David Brailer | June 11, 2020
Editor’s Note: In order to advance the following agenda, Health Evolution this week is launching the Health Evolution Forum, a virtual year-round collaboration of health care CEOs, policymakers and thought leaders. The Forum will focus on forming private sector partnerships to drive change without asking for action from Congress. The forum will launch Roundtables focusing on Health Assurance and Reinvented Chronic Care Management, New Models of Care Delivery, and Next Generation IT in Health Care. Health Evolution expresses our deepest gratitude to an amazing group of founding Leadership Fellows, who have worked with us to design the Forum and who will oversee it for the year 2020-21.
I have spent 30 years working on many aspects of health care reform. My peers have been equally eager to see pressing challenges in health care addressed and solved. We wanted to bring a new consciousness for the “three aims” – quality, access and cost – through our leadership of commercial and public organizations. The issues that consumed us were having widespread access to high quality care, using emerging information technologies to improve quality and prevent errors, controlling skyrocketing costs and engaging consumers more in their care. We believed that these challenges resulted from policy mishaps and unintended consequences of our forebearer’s work. They were big problems that kept American health care from being in the top ranks of the OECD comparators, and causes of the eternal question: “is this all we get from spending so much money?”
Today, the foundational issues of cost, quality and access remain unsolved. We somehow have been able to resist change at the core of the industry at the same time we are driving innovations faster than ever. But, like an engine that is revving too fast for its design, it isn’t sustainable. Despite advances, the industrial framework of the health care system, the five underlying models –population health, care delivery, business, information and innovation – are worn thin. The devastating impact of COVID on the health care system has shown that there should be little doubt about this.
I wrote last week about the many ways COVID damaged the health care system and, more broadly, how the pandemic revealed failures in our attempts to reform. This week I am writing about a new post-COVID agenda for health reform with a focus on the core principles that should guide rethinking our health care system. I am not advocating for federal policy change – indeed, just the opposite. I fear for what policies will come from a Congress inflamed and embittered by a pandemic, a brutal recession and a stressed civil society. If federal action is taken on health care now, it is likely to be another massive step toward government control. I am therefore advocating that the private sector take action without the need for sweeping reform and, in fact, to avoid it.
The following principles and overarching goals for each model are designed to steer CEOs, policymakers, subject matter experts and other leaders toward impactful reform of the U.S. health care system.
Population model. The overarching goal of the population model for health care is to provide a health safety net for all and to prevent the onset of disease as early as possible. To date, neither the government nor the private sector has been successful in providing a seamless health care marketplace. But it is essential now and will either be done by the private sector or done to it. Three principles should be applied when rethinking the model of population health. First and foremost, the most compelling principle is community-based population health. We have learned from COVID that the community is the basic unit of population health – individual risks are directly related to how the locality manages prevention and exposure. It should be this way for all health issues as well – the community can address access to care, social determinants, prevention and other health influencers. Communities can focus on the real barriers to health disparities and their drivers in ways federal policy simply cannot. Second, population health needs to start far upstream of traditional health care, and must address the underlying social, economic, nutritional, housing and other drivers of health status and outcomes. This means health care systems, clinicians, plans, employers and others must work with local leaders to develop a program for addressing health determinants in that community. Cities like Nashville have seen success with this approach. Third, particularly in the era of COVID, public health and surveillance needs to be integrated directly into care. No longer can we afford the luxury of treating public health as a separate and ancillary function. It needs to be integrated and operate hand-in-hand with community health, both during the pandemic and later as a partner in health improvement.
Care model. The overarching goal of the model of care has been and remains “right treatment at the right time at the right cost”. Unfortunately, we aren’t close to realizing this goal – care is too often based on an incorrect diagnosis or isn’t appropriate for the person. It has meant people going to hospitals rather than taking health care to them. COVID forced some rapid progress here, but there is much more work to be done. Noting that the model of care is directly impacted by changes in the business model and information model of health care, two principles should be applied in rethinking our model of care. The first is site neutrality. Health care should be delivered anywhere at any time and should integrated into daily life in ways that make health access easy and seamless. Yes, surgeries need operating rooms and severely ill people need ICUs, but most other care services only require a trained clinician, communication channels and diagnostic tools. There is no reason – other than convenience of clinicians – why primary care should be close to hospitals. If anything, COVID taught that co-location is a bad idea when the public shuns seeking routine care for risk of being infected. Retail sites, often discussed as sites of care but rarely seen, should become the new front door of primacy care. The home and smart phone should become primary care sites also. The explosion of telemedicine during COVID shows us, if nothing else, how overdue this change is. But if the industry doesn’t act to tie telemedicine directly into the delivery of care, it could slip backwards post-COVID. Second, we have to engage consumers in their care. Concerns have been expressed for years about how to deal with the apparent apathy of consumers in seeking the best care for themselves. COVID has shown that those concerns are misplaced and wrong. Hundreds of millions of people began to reduce travel, assembly and onsite work weeks before public health officials called the alarm on COVID. The same is true for face masks. People will act in their health interest when two things happen: they understand the risks, and they know what they should do. Legacy health care has shown itself poorly equipped to do either. Consumer advice is too often hidden in layers to informed consent, whose purpose is to avoid litigation, not empower consumers. It is time to rely on the consumer and give them transparent information so they can make appropriate health decisions.
