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The New Script for the Work of Health in America

Our board member Dr. Tim Porter O’Grady submitted the following guest blog interpreting the radical transformation of the US healthcare system required by the Patient Protection and Affordable Care Act.  Technology can help, but the biggest changes will begin with linking process to outcomes via intelligent process design and meaningful analytics.

Now that the Supreme Court has ruled on aspects of the Patient Protection and Affordable Care Act, the healthcare system is in overdrive as it attempts to reconfigure itself within the context of the Act (PPACA). The central driver for both the formation of the act and the response of the healthcare system has been the accelerating, some would say spiraling, costs of healthcare. In 2009, the gross domestic product percentage devoted to health care was just over 17%. In 2008 it was just over 16%; in 2001 it was under 15%. Clearly, the accelerating costs of providing contemporary healthcare and its growing portion of the gross domestic product have made continuing the existing tertiary care late stage engagement model impossible to sustain. As a result of the passage of the PPACA, major recalibration of the way health services will be provided over the next two decades is underway with shifts in policy, regulation, and program design. Growing emphasis on terms such as “value” and “accountability” are shifting the focus of healthcare away from emphasis on “process and volume” toward “product and value”.

The rising public and private costs of healthcare are insupportable by governments, employers, small businesses, and individuals. At the same time, costs of health service are rising and despite high levels of spending in healthcare, measures of impact, outcome, quality as tested by quality-of-life indicators such as health status, life expectancy, and infant mortality compares dramatically unfavorably with other developed nations. While advances in clinical technology have progressed significantly in the United States, providers lag notably behind the European Community, Australia, and New Zealand in the use of electronic health information systems. On top of these realities, the average annual health insurance premium for a family hovers around $14,000, nearly 55% greater than the family costs for healthcare in 2000.

There is simply no longer any doubt that major change toward higher levels of accountability from providers and a more clearly delineated health outcome needs to be more firmly embedded in a transformed health system. As all services generally become more “user-driven”, emerging models of health service must also reflect “user” or “patient-centered” approaches to delivering service. At the same time, services must result in a net aggregate positive impact on sustainable health status of both individuals and populations. With this reality as a centerpiece for healthcare design, providers must now focus their efforts within a different context in a way that demonstrates the convergence between discernible and intentional processes and their goodness-of-fit with clearly delineated and measurable health impact and outcome.

The challenge with this shift away from process emphasis is reflected in the esteem that providers have for their own good process. Indeed, indicators and measures of productivity have historically been driven by workflow, time and motion, and physical efficiency measures. This overarching emphasis on process and productivity has done much to focus on efficiency but has had little discernible impact on effectiveness. Emerging understanding of the character of professional work and judgment-based decision-making points to the inestimable value of assessment-reflection-evaluation as a foundation for delineations of value-defined productivity. The factors that now emerge as important in professional work more emphatically advance the value of creating a goodness-of-fit between effective process and relevant outcome. Indeed, the structure of service payment in the provision of healthcare will reflect how the convergence between effort and effect demonstrates best practice. Comparative effectiveness data will now compare and contrast the variety of service settings devoted to addressing particular health concerns or the health of specific populations. It is here where the shift in the minds and efforts of providers from volume to value will be most challenging.

The historic vertically constructed and compartmentalized service infrastructure in healthcare that insulated providers within the walls of their own clinical categorization and role boundaries now must become more porous. Individual disciplines must now configure in a more intentional and enumerated interface with a community of other disciplines who play a determined and articulated role in a complex mosaic of population specific health-generating activities. Financial and service success in a value-driven equation now depends on the intensity of interface and relational effectiveness between each member of the service team and the aggregated convergence of effort they all exhibit in the achievement or advancement of particular health outcomes for given populations or services. In order to both achieve and sustain this quality and value paradigm several key dramatic systems and role changes must occur:

  1. Providers in each discipline will need to create a common understandable language which clearly elucidates their specific roles and contribution to the team’s collective effort in the individual patient experience.
  2. Organization of healthcare services now must configure around a “health script” in a way that relates to advancing the health of specific persons or populations.
  3. Provider communities must be constructed and effectively configured to work conjointly both in defining unique discipline-specific contributions and collective impact and values achieved by the convergence of mutual effort.
  4. Patient “users” must now be incorporated as members of the clinical team demonstrating their commitment and accountability for their own health and for their role in contributing to the health of the community.
  5. Measures of quality and value (including financial) will now be deeply embedded in indicators of aggregated community health and wellness sustainability.

There has not been as dramatic and broad a systems shift in health services perhaps since the introduction of Medicare. Both broad and deep changes in the configuration and payment of healthcare services will call for different delineation of clinical work, relationships, productivity, effectiveness, integration, and impact. This cycle of change is early in its dynamic and it is far too soon to determine the extent of viable change and the degree of its impact. For the cynics, it may imply nothing more than rearranging the deck chairs, and for the optimists, the achievement of meaningful and sustainable community health.

As always, reality lies somewhere in the midline between these two extremes. However, what is not sustainable is an increasing acceleration of costs for health service and a concomitant decline in health status. What results in this dramatic health system transformation will, as usual, not look anything like what is imagined at its initiation. Innovation, creativity, availability to change, and adaptation will be the usual attributes that characterize successful transformation. Re-languaging health service, recalibrating service design, and evaluating provider and programmatic impact and value will be necessary for all participants and will require evaluating effectiveness within a just-in-time frame. Never having reconfigured in process and innovated on the go, healthcare leaders will have to demonstrate new competence and capacity for network management, emergent dynamics, collective enterprise, and new financial/payment arrangements. For everyone in America we are at the “Nike moment” in health transformation and it is now time to “just do it”.

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