CHAPTER
8
A Compassionate Connected Healthcare Industry

EARLY IN THIS book, I described my own experiences as a patient and as a family member of patients. In this final chapter, I’d like to tell you a bit about my mother-in-law, Norma. She is 85 years old, but sadly, not a “young” 85. A retired nurse, she smoked and struggled with her weight for decades, eating a diet rich in high-calorie, fried foods. Such a diet was the norm where she lived, part of the culture. My husband recalls that when we were first dating and my mother invited him over for dinner, she served alfalfa sprouts. “I had never seen them before,” he says. “I thought it was grass. I grew up eating fried pork chops, fried potatoes—everything fried. That’s what we ate.”

By her late forties, my mother-in-law had developed type 2 diabetes. She did stop smoking in her late fifties, but her health woes worsened nonetheless. Years of walking around with excess weight took a toll on her joints, leading her to undergo two knee replacement surgeries. By her early seventies, she was going blind from the diabetes and developed kidney problems, among other ailments. As of this writing, she is completely blind, in kidney failure, and dependent on others for her basic needs. She relies on a walker to get around and has to be accompanied to meals at her assisted-living center because she tends to fall if left on her own. Suffering pervades her daily life. As she says, “I’m tired. I can’t even see the faces of my grandchildren. I can’t walk without falling down. Honestly, I don’t want to do this anymore.”

Is the suffering my mother-in-law experiences inherent, simply a part of growing older? Not exactly. Although genetics obviously affects how we age, lifestyle choices play an important role. Had my mother-in-law stopped smoking or never started, and had she kept her weight under control with exercise and a healthy diet, she likely would not be where she is today. My own mother, also a former nurse, offers a helpful counterpoint. She, too, smoked as a young woman and quit in her forties. Otherwise, though, she has largely cultivated healthy habits. She has eaten a healthy diet throughout her life (lots of alfalfa sprouts), and today she is a vegetarian. She exercises daily and hikes a portion of the Appalachian Trail every fall. She takes a multitude of vitamins and a statin to lower her cholesterol. She is the healthiest person I know and endures none of the chronic conditions that makes my mother-in-law’s life so difficult.

In recent years, the healthcare industry has come to recognize the importance not just of offering excellent care for sick people but of preventing people from getting sick in the first place. Medical science knows a great deal about how to keep people out of the hospital and enjoying life longer through nutrition, exercise, mindfulness, and preventive measures. What better way to prevent suffering—and reduce the burden on our healthcare system—than that? And yet the healthcare industry hasn’t gotten behind wellness as much as it might. We’ve improved at caring for patients at home after they’ve been in the hospital, but we don’t reimburse healthcare organizations enough for keeping people well, nor do we give patients enough financial incentives to keep themselves well. As a result, Americans suffer more from chronic illness than residents of other developed countries. As a 2015 report by the Commonwealth Fund found, the United States had “poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions” than 12 other high-income countries, even though we spend more on healthcare than these countries.¹

Wellness is just one area in which the healthcare industry as a whole might mobilize to reduce or alleviate suffering. By engaging on the level of policy around safety, waste, provider diversity, population health management, and a number of other issues, we can not only cut costs and improve outcomes but improve the patient and caregiver experiences and reduce suffering. As we’ve seen, action at the individual, team, and organizational levels is essential to bring the Compassionate Connected Care model to life. Still, we’ll never achieve deep, sustainable changes unless the larger system of healthcare delivery changes. All of us—individuals, teams, and organizations—need support from systemwide policies and mandates that put the experience of patients and caregivers first.

The History of Healthcare Reform

Supporting compassionate and connected care at the industry level isn’t just a matter of adopting policies that enable frontline caregivers to put people and their needs first. In the broadest sense, we cannot provide state-of-the-art, patient-centered care unless we simultaneously address another basic factor: cost. The economics of healthcare matter—they are an inescapable reality. Our healthcare system can expend endless effort trying to reduce suffering, but if it doesn’t also contain costs while also assuring high quality, our efforts on behalf of patient and caregiver experience won’t be sustainable. Healthcare must be safe, effective, patient centered, and efficient.

