A Modern Healthcare System: From Producing Services to Producing Met Needs

Healthcare has evolved dramatically over the past century. While we've seen remarkable advances in treatments and technologies, we've also witnessed the rise of an impersonal, fragmented, and increasingly expensive system. To address these challenges, we need to fundamentally reframe – in practical terms – our approach to improving healthcare delivery.

In my previous blog, I suggested a crucial part of the solution is changing our fundamental unit of health system production to "meeting needs" – a patient-centered approach that aligns with the complexities of modern healthcare.?

Traditionally, an accountable individual – typically a General Practitioner, Family Practitioner, General Internist or General Pediatrician –? “provided services” and “met needs” that were one and the same.? However, as the world has become more complex, we have tended to propagate piecemeal solutions all with the same structure and in many ways, the health system has gotten worse.? In system thinking terms, our focus on providing more and more types of services constitutes a “fixes that fail” dynamic.? Tangible examples of system failure include:

·????? Fragmentation: The rise of specialization has eroded the role of primary care providers as leaders of patient care, resulting in gaps in accountability and communication.? With multiple “service production islands”, in practice everyone is accountable, which means that no one is accountable.?

·????? Cost inflation: With services as the unit of production, it is only natural that payment is based on the provision of services, that is fee-for-service.? Fee-for-service incentivizes quantity of services.? The advent of insurance payment based on services adds fuel to the fire.?

·????? Proliferation of low value services with high margins. Fee-for-service payment based on units of service incentivizes quantity of high-margin (i.e., profit or surplus generating) services.? Often the services with the highest margin are not the services that are likely to most positively impact future life course.

·????? Patient confusion: Patients often request suboptimal services due to misinformation, or self-serving marketers.

We propose a practical solution that addresses these issues by changing the measure of health system production from “units of services” to "units of met needs".

So, let’s dig into what a transition to a needs-driven metric of production means in concept and in practice.

The "Meeting Needs" Approach:

What does a need-based unit of production even mean?

Conceptually, measuring healthcare system production as "units of met needs" follows 5 overarching principles:

1.??????? Focus on needs that meet the relatively high bar of evidence or strongly held expert opinion that meeting a specific need has a high likelihood of optimizing health and, to the conversely, failing to meet needs is highly likely to lead to worsening.

2.??????? Define health-related needs functionally, based on what successfully fulfilling the need looks like for the patient.

3.??????? Use a simple classification system to identify typical sets of needs for different patient groups.?

4.??????? Identify patients with specific needs using a parsimonious list of characteristics.? As a test of importance, each characteristic in our list would typically be included in a brief transfer discussion or note intended to communicate information that allows the receiving provider to deliver seamless care, making them aware of potential “bumps” in the care road.? A corollary is that if the provider was not aware of a characteristic in the list, in order to provide adequate care, they should become aware.

5.??????? Align with the goals of a "learning health system" that is intelligible by both clinicians and administrators, allowing coherent conversation and effective governance.

Our research team at Duke-NUS, Singapore has developed a needs-based segmentation too, the Simple Segmentation Tool? (SST) that follows the principles described here.? In early development, the SST has demonstrated high interrater reliability in clinic settings and validity in emergency room patients, inpatient, and outpatients.? Three versions of the SST are available: clinical (for the provider), survey (for the patient or a community surveyor), and national data versions (for national policy makers) are available.? Each is in ongoing development and we welcome community involvement to pilot this instrument in clinical, community, and policy settings (See: https://www.duke-nus.edu.sg/hssr/simple-segmentation-tool).?

What follows is a brief of how meeting needs as a measure of healthcare production works in concrete terms.

What is a “Need”?

A need, for our purposes, is anything that is necessary to achieve some objective; the primary objective of a healthcare system, is health.? Now, in medical school, I learned about Maslow’s Hierarchy of Needs in which the potential list of human needs could include anything from oxygen to transcendence.? Certainly, oxygen and, arguably, transcendence could be considered needs that are in the purview of the healthcare system, but for current purposes, let’s consider a practical perspective: a health-related need is one that if met reduces the risk of progressing to more adverse health states that restrict engaging in life activities.? As a foundation, we started with a list of health states adapted from the work by Lynn, et al. (2008) on “Bridges to Health” framework, along with a general set of needs:

Table 1. Health State/Exemplar needs

Healthy

·?Preventive care

·?Health education

Acutely Ill

·?Short-term treatment

·?Recovery support

Chronically Ill

·?Disease management

·??Medication adherence

Frail

·?Functional support

·?Fall prevention

·?Social support

End of Life

·?Palliative care

·?Advance care planning

Bridges to Health provides a general roadmap.? To be useful, we need a bit more detail on needs.

