One of the more significant contributors to the fragmented high-cost US health system is the lack of collaboration between providers. The ‘system’ we’ve got is really a Rube Goldberg-type of device that’s designed to deliver and pay for services, a kind of widget production line. Little infrastructure exists to coordinate care; a tremendous structure exists to monitor and manage care. And as many have written, we’re not getting much for our money.
The reasons are many, but essentially no one has ever had a significant enough financial interest to care, so the reward has been too small to pursue–at least, in theory. Providers will claim to care, but many cultural barriers prevent them from doing so. Health plans will claim they care or already do, but most of their business inefficiencies are simply passed along to those actually paying for the care: employers and individual plan purchasers. And the goals of these delivery systems rarely include having patient/consumers part of the conversation. Perhaps it’s time they do.
As reported by ABC News online, using 2009 as a sample year, we spent $750 billion on unnecessary and overpriced medical tests and treatments, fraud and abuse. Of that, $340 billion alone was spent on unnecessary and inefficiently delivered services.
Fixing this from the ‘system’ side is as politically and economically complicated as it can get–and hence, likely unsolvable, at least in our life times. One alternate solution might be to have the providers themselves get together and collaborate on improving the health of the populations they serve. This is not an easy task: there are multiple populations, widely varying sets of needs, and little practical experience in having different provider groups collaborate on addressing those needs–let alone setting goals for those efforts.
But fixing it from the ‘demand’ or service side may be more feasible than from the ‘supply’ or system side. What might happen if a group of providers sat down to explore defining health goals for one distinct population? That might be a program population; it might be a geographical population; it might be a specific demographic carveout of another population. It probably does not matter. But as a population that can be defined, if goals for the health and wellness of that population were to be defined, it would then be potentially possible to look at how multiple sources of services might be aligned to meet those goals.
This is the essence of a ‘patient centered medical home‘ or ‘patient centered health home.’ These technically require a number of things, including a common record, access to care when needed, as well as other things. But medical/health homes are typically being created by delivery service sources (health plans) and don’t typically include population health assessments that actually include their own patients/customers.
One of the signs of hubris in the health care system is that providers are trained to believe they know what the needs are of their patients. In terms of objective signs, that’s likely to be true in arriving at a diagnosis. But it’s axiomatic that if you’re not listening to your patient, you’re not hearing their story–and it is within their story that the full understanding of both their problem and its context lie. Without context, effective treatment becomes challenging. (There’s a whole ‘new’ segment being rediscovered: it’s called ‘narrative-based medicine‘…based on actually listening to patients. What a concept!)
And what might also happen if that group of providers sat with a group of representatives of the population they want to serve? What might be learned from a conversation about what the population or community desires for itself in terms of health goals? In retail, this is a normal part of gathering market intelligence about meeting the interests and needs of your customers. In health care, this involves a shared power dynamic that many providers will find to be very uncomfortable.
And what might be possible if the paradigm being used to establish population health goals was more about promoting wellness than minimizing disease? If people actually embody the capacities of being self-directed, self-growing, self-healing and self-maintaining, and those capacities were explicitly supported by a collaborative effort between providers, what might we see as actual changes? And potentially significant savings in the cost of care and prevention of disease? (And if people don’t actually embody those qualities, how is it that we heal from anything at all? No health intervention confers healing; they just facilitate what we are going to do, anyway.)
Every health profession has its limits–and also a potentially significant contribution. What has not been done to my knowledge is an effort that took population health goals based on what the population itself determined its needs to be and that then sought to identify what a focused clinical contribution from different health providers might be. Or what different options might be that could all achieve the desired goals. The effort could offer a significant model to test: a set of population health goals defined collaboratively between consumer/patients and a set of providers who then develop a horizontally integrated set of delivery options that everyone participates in. And by measuring the performance of meeting those outcomes, new insights could come from the effectiveness of that integrated model.
This type of effort would require immense courage on the part of providers, because it’s a natural impulse to want to care for the whole person–all by yourself. For many (if not most) providers, the depth of relationship with a patient/consumer that this effort requires is one of the most rewarding aspects of being in health care. But the reality is that most of the time one type of provider can’t do it all…and probably shouldn’t try. So it may be that it’s time this conversation began to take place. Who will be first?