To understand the link between patient experience and cost, consider for a moment why an aspirin costs $10 in the hospital even though you can buy a whole bottle of aspirin at retail for less than half that amount. Have you ever thought about this? Your local drugstore’s price contains a markup that reflects the drugstore’s own costs, including compensation for clerks and other team members as well as the money the drugstore must pay to distributors to buy the aspirin. The price also reflects a profit margin for the drugstore.

Hospitals have an entirely different—and more formidable—cost structure. Yes, hospitals must buy the aspirin from a distributor, which costs money. But after the hospital receives the aspirin, it goes to a pharmacy, which must be staffed. The pharmacists and technicians cannot dispense the medication without an order from a provider (more costs there). Meanwhile, in order to receive the aspirin, patients must be admitted, which means that the hospital must pay costs associated with their room and nursing care. Oh, and that electronic medical record the physician uses to enter the order for aspirin? That entails a huge capital outlay to buy, implement, and maintain. In short, each step in the provision of aspirin to a patient in a hospital setting costs money. And each step also holds the potential for suffering, in the form of waiting, error, duplication, and adverse outcomes. What if the provider misses a potential drug interaction when prescribing aspirin? What if the nurse provides the aspirin as ordered without waiting for the pharmacist or the alerts in the electronic medical record? What if such errors lead to significant bleeding for the patient? And what if the whole process takes so long that a patient suffering from a headache has to wait three hours or more for pain relief?

These questions aren’t hypothetical. They arise every day in healthcare organizations. And they don’t just apply to aspirin but to everything in healthcare—every drug, every procedure, every test. Out-of-control costs and out-of-control suffering are facts of life, and the welfare of patients and healthcare organizations themselves hangs in the balance. Hospitals aren’t like banks, whose profit margins exceed 20 percent.² As I’ve noted, many hospitals limp by on margins of 3 percent. If the hospital doesn’t offset its cost of ordering, supplying, stocking, distributing, and providing medications, it will operate at a loss and eventually close its doors.

The bottom line is this: we must keep patients at the center of our business models, treating them with compassion and connection. But if we can’t afford to keep the doors open, we can’t treat patients in the way that we should. That begets the question: How might we structure the provision of care to increase access, reduce costs, maintain quality, and improve the experience of patients and caregivers? For much of the past century, government policymakers and healthcare leaders had sought answers, with varying degrees of success. Before we examine policy areas that the healthcare industry should address in order to reduce suffering, let’s pause for a moment to glance back at previous reform efforts.

During the 1940s, in the wake of the New Deal, healthcare consumed a greater portion of our gross domestic product, and Americans were increasingly unable to pay for care, especially when they were aged or indigent. To solve this problem, President Harry Truman pursued universal healthcare coverage. The American Medical Association (AMA) fought this idea, and legislation promoting universal coverage died in Congress. Truman’s efforts did ultimately lead to the Hospital Survey and Construction Act (1946), which provided federal grants and loans to support the growth and modernization of hospitals.

A subsequent push to increase access to healthcare for all Americans took place during the Kennedy administration. In particular, President John Kennedy supported legislation that would provide health insurance coverage as part of Social Security to Americans aged 65 or older. Once again, interest groups including the AMA defeated the bill. Lyndon Johnson finally signed a version of the legislation in 1965, creating the Medicare and Medicaid programs. These laws provided coverage for healthcare at hospitals and other facilities to Americans 65 years of age and older, as well as to poor, blind, and disabled individuals.

During the 1970s, President Jimmy Carter took up the fight for universal healthcare coverage, but he didn’t accomplish much, despite weak support from the American Hospital Association and the AMA. His successor, President, Ronald Reagan, was concerned primarily about reducing healthcare costs, and during his presidency, several laws were passed to reduce federal spending and to improve efficiency. The legislation accomplished these goals by changing Medicare’s reimbursement methods, and specifically, by reducing reimbursement to hospitals and physicians and boosting antifraud measures. These efforts to curb costs continued under President George H. W. Bush, who signed into law the Stark I legislation that prohibited physicians from referring patients to the physicians’ own clinical lab services.