[By the way, to those who favor Maslow’s need set as an aspirational goal for the healthcare system, I will not argue the point.? We need to start somewhere we have problems and while optimizing health alone doesn’t assure Maslow’s self-actualization i.e., becoming the most that one can be, it at least provides for a level playing field in which that can happen.]

This raises a key operational question: What need relevant to the healthcare system should be considered in a core metric?? Here we follow 3 principles to identify a core need.?

1.??????? To be considered a health need, we include activities within the span of control by the healthcare enterprise.?

2.??????? Amongst those “possible needs” we further restrict (as noted above) the operational list of need to those meeting a high bar – highly likely to have a salutary effect on health.?

3.??????? In the spirit of avoiding making the perfect the enemy of the good, consider the span to include activities that fulfill a range of health (i.e., medical) and health-related social service needs consistent with what the system already does (though perhaps not as well as we would like). Add a few extra elements that may not be traditional but strongly influence health and the ability of providers to successfully meet medical needs (e.g., addressing social determinants such as housing insecurity, food insecurity, as well as interpersonal violence which is a major influence on health and service utilization).

How does a “needs-based” metric deviate from a measure of “service-based” production?

?In a service production system, needs are met if the means of service (a doctor visit, a home care worker, and so on) is intended to fulfill the need. In a met needs production system, needs are met if the means of service actually fulfills the patient’s need. This does not mean that the means of providing services is not relevant to whether needs are assessed as being met since some needs can only be fulfilled by someone with training, registration, and liability coverage. But the distinction between intention and actual fulfillment remains and has 2 profound implications.??

·????? Simply engaging a means (i.e., a service) on behalf of a patient is not included in our measure of production, only the intended needs the service fulfills.?

·????? Needs are open to be fulfilled by any means suitable to the resources and constraints of the system, providers, patient, family, and community, as long as they do fulfill the need.?

The key to a practically operational needs-based health system is to de-conflate needs from specific service means.? This is a challenge as, traditionally, meeting needs is linked directly to a particular service means (e.g., a home nurse, a physician).? In the current framework, a need is linked to a function that when performed as intended will meet needs (and, in turn, reduce the risk of progressing to more adverse health states that restrict engaging in life activities).? These functions are defined in terms of what constitutes success.?

An illustrative list of needs and associated functions

Below is an example of health and health-related service needs in terms of the functions they are intended to fulfil.?

Health needs aimed at optimizing physiological and psychological health include prevention based on age and gender (e.g., vaccination, screening for risk factors and early asymptomatic conditions, falls risk), primary care for common acute and chronic conditions (both physical and psychological), and specialty referral for alleviation of the effects of advanced or rare conditions, and special procedures).?

Health-related service needs would relate to patient features that can complicate managing the health condition, including difficulty with activities of daily living, social isolation, polypharmacy, unobserved physiologic changes such as weight gain with heart failure, disruptive behavioral features and so on.??

Functions are “means agnostic”, that is each function is defined in terms of what it looks like if the patient had that function successfully fulfilled: all prevention goals met, physiological parameters at prescribed targets, no difficulties with ADLs, not experiencing loneliness, on a core list of medications that are being taken consistently, in a safe and supportive environment, and so on.? In our work with the SST, about 16 success-defined functions covers what the health system does (or could do) to optimize health.

Table 2. Service Function/Definitions

1.??????? Regular primary care services

Development, evaluation, and follow up of healthcare plans, focusing on elements that require a registered generalist physician’s skill, or a physician extender with physician supervision. This includes standard prevention services (e.g., based on age and gender).

2.??????? Specialist medical services

?Healthcare services for conditions that typically benefit from care by registered specialists trained and experienced in uncommon and severe conditions or requiring procedures prescribed and limited to a registered specialist.? This includes mental health services, but not services prescribed by a physician (e.g., radiologic or lab tests) or otherwise covered by other needs specified here (e.g., rehabilitation).

