have had their worst earnings in decades caused by millennials having significantly different purchasing habits than their parents. The status quo in our current legacy health care system is nearly a perfect opposite of what millennials want and value. Organizations that think they’re entitled to their patients’ kids are in for a rude awakening. For most provider organizations, private employers are their most lucrative revenue stream. Millennials are already the biggest chunk of the workforce and expected to be 75 percent of the workforce in 10 years. As millennials wake up to the reality that they will be indentured servants to the health care system without change, expect their voices to be heard like never before. Health 3.0 is just what millennials want.

  3. Destructive Doctor Relationships Will Destroy Hospitals’ Success

  It’s not just doctors that feel abused by the Health care 2.0 system. However, the economic impact of doctors leaving in droves to new players and from burnout will enormously harm health systems. The ZDoggMD “Lose Yourself” anthem highlights the rising revolution of nurses, doctors and clinicians who are saying “enough” and leaving for organizations focused on the Quadruple Aim.165

  Government Officials

  With Health 3.0, government will experience implications within the many roles it plays.

  1. Be a smart buyer

  It seems every local, state, and federal government entity is struggling with budget challenges—largely the result of health benefits being the second biggest expense after wages for many entities. As one public entity found, the best way to slash health care costs is to improve benefits (e.g., greatly improved access to value-based primary care).166 Innovative new health care delivery organizations can serve a broader audience faste
r if the government is an early adopter of higher-performing health benefits. The employee and government entity can both win when employees get access to superior care that also reduces total health spending. Money is freed up to contribute to the other social determinants of health that governments can impact.

  2. Don’t rob from Peter to pay Paul

  Government is in a unique position to improve public health and other social determinants of health. Sadly, hyper-inflating health benefits costs unnecessarily steal funds from public health and social determinant programs. These social and economic factors drive ~40 percent of health outcomes, while clinical care only drives ~20 percent.167 Yet it consumes far more financial resources. Wise government leaders recognize the opportunity for cultivating what we call economic development 3.0, playing the high-performance health care system card. Those that have done this have created enormous value for their constituents.168 We all intuitively know that health care spending comes at the expense of other household spending. Economic Development 3.0 properly aligns limited public resources to improve social determinants of health and reduce middle class wage stagnation.169

  3. Why accept in health care what we’d never accept elsewhere?

  Imagine if local, state, and federal government contracts for road and highway construction did not require smooth connections between road sections. This is exactly what happens in health care. We pay trillions of taxpayer dollars to tax-exempt health care organizations (many health systems are tax-exempt), yet permit them to prevent implementation of many simple care improving processes, reporting, and technologies, such as simple exchange of vital patient information critical to enabling clinicians to provide high-quality care. Collectively, trillions have gone to health care organizations that lack even basic modern connectivity. Nowhere in our society are more lives in jeopardy. It’s like military generals who are actively prevented from seeing the full battlefield.