The Clinton administration tried anew to make healthcare accessible to all, this time via “managed competition.” Championed by First Lady Hillary Rodham Clinton, this approach called for private insurance companies to vie for patients in, as one historian called it, “a highly regulated market, overseen and coordinated by regional health alliances to be established in each state. All health plans would be required to provide a minimum level of benefits. Employers would be required to provide insurance coverage for their employees and pay 80 percent of the premium.”³ Although this legislation died after failing to receive broad support in the healthcare and insurance agencies, the Clinton years did see passage of “The Health Insurance Portability and Accountability Act, a significant expansion of the Stark physician self-referral law (Stark II), and the State Children’s Health Insurance Program.” Another significant expansion of coverage occurred under President George W. Bush, with passage of a law—the Medicare Drug Improvement and Modernization Act of 2003—that provided prescription drug coverage under Medicare Part D.⁴

The most notable piece of healthcare reform legislation passed in recent decades was, of course, the Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act, signed into law by President Barack Obama. The legislation restructured the healthcare system in a bid to lower costs, improve coverage, and improve quality of care. The PPACA mandated that employers of a certain size buy health coverage for employees, that almost all private citizens have some sort of health coverage, that insurers provide minimum levels of benefits, and that they no longer deny coverage based on preexisting conditions. The law also provided federal payments to the states to help cover more low-income patients.⁵

From its inception, the PPACA was highly controversial, and it remains so to this day. Following the election of President Donald Trump, the House of Representatives passed healthcare reform legislation that would modify the PPACA (as of this writing the Senate was considering its own version of this legislation). According to the Congressional Budget Office, the American Healthcare Act passed by the House in 2017 would cause 23 million people to lose insurance by 2026 and decrease the deficit by $119 billion. The Senate bill was similar to its counterpart in the House, though it also allocated funds to stabilize health insurance exchanges created under the Affordable Care Act. Notably, the Senate’s bill did not penalize people for lacking coverage, as the Affordable Care Act did.⁶

The challenge of providing for access, quality, and cost has been a formidable one, and today the overall direction of reform remains uncertain. The good news is that by taking steps at the industry level to address suffering, we can simultaneously move toward other critically important goals that efforts at healthcare reform have sought to address. Let’s now consider five areas that policymakers should address in order to support the drive for more compassionate and connected care.

Policy Focus #1: Promote Safety

In Chapter 7, I argued that organizations need to prioritize safety and become high-reliability organizations (HROs) in order to reduce patient and caregiver suffering. We need to take action on safety industrywide, mandating that all organizations become HROs. Healthcare in the United States is not nearly as safe as it should be. Each year, poor care delivery causes as many as 440,000 patient deaths. Just think of the untold human suffering that this represents.

We can turn to industries outside healthcare in order to drive our own, industry-level action. Craig Clapper, a colleague at Press Ganey, worked for a decade as a nuclear engineer and engineering leader at two power companies, Arizona Public Service Company and Public Service Electric and Gas. He later applied these methods as a consultant in power, transportation, manufacturing, and, most recently, healthcare. While working in nuclear power, Craig personally observed work at 64 of the 103 operating nuclear reactor sites in the United States. All these sites deployed high-reliability organizations or another methodology known as safety science, in part through the Institute of Nuclear Power Operations (INPO), an industry group dedicated to promoting the highest safety standards. As a result of these efforts, the number of significant safety events per reactor site fell from a high of 0.90 events per reactor site in 1989 (that is, nearly one event at every one of those 100 reactor sites every year) to 0.01 events per reactor site in 2014 (that is, only one event for all 100 of the reactor sites in one year). This amounts to a reduction of 98.9 percent over a 25-year period. Moreover, those significant safety events were only “precursor” events. No actual damage to the reactor cores at these facilities occurred during those years.⁷

Imagine if the entire healthcare industry could achieve comparable results. We might, by focusing—as nuclear power facilities did—on cultural transformation. In truth, nuclear power facilities approached the challenge of increasing reliability in two ways. First, they streamlined and standardized processes and fixed equipment. But second, they used people and culture to enhance the ability of workforces to anticipate and adjust to complex situations as they arose. This latter approach mobilized specific tools and universal skills—called “safety behaviors” or “error prevention techniques”—that leaders use every day. Together the tools and the skills formed the foundation of a safety culture at these facilities. INPO eventually standardized the elements of nuclear safety culture in its publication “Traits of a Healthy Nuclear Safety Culture.” The publication included elements such as personal accountability, the avoidance of complacency, effective communication, a respectful work environment, and continuous learning.⁸

As we saw in Chapter 7, the HRO methodology helps organizations improve not only safety but quality, experience of care, engagement of caregivers, and efficiency. Used industrywide, the methodology would lead to substantial reductions in patient and caregiver suffering across our healthcare system. Significantly, the HRO and safety science approaches don’t add more cost or work to our already-strained healthcare system. That’s because HRO is not another thing we need to do. Rather, it’s about changing how we do what we already do.

