Move from volume to value by fundamentally challenging the status quo
The transformation of healthcare is no longer a futurist’s prediction. Health insurers, providers and health systems have spent the last several years reacting to reform and external changes by cutting costs, developing strategic plans and enlisting the help of outside consultants to “guide the path” to readiness.
However, the shape of transformation is already becoming clear. Leaders may now assess how to use new technologies and processes to fundamentally transform the system and change the basics of healthcare beyond incremental approaches.
Healthcare will not change without fundamentally changing the way physicians and providers view the world. The Wharton School has been analyzing the biases physicians bring to the table that affect their ability to embrace-or even accept-change. Among these is a competitive, hierarchical and autonomy bias that makes doctors feel like they are losing control when governments and health plans make changes.
Medical schools and residency programs need to transform how they select and educate physicians. Educators must counter the biases observed in medical trainees-biases that currently favor autonomy and hierarchy, instead of teamwork and communication. Universities still accept medical students based on test scores and organic chemistry grades, yet somehow are amazed that doctors are not more empathetic, communicative and creative.
The educational process puts students and residents through a competitive, hierarchical culture, making it difficult for hospitals and groups to succeed in training physicians to work as part of high-performing teams. Furthermore, hospital and group medical staff bylaws, in addition to the pitifully small amount spent on real physician leadership transformation, inhibit fundamental change in the most important ingredient of any health system-the providers who see the patients and make the volume/value decisions.
Educational leaders need to change the academic medical selection and education system to one that chooses physicians, nurses and pharmacists based on emotional intelligence and ability to adapt. Medical student and residency curricula must reflect the provider society needs for the future. And institutions need to invest in true leadership development of the “silent majority” of the medical staff to help them become change agents for the future.
Hospital readmissions have ballooned in this country and are a major cause of increased expense with little increased value. As reimbursement moves from a perverse-incentive system where readmissions were “covered,” to one where too many readmissions could doom a system or health plan to failure, hospitals will need to move from a reactive model accounting for what happens when those patients return, to a transformative model of reducing some of the root causes for readmission.
The use of extensivists, telehealth and population-designed interventions will become part of that transformative model.
America has moved from a model where family physicians were ubiquitous in their delivery to a bright line between outpatient primary provider-most of whom hardly enter the hospital-to hospitalists-who rarely leave the hospital. Most of the 90-day readmission problems happen somewhere in between and involve a combination of hand-off issues, communication failures, and insecurity by patients and providers that leads to emergency room visits and readmissions.
Loosely defined, extensivists, supported by sophisticated information technology systems, split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged members and those at high risk of readmission. In the health plans and hospital systems where these have been employed, readmission rates have decreased significantly, with reduced inpatient admissions in high-acuity populations.
One of the major expenses and least talked about causes of inefficiency in the healthcare system is the learning curve inherent in new technologies and American medicine’s inability and unwillingness to measure and ensure proficiency. Surgeons can often go their entire career without having their technical or teamwork proficiency objectively monitored.
This is especially true for new and expensive surgical modalities such as hybrid ORs, robotics and minimally invasive surgery. The risk of morbidity and readmission is extremely variable among providers for these procedures and research proves that expenses, readmissions and outcomes are less desirable at the beginning of a surgeon’s experience with the modality.
Now that the data and simulation centers exist to both train and test competence, it is owed to patients and the institution’s financial health to ensure that every provider using a modality is within a mean and a standard deviation of skill in each technique. Health plans need to work with providers and hospital systems to utilize these new simulation technologies and reward those who can prove competence and proficiency in highly technical procedures.
Every discussion about the “new healthcare” always includes a passing allusion to the lack of primary care providers. Unfortunately, the fantasy of health plans, policymakers and health systems alike has been that medical students will reverse the trend of the last 30 years and decide to take up the noble provision of primary care.
Policymakers react to the family physician shortage by increasing family practice residencies and in some states instituting loan forgiveness programs for those who choose that route. That’s not a transformation. The transformation will occur when policymakers recognize that family physicians often earn 20% to 30% of what some specialists earn.
The new model affords the family physician an opportunity to lead a primary care team of physician and non-physician providers. In many states, doctors stubbornly still fight privileges that would allow this team approach. Doctors of nursing practice, advanced nurse practitioners, physicians assistants, healthcare coaches, telehealth professionals and clinical pharmacists will be the new currency for a dynamic family health practice.
For example, at University of South Florida Health, the practice group began an ACO at The Villages, a 100,000-person retirement community. Working with The Villages, the university recruited 40 family physicians who wanted to lead a team of professionals. The care center’s visit rooms are based on two primary care physician “buddies,” with physician extenders that together care for 2,500 patients. In this way, everyone is doing what they were trained for, more patients can be seen, and family doctors are paid and respected as leaders of a team, instead of autonomous and individual caregivers.
More money is spent on healthcare research, development and delivery in the United States, and yet health outcomes and quality of care are considered suboptimal. It comes down to big data. The industry has reacted by purchasing expensive data systems and unilaterally “massaging the data” to begin the process of analyzing the population.
But the transformation will occur when healthcare starts to work with other industries that have utilized predictive modeling, partner with mathematicians, engineers and scientists and take an entrepreneurial academic approach to population health, decision support, modeling and comparative effectiveness. American healthcare can bend the cost curve if health plans, hospital systems and provider groups are able to partner with these resources to reduce the risk of readmission for key patient groups; compare primary care physician resource utilization as it relates to conformance with pay-for-performance criteria; evaluate the admission trajectory; and investigate what interventions will make employees healthier.
After all, why should a football coach have more mathematical backbone supporting a decision on what play to call than a health system CEO has to decide where to devote resources?
Stephen K. Klasko, MD, MBA, is president and CEO of Thomas Jefferson University and Hospital System.