3.??????? Support of Daily Living Function

Care to meet basic and instrumental activities of daily living (e.g., assistance with dressing, bathing, meal preparation)

4.??????? Social support

Support that aids patients with needs for companionship (e.g., befriending services), health care decision making, and non-health services in support of health needs (e.g., transportation to a clinic)

5.??????? Physiological monitoring & prompt follow-up

Frequent (i.e., daily to weekly) monitoring of physiological signs (e.g., weight, dyspnea, blood pressure) and prompt responses to abnormalities to alleviate avoidable ED or hospital admission (e.g., diuretic adjustments for CHF, rescue medications for COPD).? The plan for this does require physician involvement; however, this function can be implemented by a non-health professional with supervision.

6.??????? Medication management

Process of reconciling multiple medications to prevent adverse outcomes (e.g., pharmacist medication reconciliation) as well as services which facilitate/enhance medication adherence (e.g., medication reminders, medication sorting)

7.??????? Supervisory care

Supervision of patients over stipulated period (e.g., community day care or home sitter to assure safety and an enriched environment).

8.??????? Nursing-type skilled services

Provide nursing type healthcare tasks that require specific skills training to perform (e.g., wound care, parenteral therapy).

9.??????? Rehabilitation-type skilled services

Provide rehabilitative-type healthcare tasks that require specific skills training to perform (e.g. physiotherapy, speech therapy, occupational therapy).

10.? Care coordination

Systematic interfacing between multiple providers (e.g., patient navigator).

11.? Patient skills education

Teach patients to engage in patient-specific skilled health-supporting activities (e.g., self-care of diabetes, wound care) through a prescribed program of education, counseling and support.? This is separate from health education that is of general value, such as how to use digital health resources.

12.? Caregiver skills education

Teach caregiver to engage in specific skilled health-supporting activities specific to the care recipient (e.g., self-care of diabetes, wound care) through a prescribed program of education, counseling and support. This is separate from health education that is of general value, such as how to use digital health resources.

13.? End-of-life care

Multidisciplinary medical care for terminally ill patients (e.g., symptom management).

14.? Financial counselling services

Personalized guidance for patients whose financial situation is creating difficulty with receiving appropriate health care, including personal financial management and advice about financial assistance.

15.? Social determinants of healthassistance

Provision of resources to meet basic needs that are minimally required to enable an adequate level of survival (e.g., housing/utilities, food, transportation, interpersonal safety).

16.? Financial guidance assistance

Personalized guidance for patients whose financial situation is creating difficulty with receiving appropriate health care, including personal financial management and advice about financial assistance

Classifying patients into segments with functions that needs to be met

For a useful metric for met needs, we identify a core set of patient features that individually or in combination typically correspond to one or more needs in our list.? While this can get quite granular; for the purpose of flagging who might have a particular need or set of needs, in the SST the current list of patient features is limited to 11 core characteristics:

Table 3. Core patient characteristics/ Levels

A.?????? Global Indicator:

I.??Healthy

II. Chronic condition(s), asymptomatic

III.?Chronic condition(s), stable but moderately/ seriously symptomatic or silently severe

IV.?Long course of decline

V.? Limited reserve and serious exacerbations

VI.??Short period of decline before dying

B. Functional deficits, ADL/IADL:? Deficit implies dependence on caregiver assistance to perform basic or instrumental ADL; Patient is unable to perform tasks independently otherwise.

0 = no deficit

1 = any IADL deficit, no ADL deficit

2 = any ADL deficit

C.??Nursing-type skilled task needs: Healthcare tasks which require specific skills training to perform (e.g., wound dressing, injections, change of feeding tube or urinary catheter.? Often can be performed by patient/caregiver/domestic worker if properly trained.

0 = none

1 = moderate (1 task)

2 = high (2 or more tasks)

D.?Rehabilitation-type skilled task needs: Same as C, including physiotherapy, speech therapy, occupational therapy ?

0 = none

1 = moderate (1 task)

2 = high (2 or more tasks)

E.?Organization of care: Degree of care fragmentation due to high number of providers and institutions involved in patient care.)