In effect, every outcome in healthcare today has its own subculture, and as a result, our processes for delivering care are woefully suboptimized. We improve one outcome to the detriment of other outcomes. What kind of progress is that? We need real system improvement that results in better outcomes (and indirectly, lower patient and caregiver suffering) without adding more control, cost, or work. In the nuclear power industry, a focus on safety provided better outcomes while actually lowering costs. According to the Nuclear Energy Institute, the number of significant safety events in the nuclear power industry fell by 70.6 percent between 1995 and 2005. During those same years, quality of production (what is called the unit capability factor, or the amount of electricity produced) rose by 13.3 percent. Power plants became more efficient, cutting the cost of operations, maintenance, and fuel by 28.7 percent.⁹

Think about the connection between safety and cost as applied to healthcare. How much would you pay for safer healthcare? Would you pay 100 percent more? Probably not. How about 50 percent more? Again, probably not. Most people would probably not pay in excess of 25 percent more for improved safety. But what if you cut costs by 28 percent and still received care that was much safer? That’s the promise that safety science and HRO hold for healthcare. We all should be using safety science and HRO to improve care delivery to sharply reduce harm, significantly increase quality, connect care, and—above all—inject more compassion back into care. Our industry should mandate it.

Policy Focus #2: Reduce Waste

When I served as director of perioperative services, I realized pretty quickly that waste was endemic, not only in perioperative care but in healthcare overall. Over the years, as I did research and worked with lean, six sigma, PDSA, and other performance improvement tools, I came to understand that if we were ever to optimize reimbursement, reduce cost, and improve patient and caregiver experience, we had to get rid of the waste. Make no mistake: waste is absolutely a precursor for suffering. When patients wait, when they receive too much treatment, and when they experience errors and adverse events, we find both waste and suffering.

Researchers have documented the proliferation of waste in healthcare. In a 2012 article in the Journal of the American Medical Association, former CMS administrator Donald Berwick and Andrew Hackbarth, an assistant policy analyst at the RAND Corporation, identified six categories of waste in healthcare: “overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse.” As they observed, these categories account for, at a minimum, “20% of total healthcare expenditures.” The industry could save much more if it cut back on waste than if it cut back on the care it provided to patients.¹⁰ The Institute of Medicine (IOM) has evoked the magnitude of waste by comparing healthcare to other industries. Imagine waiting days for an ATM transaction instead of seconds. Imagine if tradespeople all worked from different blueprints when performing renovations on your house. Imagine if individual airline pilots could check their plane’s safety in their own way, or not perform a safety check. That’s what would happen, the IOM observed, if banking, construction, and the airline industry embraced healthcare’s inefficient and wasteful ways.¹¹

One especially obvious form of waste in healthcare is the duplication of services. Many providers lack information about diagnostic tests performed on patients, whether due to poor communication, a lack of available information, fragmentation of services, or human error. Rather than waiting to learn if a test has been performed or not, providers simply order one, often duplicating the testing. Patients suffer more in turn from the stress of waiting and the inconvenience and pain of having to submit to unnecessary tests—not to mention the additional costs.

To reduce the risk of duplication, the IOM has advocated more shared decision making on the part of hospital staff. By making decisions collaboratively, caregivers can “encourage open communication among patients and ensure the development of an evidence-based care plan free of duplication and waste. Once properly informed about their care options, patients often reveal preferences for lower-cost and less-intensive treatments, which can reduce costs associated with overuse.”¹²

It’s not enough to focus on reducing duplication or other forms of waste at the organizational level. We must do so across the healthcare industry. As data about patient experience, caregiver engagement, and clinical quality show, waste translates into waiting for patients, families, and caregivers. When patients call providers to schedule an appointment, how many people must they speak with? Do they even have an opportunity to speak with a live person? When patients appear at provider practices, how long do they languish in the waiting room before a staff member shows them to an exam room? Once in the exam room, how long does it take for providers to arrive and see patients for 10 minutes? If diagnostic testing occurs, how long does it take to schedule and perform those tests or to get the results back? When patients come to the ED, how long must they wait in a waiting room, scared and in pain and looking for answers? How long must they wait for admission to hospital beds? Will caregivers even place them in beds, or will they place them on gurneys in hallways? How long will they have to wait to go to the OR?

