How to Create the Big Fix

Atul Gawande had a big challenge as the newly appointed CEO of the Three Amigos Sick Care Venture. Here are some of the major challenges he faced and some tactics to solve them.

Things didn't work out for the initivative.

The US sick-care system of systems, masquerading as a healthcare system, is sick and badly in need of medical attention. The Coronapocalypse has magnified the flaws.

The vital signs are worrisome:

1. The United States health care system is the most expensive in the world but underperforms relative to other countries on most dimensions of performance. The U.S. fails to achieve better health outcomes than?other developed?countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity
2. While arguable, conventional wisdom states that about 30% of health care spending goes to billing and bureaucracy
3. It is estimated that in?2019 per capita?health?expenditures?will be around 11.5 thousand?U.S.?dollars. For comparison, in 1960,?per capital expenditures?for health stood at 146?U.S.?dollars. According to recent data, the?U.S.?has some of the highest?health care costs?in the world.
4. 2013 total national health expenditures were $2.9 Trillion, accounting for 17.4% of Gross Domestic Product . 2019 health expenditures are expected to increase to 3.8 trillion U.S. dollars.
5. A study done at Harvard University indicates that medical expenses are the biggest cause of bankruptcy, representing 62% of all personal bankruptcies. One of the interesting caveats of this study shows that 78% of filers had some form of health insurance, thus bucking the myth that medical bills affect only the uninsured.
6. High profile cases have drawn attention to the rising costs of drug prices, the most common cause of concern for Americans about their health system
7. The US is slipping as the global leader in biomedical research
8. Chronic disease burdens are rapidly increasing particularly obesity. 5% spend 50%. The five most expensive health conditions were heart disease, cancer, trauma, mental disorders and pulmonary conditions.
9. There are persistent gaps in behavioral and mental health diagnosis and treatment
10. Health information systems continue to evolve, plagued by security, non-interoperability issues, and compliance mandates that are a primary source of physician burnout.

?So, how do we transform a fee for service, specialty driven, facility centered, structure and process-oriented , inequitable sick care system into a value-oriented, generalist driven, patient-centered, outcomes-oriented more equitable system? There is no shortage of suggestions on how to get control of costs.

One is to eliminate employer based insurance.

Changing the system means following some basic principles.

Fixing the US "healthcare" system in ongoing and will require balancing quality, cost, physician experience, patient experience, and equitable access and optimizing resources. Ultimately the solution, however,?will require reducing the supply and demand for sick care by eliminating worthless, unnecessary, and inappropriate interventions and transforming sick care to health care. Accomplishing that will mean making substantive changes in payer, patient, and practitioner behavior.

Indeed, there is a lot to fix, but I suggest we focus on the following:

1. Change the rules. Access and reimbursement policies should reward disease prevention and health maintenance. Change the sickcare EMR to a healthcare EMR. Change sickcare insurance to healthcare insurance.?
2. ?Change how we educate a 21st-century healthcare workforce, providing them with the bioentrepreneurship, digital health, and population management knowledge, skills, and attitudes they need to serve their communities. Creating more MD/MBAs won't get us there. We also need to rethink how we train the leaders of sick care transformation in HA programs.

?Target research and development funds to supplement disease prevention?research and deployment and make innovative universities into entrepreneurial ones.

• Create innovative non-brick and mortar eCare delivery channels that are easy to use, cheap, and accessible. What is your digical health strategy?
• ?Empower patients to take control of their care and information e.g. using?Open Notes?and provide them with value transparency to they can make informed resource utilization decisions.
• ?Encourage appropriate DIY medicine and use behavioral econometric and other techniques to change the behavior of both doctors and patients.
• ?Support?patient and physician entrepreneurs?and other community-based innovation networks.
• 8.?Give patients the information, resources, networks, and incentives to take care of themselves and other family members.
• ?9. Create an integrated?health information whole product solution?that is patient-centric
• 10. Create the intellectual property, reimbursement and regulatory affairs infrastracture to catalyze biomedical and health innovation and entrepreneurship
• 11. Address the non-medical socioeconomic determinants that drive the majority of health outcomes. like poverty,?wage growth, employment, education, reproductive and women's rights, minority opportunity, and immigration.
• 12. Continue to refine health data science and cybersecurity. Treat digital health gaposis.
• 13. Figure out how to change doctor and patient behavior.
• 14. Eliminate the barriers to sick care innovation.
• 15.Create a healthcare information technology whole product solution. not a sick care one, that is a machine designed to change both doctor and patient behavior.

The future of moving sick care to healthcare will demand different skill sets:

1. 1?Risk pricing and analysis as part of value-based care
2. Entrepreneurial mindset
3. Healthcare IT skills, particularly data and analytics
4. Soft skills, project management, and team building
5. Leading innovators
6. International business
7. Cultural competency
8. Continuous quality and safety improvement
9. Sales and marketing
10. Supply chain management

We need a separate but integrated health care system to supplement the existing sick care system:

1. Replace high priced knowledge technicians with lower-paid behavior change specialists

2. Pay for the prevention reimbursement system

3. Create future jobs that don't exist

4. Train health care workers to win the 4th industrial revolution

5. Match every sick care worker with health care worker on the team

6. Unbundle primary and secondary care education, training and practice

7. Replace the present higher ed business model with cheaper, faster, better, smarter market defined solutions (think Galvanize for healthcare)

8. Teach MPH students public health entrepreneurship

9. Create interprofessional entrepreneurial teams

10. Create social and workforce support systems for workers no longer interested in participating in an industrial model created 100 years ago

Of course if the proposed healthcare system is as wasteful as the present sick care system, will make things worse, not better.

Some think we need to embrace reverse innovation to change the US sick care system, stealing ideas from underdeveloped nations.

Each one of these is a formidable task and will require substantial political will and will take generations of experimentation. Ultimately, however, the existing models of care need to be made obsolete to meet the ever-increasing demands without bankrupting nations and the patients who inhabit them.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@SoPEOfficial and Facebook page