0 = patient sees no more than 1 doctor, from 1 site of care

1 = patient sees more than 1 doctor, from 1 site of care

2 = patient sees more than 1 doctor, from more than 1 site of care

F.?Activation in own care: Knowledge, skill, and confidence for managing one's health and healthcare as well as cooperation with treatment

0 = ready, understands and interested in treatment; active cooperation and participative

1 = unsure but willing to cooperate, can be expected to provide at least a moderate level of self-care

2 = major disconnect, unaware/ no insight, may be defiant and can't be expected to provide even a modest level of self-care

G.??Disruptive behavioral issues: Behaviors are disruptive if they significantly affect care, which is defined as typically requiring time and attention from people in the patient’s environment or induce distress.? These include conditions that are included in the Global Indicator of medical needs, such as substance abuse, depression, schizophrenia, and dementia but also have disruptive aspects such as self-harm, dissociative problems, abusiveness, wandering and physical aggression towards others.

0 = none

1 = 1 or more, not significantly affecting care

2 = 1 or more, significantly affecting care

H.??Social support in case of need: Family or friends who provide support through companionship and basic healthcare services in case of need.? Healthcare services are any of those listed here that can be provided by a non-professional with appropriate training.

0 = has support for both basic healthcare services and companionship

1 = no support for either basic healthcare services or companionship

2 = dysfunctional social circumstance

I.??Hospital admissions in last 6 months:? Overnight inpatient hospital ward stays for diagnosis and treatment.

0 = none

1 = 1 to 2?

2 = 3 or more

J.?Polypharmacy: Many prescription medications, raising the potential for adverse effects or non-adherence.

0 = fewer than 5 prescription medications

1 = 5 to 8 prescription medications

2 = 9 or more prescription medications

K.?Social Determinants of Health: Non-medical necessities (e.g., housing/utilities, food, transportation, interpersonal safety) essential for maintaining an adequate level of survival.

0 = Has stable and secure access to all areas of social determinants of health

1 = Has some, intermittent concerns with at least one area of social determinants of health

2 = Has major ongoing problems with at least one area of social determinants of health

Pulling this together in a practical setting: a primary care practice in a regional health system

Imagine a large primary care practice embedded in a regional health system, serving a diverse urban population. Instead of focusing solely on the number of patients seen or services provided, the practice with its regional administrators adopt a consistent "meeting needs" approach.? As an exemplar patient, consider a 70-year-old man with multiple chronic medical problems, including heart failure which has led to multiple recent hospitalizations for exacerbations. He is seeing 3 different doctors and has difficulty remembering what medications he is on and often forgets to take his medications

On his clinic visit, he completes a 15-minute health assessment, the SST brief survey version which captures characteristics in Table 3.? If he had been unable or unwilling, a provider can complete the 2-minute SST clinician version.? Some entries are entered automatically via EMR (e.g., polypharmacy with inconsistent refill requests, multiple medical providers in multiple locations, frequent cycles of hospitalization).? He indicates no other complicating features.

1.??????? From the SST based on Table 3, the patient is classified clinically as Global Impression V (Limited reserve and serious exacerbations) due to his dominant condition (heart failure) that leads to exacerbations, and complicating features including a complex web of providers (E2, patient sees more than 1 doctor, from more than 1 site of care), several hospitalizations over a 6-month period for exacerbations of heart failure (I2, 3 or more hospitalizations in the past 6 months), and major polypharmacy (J2, 9 or more prescription medications).

2.??????? The SST uses an algorithm based on evidence and expert opinion to flag potential unmet needs (Table 2).? In this case, in addition to universal age- and gender-related screening and vaccination including falls and fracture risk assessment (service function 1), the flags would indicate the potential value of at least a single specialist consultation for recurrent heart failure (service function 2), support coordinating his multiple medical providers (service function 10), monitoring of his heart failure status such as through monitoring of weight and symptoms (service function 5), and medication reconciliation and assistance with adherence (service function 6).

3.??????? The SST flags can serve as an opportunity for the primary care doctor to clarify and make an appropriate referral.? But if our patient has numerous flags or otherwise is too complex to have all their needs addressed in the immediate visit, the provider can refer him to a care planner trained for the task, armed with the list of potential means ranging from self-care (as he acknowledges activation in his own care) to other care providers (as he indicates the presence of social support for both medical decisions and basic healthcare services).? Importantly, the resulting action/referral includes the function to be fulfilled.

4.??????? As it is simple, the SST could be re-assessment at intervals depending on the patient’s complexity, and at points of transition to more adverse states, and during transfer between providers and settings.? If the SST results are incorporated as the patient’s “core” data set maintained in an EMR, characteristics, flags, and associated care plans can be accessed and updated by all providers involved in a patient's care, regardless of setting.

What clinical problems are solved by a simple “needs-based” segmentation approach?