Quantified hourly, all this waiting amounts to tens of billions of dollars of waste in our healthcare delivery system every year. A study published in 2015 in the American Journal of Managed Care calculated the opportunity costs that patients accrued while waiting in ambulatory care alone. Researchers found that patients spent, on average, 121 minutes per visit. This included 84 minutes spent in the clinic itself and 37 minutes spent traveling. “The average opportunity cost per visit was $43 which exceeds the average patient’s out-of-pocket payment.” In 2010, physician visits in the United States exacted $52 billion in total opportunity costs, a heavy burden indeed. “For every dollar spent in visit reimbursement,” concluded the study, “an additional 15 cents were spent in opportunity costs.”¹³ Significantly, these data date from 2010. Despite the Affordable Care Act, not much has changed. As journalist Mattie Quinn observes, “The average wait time at a hospital in 2014—the first year that Americans were required to have health insurance—was 24 minutes, down only four minutes from 2012.”¹⁴

Wait times matter, and while they are difficult to address, we must do so. More broadly, we must mobilize our professional associations to demand a wholesale reduction of waste across our healthcare system. And we must mandate the universal use of tools like lean and six sigma and guidelines proffered by organizations like the IOM to reduce waste inside organizations. We have the technology and knowledge to significantly reduce waste. But do we have the will?

Policy Focus #3: Foster Transparency

In Chapter 7, I argued that organizations should pursue more transparent communication with stakeholders, given patients’ preference today to engage as consumers. One organization that has benefited from transparent communications in an especially impressive way is Geisinger Health System in Pennsylvania.¹⁵ Nearly a decade ago, Geisinger took pay-for-performance medicine to a new level with its ProvenCare evidence-based approach for ensuring care quality. Geisinger charged a flat fee for standardized, best practice care processes associated with certain high-volume diagnosis-related groups, essentially attaching a service warranty to these procedures. For coronary artery bypass surgery, for example, clinical work groups established a bundle of 40 evidence-based practices and designed improved workflow processes. Information technology staff hardwired each element of the bundle into the electronic health record through templates, order sets, and reminders. If the patient suffered a complication, infection, or some other abnormality, Geisinger, not the patient’s health insurance, would bear responsibility for the cost of that care, regardless of how much it exceeded the flat rate. More recently, Geisinger Health System has extended its ProvenCare model for ensuring care safety and quality into the patient experience domain with its innovative ProvenExperience program, which offers a money-back guarantee for care experiences that don’t meet patients’ expectations. Online physician ratings, family participation in morbidity and mortality conferences, patient presentations to executives, patient access to physician notes, and leadership and board rounding provide patients and providers unprecedented access to information and to one another.

ProvenExperience was radical, but as Geisinger’s chief patient experience officer, Dr. Greg Burke, explains, it was the right thing to do. “If you have a bad cup of coffee at Starbucks,” he said, “they give you your money back or a new cup of coffee. Healthcare is a profession bound by an oath. We have to be even more accountable.”¹⁶ As Burke has recounted, Geisinger first unrolled ProvenExperience for patients undergoing back and bariatric surgery. The organization asked patients who weren’t happy with their care to explain why and state (via an app) how much of a refund they believed they should receive. “Geisinger is riding the risk for this,” Burke allowed. “There is the possibility that people might try to take advantage of us, but our experience to date is that most people don’t. A lot of the requests have been small copays. What this comes down to is trust. We include a comment in the app: ‘You put your trust in us, so we should put our trust in you.’”¹⁷

On the strength of this program and other initiatives, Geisinger joined the Employee Centers of Excellence Network (ECEN), an organization that, according to a Harvard Business Review profile, “helps employers identify quality providers and negotiate bundled payments.”¹⁸ Participating firms pay for all employee travel and medical costs accrued at specific healthcare organizations, with employees of these companies paying nothing out of pocket. ECEN’s rigorous selection process assures that companies secure quality care for their employees, at a considerable cost savings due to the fixed rates negotiated for bundled care. Meanwhile, healthcare organizations like Geisinger that provide the care gain access to a lucrative market, while also maintaining and improving care delivery. Everyone wins—and it all hinges on transparency in the communication of outcomes, as well as on measuring the specialty-specific patient-reported outcome measures. Instead of contenting itself with standard metrics like length of stay, infection rate, or return to surgery, Geisinger transparently reports metrics that patient care about: Can they walk after total joint surgery? Can they breathe after their coronary artery bypass graft? Were their goals and life needs met?¹⁹

We need the entire industry to follow the lead of organizations like Geisinger and move toward innovative, patient-centered, bundled care. More fundamentally, we need the entire industry to measure what matters to patients, to report it transparently, and to take real responsibility for meeting patients’ needs efficiently and effectively.

