How can Advanced Direct Primary Care align value-based and equity-based care?

Tear down this fence.

Spectators take to field and become health players to prevent the need for healthcare.

Ask evocative questions to open closed mindsets

People who need the most healthcare get the least, and people who need the least get the most (Inverse Care Law 1971).

How can we elevate the following ethical questions in public policy debates about transforming healthcare?

• What’s most unfair about health and healthcare?
• Why is healthcare such an uneven playing field?
• Why is healthcare not a human right for all?
• How can we address the ethics of equity with equanimity?

Equity is about designing systems that give all people fair opportunities to reach their highest potential of developing healthy well-being, human flourishing and virtues.

What are the barriers to address these ethical questions?

Closed mindsets set up dysfunctional political polarizations and inhibit our creative capabilities in developing innovative policies and practices to strive toward greater health equity. Efforts to reduce inequities are swimming upstream against dysfunctional polarizations in politics and in healthcare.

A top-down, hospital-centric, non-integrated care system is severely handicapped in reducing inequities in the community. This hierarchical framework sets up a three-tier class system: hospital centric, secondary-tertiary care as first-class citizens, primary care as second class citizens and community care as third class citizens. This political cast system sets up the structural and systemic discriminations that exacerbate health inequities.

Hospital-centric systems use volume-based, integrated Advanced Primary Care" (APC) for its amplifier effects: increased referrals, diagnostic tests, procedures, and surgeries. This top-down hierarchical approach does not invest in community-based and primary care as the means to reduce overall demands on hospital systems. Furthermore, this approach was originally not designed to reduce health disparities.

How can Direct Primary Care address these ethical questions?

Direct Primary Care (#DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. 

#DPC physicians are liberated from hospital-centric controls, the fee-for-service hamster mills, and the finance-based coding systems that burn-out primary care physicians. This type of #DPC model is based on professional autonomy and the sacrosanct boundaries of the doctor-patient relationship, but without public accountability to quality metrics.

In contrast, Advanced Direct Primary Care (#ADPC) models are based on public accountability to quality metrics. This calls for comparing the performances of integrated #ADPC clinical-business models that improve professional well-being and deliver convenient, person-centered and value-based care, in stark comparison to hospital-centric integrated APC, fee-for-service, volume-based business models.

How can we transform healthcare financing models to create community-based #ADPC integrated systems that become the hub and core driver for aligning equity-based care to value-based care. With this bottom-up approach, primary and community care are the investment centers to reduce the downstream costs of hospital systems. This investment centers reduce unnecessary demands on the hospitals: the costs centers of the healthcare systems.

What is value-based and equity-based care?

Quality care is a complex, multi-dimensional, person-centered construct with bio-psycho-socio-spiritual dimensions, and not just check-boxes of fee-for-service, pseudo value-based care. Pseudo value-based care is a flawed clinical concept of metrics.

• How do we measure what matters most to patients, providers and payors?
• How do we design systems to deliver the comprehensive value-based care (VBC)?

The comprehensive VBC equation =

+ Enhance team work vitality

+ Facilitate learning lifelong, continuous improvement and innovation

+ Improve the quality of healthcare and reduce costs

+ Tracking and improving population-based lifestyle metrics over time

+ Enhance patient and family care experiences of health care

+ Promote patient safety

+ Eliminate inappropriate and overpriced care.

Quality care goes beyond a limited number of process measures to focus on improving lifestyle metrics, functional status, self-perceptions of health and well-being, shared-decision making data to incorporate patients' values and preferences, healing experiences, advanced directive completions, and reducing dis-ease, family distress, disease burdens and caregiver burden, and improving disease-specific outcomes and preventive care metrics.

What is equity-based care?

Health equity is the principle underlying a commitment to reduce—and, ultimately, eliminate—disparities in health and in its determinants, including the social determinants. Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions.

The equity-based care equation =

+ Redesign systems to integrate, innovate and improve care for the greater good of all

+ Assure that all people have fair opportunities to reach their highest potential of developing healthy well-being, human flourishing and virtues

+ Align providers, payers and communities to reduce disparities and inequities

+ Implement and disseminate peer health coaching, support and learning systems

+ Enhance value-based care

How do our malaligned mindsets affect healthcare delivery?

Uncompensated care and low reimbursement rates from Medicaid and Medicare add to the financial burden of hospital systems. Despite what is proposed for value-based care, many hospital-centric care systems remain primarily finance-driven, volume-based organizations to maximize reimbursements and profits for services rendered. They use the burden of cost shifting to justify increases in premiums. Health insurance companies work in opposition to hospital systems with their cost containment approaches. Employers and patients pay the cost for these dysfunctional triangulations.