Having worked with numerous health systems, I have regularly observed that the sentiment of integrated population care is stymied by a cacophony of measures, often inconsistent with each other and all inconsistently used within the same organization.? This common framework facilitates better communication between providers in different settings, ensuring everyone understands the patient's overall health status and needs.? Perhaps most importantly, by de-conflating what we want to do to support our patients’ health from the means, we open ourselves to the healthcare system of the future – one that is flexible and responsive to patient needs.?

Focusing on met needs as the health system unit of production has multiple additional benefits:

·????? It reflects the reality that while we may occasionally be missing the odd need, we are often missing the common needs.

·????? The definition of needs directly defines success. Success is when the need is met. It is not merely met when a patient with heart failure is weighed.? The need is met when the function is fulfilled – that a progressive increase in weight is promptly followed up in a way that can short-circuit an ED visit and hospitalization.? In the needs-based framework the prompt follow up is explicitly part of definition of the function (i.e., physiological monitoring and prompt follow up).? And when the initial means for fulfilling the function fails to meet the need as intended, this can trigger a revision in the care plan.

·????? It promotes innovation in meeting needs as functions might be performed by a range of existing options (including, say, family learning wound care), to new technologies such as wound care robots.

·????? Given the flexibility in selecting means, the approach can improve the likelihood that a solution to meeting needs will be suitable to the patient and their families.

What are administrative benefits?

In addition to these clinical applications, a needs-based measure of production can be used to promote more effective and nimble administrative decision making:

·????? It can lead to a scoring system to quantify how well needs are being met for each individual and across the population. For instance: Calculate a "Needs Met" score for each individual by summing scores across all relevant needs (0 = Need not addressed; 1 = Need partially addressed; 2 = Need fully addressed).

·????? The SST can be used to track changes in the population health status over time to assess how well the system is meeting evolving needs as patients move between categories.

o?? Report scores that are inherently consistent with reality in the clinic can be aggregated at various levels: by SST category, by provider, by clinic, and system-wide.

o?? Patients can be categorized into groups based on their needs profiles to identify new ways of coordinating addressing needs for patients with common sets of needs. This can incorporate advanced methods of predictive analytics, to target individuals most likely to transition to worse health states.

o?? The instrument can be used as a global measure of success for developing payment models that incentivize meeting needs across all SST categories, rather than just providing services.

o?? Resource allocation decision making can be more rational: Use the SST-based needs metric to guide resource allocation, including capitation formulas. Areas with lower "Needs Met" scores may require additional attention or resources.

o?? Links to quality improvement: Identify patterns in unmet needs within and across SST categories to drive targeted quality improvement initiatives.

If adopted, needs-based segmentation can facilitate system improving research:

·????? New innovations can be compared in terms of effectiveness and cost-effectiveness analysis of interventions, using randomized controlled trials or quasi-experimental studies to rigorously evaluate the impact of the approach.

·????? Needs segments can be used to design qualitative studies with focus groups of patients and providers to gather insights on the perceived effectiveness and challenges of the approach.

·????? The approach itself can be studied for ongoing methods improvement, compare variations of the "meeting needs" approach to traditional service-based models in terms of health outcomes and cost-effectiveness.

·????? Needs-based segmentation can be subjected to external evaluation by independent researchers or health services research organizations to validate the measurement approach and results.? It is suitable for tailoring; the specific measures and methods may need to be adjusted based on data relevant to the local healthcare setting and patient population. The key to tailoring remains unchanged: patient characteristics are indicative of needs, which, defined in functional terms, can be fulfilled by a range of available means that can be monitored and improved leading to progressive improvement in health outcomes and system efficiency.

By implementing such a comprehensive measurement and evaluation system, healthcare organizations can rigorously assess the effectiveness of the "meeting needs" approach. This data-driven method allows for continuous improvement and provides evidence to support broader adoption of the model if a specific innovation proves effective in pilot testing.

Closing remarks: The value of a standard measure of health system production based on met needs

A pragmatic, needs-based segmentation approach, such as the SST, provides a standardized language and framework for understanding and addressing patient needs across all care settings. This shared understanding fosters better communication and collaboration among providers, leading to more integrated and patient-centered care. By shifting our focus from services to solutions, the primary care provider can now be accountable within a healthcare system that is not only effective and efficient but also humane and responsive to the needs of the individuals it serves.