Policy Focus #4: Population Health Management

As my mother-in-law’s story suggests, the healthcare industry must take care of people before they get sick. Only then will we be able to reduce suffering while cutting cost and improving value. At present, however, it isn’t lucrative in medicine to keep people healthy and out of the hospital. It is lucrative to perform procedures, keep people in hospital beds, and provide prescriptions for people who are not healthy.

So how do we move from sick care to healthcare? One solution is to care for entire populations of people, reimbursing organizations based on the number of people for whom they care and whom they keep healthy rather than for the number of procedures, tests, or office visits they provide. Caring for populations in this way incentivizes organizations to prevent people from getting sick in the first place—through more prevention, screening, rapid diagnostic testing and treatment, and innovation so that organizations and insurers can offer the right treatment in the right location by the right provider. In short, population health management is proactive care, delivered on an individualized basis. By emphasizing prevention and customization, it minimizes suffering while lowering cost and improving value.

Population health management is a key feature of the Affordable Care Act. Under this legislation, providers across the healthcare continuum could form accountable care organizations (ACOs), taking responsibility for a patient population, including the costs and quality of its care. As Melinda K. Abrams and her colleagues at the Commonwealth Fund explain, “Beginning in 2012, the ACA established the Medicare Shared Savings Program to encourage the development of ACOs. If participating ACOs meet quality benchmarks and keep spending for their attributed patients below budget, they receive half the savings that result, with the rest going to the Centers for Medicare and Medicaid Services (CMS), which administers the program.”²⁰ In order to retain an even larger share of savings (up to 60 percent), ACOs could employ a “two-sided risk” model, repaying “a share of losses if healthcare spending for attributed patients exceeded the budget target.”²¹

Policymakers hoped that this kind of “bundled payment” would encourage continuity and coordination of care, prompting organizations to focus more on disease prevention and health, which would in turn drive costs down. According to the Harvard Business Review, “By definition, a bundled payment holds the entire provider team accountable for achieving outcomes that matter to patients …”²² The risk adjustment of bundled payments incentivized providers to care for even difficult cases. If organizations didn’t provide care efficiently or if they provided it inappropriately, the government penalized them. Policymakers hoped that if they held providers accountable for outcomes that encompassed the entire continuum of care, organizations would add new services, interventions, or diagnostic tests that improved outcomes or lowered the cost of care. Michael Porter and Robert Kaplan suggested that costs could potentially decrease by up to 20 or 30 percent, without compromises in quality.²³

So far, some ACOs have delivered promising results. Health policy experts Jessica Schubel and Judith Solomon, for example, document their effectiveness in Minnesota. “Building upon its existing managed care program,” they write, “Minnesota implemented an innovative model to lower Medicaid spending and improve beneficiary health outcomes. The state allows its Medicaid health plans to partner with different types of organizations to deliver integrated medical, behavioral, and social services.” One such ACO, Hennepin Health, reduced ER use by over 9 percent between 2012 and 2013 and saw a 50 percent reduction in hospitalizations.²⁴ When patients are not waiting in emergency department waiting rooms or admitted to the hospital for care, their suffering declines. When providers are not overwhelmed by the sheer number and complexity of patients, their suffering also declines. When the healthcare industry lowers costs by keeping people healthy, the industry, and indeed the country, suffers less. Why would we not want to keep people healthy?