These dysfunctional relationships assure that macro-level efforts at containing costs are defunct. No one is in charge of managing overall costs because payors, provider systems and third party insurances are malaligned. This malalignment is our greatest barrier to value-based and equity-based care. When provider systems and third party systems are at odds in addressing the economics of healthcare, employers and employees become the financial victims of escalating healthcare costs. Employers are not exerting their economic power to reduce healthcare costs and the rise in healthcare premiums.

Hospital-centric healthcare organizations use volume-based primary care as their supply chain to amplify system productivity. Volume-based, fee for service primary care is not designed to reduce the demands on the system nor to control healthcare costs. Quite to the contrary, it is viewed as a multiplier effect for generating more specialist referrals, hospital admissions and procedures, with the inherent risks of over-investigations and over-treatments. In effect, hospitals are in the driving seat of healthcare, while primary care is in the back seat of the car. This flawed arrangement is like building hospital-centric care based on a foundation of sand. The cost of re-building keeps going up.

Given this stark reality, the legacy systems of volume-based care face enormous transformational challenges in adapting to where healthcare will go, given the new models of primary care, such as Our Health, Iora Health, Paladina Health and employer-based health plans.

How can our healthcare system implement value-based care?

Hospital-centric integrated care systems with Advanced Primary Care (APC) are not designed to address the macro-level determinants of escalating healthcare costs. They use micro-level financial incentives (such as reduced readmissions) to improve quality. This is like putting a bandaid on a bleeding artery.

Direct Primary Care (#DPC) first improves value-based care by reducing overall costs to employers and patients, but the lack of price transparency makes it very difficult for doctors, employers and patients to find low-cost, high quality specialty care and services.

For example, what is the cost for an elective repair of an inguinal hernia? A patient found a hospital sticker price of $47,000 and a cash price of $3600. The low hanging fruit for #DPC is to eliminate high-priced care and reduce inappropriate care. It is estimated the employers can save 20% (plus) within the 1 year, slow the rise in health premiums, and reduce the out-of-pocket expenses for employees.

The more complex challenge is demonstrating how to improve appropriate quality care: disease-centric, preventive and person/patient-centric metrics. Quality metrics and Press Ganey patient satisfaction scores create challenges in addressing the complexities of delivering appropriate primary care.

For example, "saying no" to unrealistic consumer expectations (on demand X-rays/investigations and antibiotic requests for viral infections) will lower patient satisfaction scores, but the scores for appropriate care are not measured. This is a shortcoming of consumer-driven healthcare within volume-based primary care and urgent care centers. Doctors, nurse practitioners and physician assistants are incentivized to concede to patients' requests due to lack of time: provide unnecessary care, increase revenues and enhance patient satisfaction scores. #DPC physicians have the time to curtail the inappropriate care and implement effective programs, such as antibiotic stewardship.

How can our health system implement equity-based care?

The original Triple Aim was flawed because it lacked the second-order vision of building community and primary care as the hub and core driver for aligning value-based care to equity-based care. It was not explicitly designed to reduce health inequities in the community, especially in rural and socially deprived areas. Equity was an afterthought for both Institute of Health Improvement and the American Hospital Association.

The American Hospital Association Equity of Care and the IHI 100 million healthier lives initiatives are well-intentioned, first-order change movements, but they are like giving blacks the right to vote without ending racism. These movements will not overcome the prejudice against establishing a national healthcare system based on primary care. The "white privilege" of hospital-centric associations and organizations prevail over primary care physicians providing universal access to affordable primary care. Paraphrasing Winston Churchill, Americans will do the right thing only after they've tried everything else.

This power imbalance between specialist and primary care calls for opening political and leadership mindsets to understand how the sovereignty of the biomedical paradigm (hospital-driven and specialist healthcare) perpetuated the structural and systemic discrimination against establishing primary and community care as the core hub and driver of the health eco-system.

A whole-systems approach to transforming healthcare calls on our leaders to address the complexities of aligning value-based care to equity-based care. Value-based care without equity-based care will create another rabbit hole of healthcare policy, because it will not address who pays for uncompensated care and who subsides the low rates of reimbursed care for Medicaid. And it will not address inequities in rural, marginalized and poor communities.

Furthermore, accountable care organizations, patient-centered medical homes and Advanced Primary Care were not designed for equity-based care. These new policy initiatives cannot address the structural defaults of a hospital-centric healthcare system. Until community and primary care becomes the core driver and hub of the healthcare system, these policy initiatives will not make the bold second-order changes needed to align value-based care to equity-based care.

#DPC is based on the free-market of self-interests. #DPC is not designed to improve equity-based care. With the national shortage of family doctors, there will never be enough #DPC physicians to provide universal access to health care. The only solution for #DPC physicians is to work with nurse practitioners and physician assistants to expand access to primary care.