Business model. The overarching goal of the business model for health care is to render financing of health care affordable and sustainable. COVID didn’t just create a one-time financial hit to health care. It showed that the perverse hybrid model of perpetual transition to value-based payments against most dollars flowing through FFS is unworkable. A model that takes decades to transition – no matter how attractive the end result – is confusing, creates conflicting incentives and never gets to the other end. In any health system, there are many legacy and new payment models that have to be balanced and that incent different and often conflicting behaviors. Taken together there is no signal for rational business leaders to follow. Two principles should be followed when rethinking the business model of health care. First, there should be three basic payment models that operate at scale – FFS, VBP (partial risk) and capitation (e.g., full risk). The industry should coalesce around common payment models – even if at different relative payment rates – so that these models are scaled and send direct and clear signals to the market. Payer-specific variations and contractual tweaks to these models should be eliminated in favor of a common paradigm for payment. Second, the application of each payment model should be based on the maturity of the market – its degrees of integration and ability to manage populations. More integrated and advanced markets should be paid with VBP or capitation, while earlier stage markets can remain at FFS. Since clinicians are spread across many health plans and health systems, market-based payment allows clinicians to practice the same way every day on every patient. This is effectively the conclusion of a return to community rating begun by Obamacare.
Information model. The overarching goal of the information model for health care is a holistic, longitudinal view of all health-related information for every person, and for them to control access to it. Despite decades of progress on digital health care, we are far from having a data asset that transforms care delivery. Three are three principles that should drive the modernization of the information model for health care. First, enterprise silos need to come down so relevant health data can be assembled for each person. Changes in government regelation earlier this year open the door for a single health record for each person, but it can only be achieved by actions of the private sector. Health care organizations need to expand their sense of what is health information as well. This data needs to include clinical status and medications, but also the environmental factors, nutrition, location and other data often seen as not health relevant. Second, we need information about people between the 3-month check-ups or hospitalizations. We need it streaming every hour of the day from their bodies, homes and worksites. For years, health information has been used to confirm or reject a potential diagnosis or to measure health status when a clinician asks for it. We need to invert this model so that health information alerts clinicians that it is time for them to do something. Third, people need to control their health information. It has become clear that HIPAA no longer fits the world of digital data where information is generated in entities not covered by HIPAA and much that data is health-relevant even though it isn’t PHI. Many states will address health care through general privacy considerations but will not likely add sufficient clarity to guide use of health information. Therefore, the private sector should take up a voluntary effort to lay out a new paradigm of privacy consistent with the modern digital era that can be applied until federal policy catches up.
Innovation model. The overarching goal of the innovation model of health care should be, simply put, to advance its population, care, business and information models. Whether it is a new therapeutic, diagnostic, algorithm or device, the principal purpose of health innovations is to sustain health improvement. Three principles should drive the reform of the innovation model of health care. First, industry should collaborate to determine what innovations it seeks. This means that health care organizations need to be more top-down in adopting innovations, rather than bottom-up, and that the industry needs to act in unison to support important innovations. Non-therapeutic innovations should be rigorously tested in terms of their benefit, cost and risk just like therapeutics are subjected to under FDA review. The industry should preferentially adopt those that add true value. Second, innovations that pass a high hurdle for benefit should be financed by payers and providers to ensure that they operate at scale. The industry should make a joint commitment to rapidly adopt innovations that advance care or sustainability of financing. Too many good ideas get stalled and can’t access the market or achieve widespread use given the piecemeal way health innovation has been pursued in the past. Third, the industry should actively kill off ideas that do not add value. Too many innovations are pushed by over-funded investors who create apparent solutions to problems that don’t exist or that provide minor incremental improvements over the status quo. These should be stopped early to not distract precious resources from other high value efforts.
We are approaching an existential moment for private sector health care in the US.
That many of the problems we face are created by poorly conceived or obsolete federal policy is no longer the issue. That the health care system has been fundamentally broken for a long time, despite the relentless efforts of health reformers over the decades, is no longer the issue, either. What matters is that patience for many societal and civic problems in America has run out — and reforms we never thought possible can happen.
Now is the time for private sector CEOs to demonstrate that they can solve the major challenges of health care — without Congress — to shape a more equitable future with new models of care delivery, cutting-edge technologies that dynamically modernize consumer engagement and partnerships that inspire health assurance as a new paradigm for all Americans.