Caring for populations is indeed the wave of the future. As of 2017, there were 744 ACOs that covered a total of 23.5 million lives.²⁵ The number of organizations and covered lives had grown more than tenfold since 2011. In January 2015, the Department of Health and Human Services stated that by the end of 2018, it would shift half of all Medicare payments to “alternative payment models.”²⁶ Meanwhile, the largest payer in the United States, United Healthcare, took population health management to a new level. In February 2015, the organization stated that its “total payments to physicians and hospitals” that were “tied to value-based arrangements” had nearly tripled over a three-year period.²⁷

In the course of shifting to population-based compensation, the industry can migrate healthcare encounters to lower-cost options while also maintaining and improving quality care delivery by embracing telehealth. According to HealthIT.gov, “The Health Resources and Services Administration of the U.S. Department of Health and Human Services defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”²⁸ In the future, as healthcare services continue to consolidate, patients increasingly will not see specialty providers in the traditional doctor’s office setting, but in their homes or primary care physicians’ offices via electronic means. This will render access to care easier and timelier, reducing suffering.

Telehealth does not come without its challenges. Healthcare organizations will have to operate seamlessly together. Reimbursement and licensure may prove tricky to navigate for providers practicing in multistate organizations, while data integrity and safety will remain important concerns. However, the movement toward delivering value (as defined by outcomes divided by cost) makes telehealth a logical alternative, one that patients will increasingly demand because of its convenience, quality, and lower cost.

In moving to telehealth, the healthcare industry must work to preserve the patient experience in its totality. Suffering remains a concern in the digital world. In Chapter 2 we discussed the unintended isolation that technology often brings about, leading to fear, anxiety, and a lack of trust. In providing telecare, the healthcare industry must assure that it involves patients in its care, encouraging them to ask questions and share in decision making. Just as making the connection with a patient in a “live” environment takes practice, so, too, does connecting in a virtual environment. But compassion, empathy, and the reduction of suffering remain paramount, regardless of the mode of care.

Policy Focus #5: Provider Diversity

Regardless of where it is delivered, healthcare today depends at least in part on people to provide it. However, workforce experts agree that a widening gap exists between the supply of and demand for primary care physicians. In 2015, the workforce added some 8,000 primary care physicians. A decade earlier, that number was 7,500. Doesn’t sound like much of a shortage, does it? It is, though, when you consider that “the number of primary care physicians who retire each year is projected to reach 8,500 in 2020.” The number of primary care physicians retiring exceeds the number entering practice, even as the aging U.S. population is requiring both more care and more expensive care.²⁹

So what do we do about this problem? In a 2013 article, Thomas Bodenheimer and Mark Smith suggested that we plug the supply-demand gap by turning to a combination of clinicians, licensed practitioners, nonlicensed practitioners, technology, and patients themselves.³⁰ If each professional on the care team works to the top of his or her license or training, the healthcare industry can spare the highest-skilled and highest-trained providers from performing tasks that don’t require their level of skill and training. With the burden on caregivers reduced, they’ll suffer and burn out less on the job. At present, if physicians can’t document the care they provide in the medical record due to issues with computer placement, lack of easy access, or poor setup and deployment of the information system, they might have to document that care during break times or during precious time at home, leading to stress and burnout. Some organizations solve this problem by utilizing scribes to document the care while the physicians interact with patients. Physicians can devote their full attention to the patient, while the scribes assure that the documentation is complete and accurate.

Nonclinicians can provide a great deal of standardized preventive care based on the U.S. Preventive Services Task Force guidelines, including “immunizations; screening for cervical, breast, and colorectal cancer; or cardiovascular risk reduction (smoking cessation, healthy eating, and physical activity).”³¹ Quality remains intact when nonclinicians provide these services, and more patients gain access. “In some practices,” health experts Bodenheimer and Smith note, “registered nurses or pharmacists have standing orders to take total care of patients with diabetes, only rarely involving the clinician.”³²

Based on the projected numbers, it seems possible that relying on a diversity of providers can help us bridge the gap between supply and demand. The number of nurse practitioners, physician assistants, pharmacists, physical therapists, and others has already begun to rise. Some 3.1 million RNs practice in the United States, and between 2012 and 2025, that number will grow by an astonishing 33 percent. The Bureau of Labor Statistics anticipates that the number of PAs will rise by 30 percent through 2024, and that the number of nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists will rise by almost a third.³³ These nonphysician medical providers “diagnose conditions and counsel and treat many patients in many settings, including primary care and acute care settings, and the results are usually comparable to physicians, and include high rates of patient satisfaction.”³⁴