The new models of Advanced Direct Primary Care (ADPC) are based on fiduciary doctor-patient relationships, professional altruism and transparent accountability. ADPC could become the prototypes for expanding care to the population-at-large. ADPC physicians work alongside nurse practitioners, physician assistants, diabetic health educators and health coaches, along with additional support services. They provide about twice as much time to patients, as compared to the traditional, fee-for-service care.

The ADPC models that publish data about the value proposition equation (described above) across practice networks will create a formidable movement to transform healthcare. Transparency accountability and aggregate data are essential for improving the value proposition of ADPC.

• Will ADPC become the front-seat driver of value-based and equity-based healthcare, with hospital care in the back seat?

This calls for creating integrated clinical-business models to manage the macro-level determinants of health care costs that are needed to create economic incentives for aligning value-based care to equity-based care.

Leadership transformational questions

With the current non-healthcare system, hospital-centric integrated care organizations are limited in slowing the escalating costs of health insurance premiums, eliminating overpriced healthcare and controlling healthcare costs. The payers have not taken responsibilities for addressing the macro-level determinants of these financial challenges.

Will Business Associations, Chambers of Commerce and CEOs of corporations and companies drive the healthcare transformation needed to:

• Align all stakeholders to work toward integrating value-based and equity-based care?
• Lobby federal and state governments to stop the need for cost-shifting, so that employers do not have to subsidize health care for uncompensated care, Medicaid and Medicare?
• Overcome the structural and systemic discrimination that prevents community and primary care from becoming the core driver and hub of the healthcare eco-system?
• Develop employer-provider insurance models based on Advanced Direct Primary Care (#ADPC)?
• Implement #ADPC models to improve the value-based care equation described above?
• Design #ADPC models that can be integrated into any hospital system?
• Make hospital systems compete for referral services?
• Adapt #ADPC models for equity-based care?

These inspiring books provide strategies and case studies about how to align value-based care to equity-based care.

• Lead True: Live Your Values, Build Your People, Inspire Your Community.
• ProvenCare: How to Deliver Value-Based Healthcare the Geisinger Way

The value-based and the equity-based questions (above) summarize these books. The greatest barrier to this moonshot mindset shift are the legacy hospital systems that are resistant to second-order change transformation, innovation and entrepreneurship.

• How can we break through leadership mindset barriers and overcome organizational resistance to change?

Launch a Moonshot Mindset Movement

A value-based and equity-based moonshot project for health and healthcare calls for learning how to scale-up large-scale transformation from the technology sector, as described in John Doerr's book, Measure What Matters. Intel and Google provides the most successful stories of scaling up large-scale transformations, using the OKRs (objectives and key results) methodology of sharing yearly objectives and quarterly progress results across all levels and sectors of the company. 

This synergistic process of transparent accountability empowers people at all levels of the system and organization to align actions for high performance and to innovate from top-down, bottom-up and side-to-side across silos.

Leaders can use a whole-system approach of using OKRs to address the wicked problems of enhancing value-based care and reducing health inequities. This holistic approach calls for creating simple rules to generate the leadership, professional and social movements for amplifying large-scale transformation. Simple rules are not prescriptive for aligning actions. They act as operating principles to foster adaptive learning, innovation and entrepreneurship.

The ultimate ethical challenge is how can we cultivate leadership mindsets to re-design our health systems for value-based and equity-based care. However, this mission has to address the political challenges of overcoming the dysfunctional polarizations between individual and community values and between the right-wing and left-wing politics.

On the right, free markets and neoliberalism are the saviors, and the state and socialism are the devils. On the left, the state and socialism are the saviors, and free-markets and neoliberalism are the devils. Such tribal demonization perpetuates dysfunctional polarization.

• How can we manage the polarities between individual and community values and and navigate a middle way between right-wing and left-wing extremism?

To move beyond dysfunctional polarizations, George Monbiot advocates for integrating the free-market, the state, households and the commons into a quadratic framework for participatory democracies. Such democracies are essential for working on the UN sustainable development goals and reversing global health inequities and planetary demise. After all, global health is entirely dependent on planetary health: one people, one earth.

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The course description below is designed to open and align our mindsets for global health equity and planetary health.

Cultivate Leadership Mindsets for Truth, Global Equity and Planetary Health: Design Learning Platforms, Practices and Policies for Exponential Impact

Self-reflective reading materials are designed to set up dialogues about our mindsets. These dialogues focus on specific questions, such as:

How can we:

• Develop a compelling rationale to align value-based care and equity-based to planetary health, within our healthcare systems, organizations and communities?
• Develop simple rules to reverse health inequities and planetary demise?
• Go upstream to address the ethical and political determinants of health inequities and planetary demise?
• Move beyond the polarities between individual and community values and the fundamentalism between right-wing and left wing politics?