According to Bodenheimer and Smith, we aren’t yet using licensed practitioners such as nurses, pharmacists, psychologists, licensed clinical social workers, and others to their full capacity, nor are we using nonlicensed personnel like medical assistants, front desk staff, and health coaches.³⁵ Still, some sectors of the healthcare industry are moving to rely more on diverse caregivers. “High-performing practices,” they write, “empower medical assistants to provide algorithm-based, periodic chronic and preventive care services. Other practices utilize registered nurses, pharmacists, or medical assistants as health coaches, assisting patients with chronic conditions to engage in behavior change and improve medication adherence.”³⁶ The Veterans Administration proposed an expansion of practice authority that would allow a range of advanced practice nurses to assess, diagnose, and prescribe medications and interpret diagnostic tests to the full extent of their education and abilities without a physician’s clinical supervision.³⁷

As much as utilizing diverse clinicians can help to optimize the total value of care, significant barriers remain. Physicians harbor concerns about clinical quality, while state health departments remain concerned about reimbursement and regulatory issues. However, if the healthcare industry ensured a consistency of professional standards for all healthcare providers, and if it strengthened accountability, it would “facilitate interprofessional collaboration, foster innovative practice, and enhance the accessibility of high-quality primary care.”³⁸

The Perfect Healthcare System

I began this chapter by describing my mother-in-law’s considerable health woes. Her chronic conditions, shared by so many in our society, derived in part from her behaviors. But they were also enabled by a healthcare industry that has traditionally emphasized sick care over healthcare, and that has been marked by enduring inefficiency, subpar quality, and poor patient and caregiver experience. It’s a system that has also, alas, been rife with suffering.

When I sit with my mother-in-law, or hear my husband talk about how she is faring, I find myself imagining what a perfect healthcare system might look like. Invariably, it contains many of the features described in this chapter. I think of a child born today whose mother would have had excellent prenatal care and whose parents would have been healthy. This child would have immunizations and wellness visits to his provider throughout his life, with screenings for various cancers and diseases at the appropriate times. As the child grows, his provider would would encourage him to wear helmets and seatbelts and to eat a healthy diet. When the teen’s behavior slipped, his provider would check in with his parents to understand if the teenager needed any kind of referral for care.

This teenager, as I imagine it, would grow to adulthood, and wellness visits would continue with appropriate immunizations and interventions. The government would pay for all this care because policymakers would understand that keeping people healthy costs much less than taking care of them when they become sick. The providers in this scenario would not all be physicians, but also advanced practice nurses, physician assistants, and pharmacists. All these providers working at the top of their licenses would provide excellent medical care for people when they get sick and perform procedures where medically indicated.

But my imaginary scenario goes on. Providers and healthcare employees would be skilled communicators, building connections, fostering trust, and spending just 56 seconds assuring that they truly know the patients who are trusting them with their health. Hospitals would be reserved for the truly sick and would become de facto ICUs equipped with the best technology. Care would be primarily ambulatory because the goal would be to keep people healthy. Patients would have a vested interest in keeping themselves healthy, with financial incentives encouraging them to eat right, exercise, give up smoking, and so on. Only sick visits would have a copay. Wellness visits would cost nothing out of pocket, and patients could accumulate points for each visit that would offset their copay if they happened to fall ill. This perfect system would also incentivize providers to keep people healthy, perhaps paying the providers a “bonus” for each cohort of patients that achieves wellness thresholds.

In this system, we would reduce waste, minimizing waiting times, duplication of services, overutilization and underutilization of services, and care in inappropriate places. The federal government, working with provider organizations, would assure that organizations maintain quality and continuously work to improve it, penalizing poor performance and rewarding optimal performance. Providers and healthcare organizations would communicate transparently, and so would patients, sharing their concerns, issues, and healthcare challenges. We would all be held accountable for the care we provide in totality—clinically, operationally, culturally, and behaviorally.

As I imagine it, that healthy baby would live to be a centenarian on account of his healthy habits. When he does finally die, as we all do, his will be a death with dignity, as free from pain and suffering as we in the healthcare industry can make it. All of this is a wonderful dream, and right now, it is only that. It’s up to the individuals, teams, and organizations to make this dream a reality. Try as we might as individuals, team members, and organizations, we cannot do so without real, substantive, and difficult reform in the industry itself. Let’s roll up our sleeves and get started. Together, we can accomplish so much.