The US Healthcare System is Schizophrenic!

Editor's Note: I conducted an off-site this week and one of the participant's gave me a key to unraveling this blog's title question.  Enjoy. As always, you can find all my blog posts from 2013 to the present on my website at http://stevemarshallassociates.com/steves-blog/  

I sat in on a nationwide webinar in the Fall of 2014, sponsored by Modern Healthcare. There were three keynote speakers, but the one that I remembered the most was Anthony Tersigni, CEO of Ascension Healthcare, the largest non-profit healthcare system in the world. He covered a lot of topics, but the most important statement he made was the following; "For the current healthcare system in America to make a successful transition to the outcomes of the Affordable Care Act, it has to adopt what he calls the "quadruple aim":

1. Patient Engagement;
2. Physician Engagement;
3. Physician Leadership; and,
4. Technology.

1. Patient Engagement

The days of going to the doctor and waiting for him to ask you, "what's wrong," are over. That approach to your own health and well-being are comparable to taking your car to a repair facility, dropping it off, and leaving it with the comment, "It's broken, fix it" and then dashing off. (Before you do that, though, please remember to leave the service manager a blank check!)

People in this country have to become more responsible for their own health in the way they eat, their exercise patterns, their daily habits, and, yes, for actually preventing or avoiding health problems before they become a real medical issue (e.g. obesity, sugar intake, etc.) The former approach to medicine has bankrupted the American way of healthcare by just structuring itself as a disease management system vs. the latter (above) of wellness and prevention. The disease management approach to delivering healthcare has cost us 17% of our gross domestic product annually from 2013 to 2015 (that's almost $3 TRILLION a year, folks!) - with all of the complaining about our spending for the military, our defense budget is only 4.5% of our GDP. What's worse, 48 million Americans were still without healthcare under that system. And, even with all that expenditure, the US still ranks 37th in the world for the quality of health care by the World Health Organization, behind such nations as Cuba, Costa Rica, most European nations, and even little countries like Cypress and Andorra.

The dirty little secret is that it really was a modern day Robin Hood conspiracy; the other 285 million insured Americans were actually subsidizing the 15% that weren't, by paying higher insurance premiums because those 48 million Americans were still getting basic healthcare.........by going to an Emergency Room, the most expensive method of delivering healthcare, especially for the common cold.

2. Physician Engagement

I am sure you could be asking yourself right now, "Well, it was working OK, so why sweat the small stuff?" And, "Why should people change their approach to healthcare; what's the incentive?" A key provision in the ACA is how physicians will be paid; whereas physicians were reimbursed by insurers in the past by the number of people they saw in a day or how many tests they ordered for a patient, no matter what the outcome. Now and going forward, that "volume" approach to reimbursement for M.D.'s is going to diminish and be replaced by "value"; in other words, what is the efficiency of the method that the M.D. prescribes, as measured by the outcome?

To be successful with this approach, "docs" will have to engage with their patients; develop a relationship, just like I did when I was a kid growing up in the 60's and I went to my family doctor. He knew quite a bit about me, even before I arrived for the appointment, and he would spend time with me to understand all about me, not just the symptoms I was presenting him with. (My family doctor even diagnosed by disruptive behavior at 15 as a side effect of a stomach ulcer, brought on by my parents divorce.)

This way of doing things, coupled with the intense financial incentives that will be placed upon patients to be more efficient and responsible about their health and well-being, will hopefully bring about a sea change in the delivery of healthcare in this country. I know that it is not as simple as it sounds; I do strategic planning with medical groups and it means customer service training for everyone in the group; bedside manner coaching for "docs", patient feedback loops, patient focus groups, etc.; a total systematic approach to the patient-physician relationship which, once common practice, has fallen by the wayside over the last several generations.

3. Physician Leadership

I am still amused by the response I get from physicians when I hear them complaining about the ACA or "Obamacare" as they call it when I tell them that it is their fault that it came to be the law of the land. Very few say, "I know"; most are flabbergasted by my accusation until I explain that lack of physician leadership and too much reliance upon the A.M.A. (American Medical Association) to take care of business in Washington, DC, resulted in the government stepping in and taking over, saying, "We cannot afford this way of doing business anymore and this is how we are going to do it moving forward." As a body, physicians abandoned their own high ground when it counted in the early 2000's as health care reform talks had begun at the very highest levels of our government; passing it all off as, "Not my job, let someone else do it; I am just a physician."

Not only do physicians have the ability to lead, but they must also seize the initiative to ensure that the mandate for patient-centered medicine does not become watered down by management in the interests of more dollars. (This is where the 'schizophrenia' comes into play - more about that later.) I have become a stringent politician and advocate for the creation of physician leadership programs in planning efforts that I am leading for medical groups; sometimes going so far as to highly recommend that leadership is both a requirement and responsibility for any/all physician recruitment efforts. Bottom line, though; the days of, "I just want to be a physician" are over.

4. Technology

Technology will play a central role for health care reform to contain costs, improve access, and save lives. A smart, ubiquitous electronic medical record system is certainly a big part of the package, but we will have to monitor our privacy to reach these lofty goals. An electronic medical record is a digital and portable version of the current paper file system that will be accessible to all doctors. That means that whenever you see a new physician, you could stop filling out endless paper forms, as your doctor could access everything about you on the computer.

"Imagine a world where everything important about a patient is known to the physician the first time that patient presents,” says Andrew Rubin, vice president for NYU Medical Center Clinical Affairs and Affiliates in New York City. Rubin says it isn’t about finding out your medical “secrets,” but about sharing important information with doctors who may not know your history.

“No one doctor currently has complete cradle to grave medical records and a lot of things fall through the cracks as a result,” says Marie Savard, MD, a clinical associate professor of internal medicine at the University of Pennsylvania in Philadelphia, and author of 'How to Save Your Own Life.' “We know that the ability to make a diagnosis is based more on medical records and your history than blood work and an exam. Having your lifelong history right there will actually assure that the diagnosis is more accurate and fewer mistakes will get made,” Savard says.

But “an electronic medical record is only as good as its availability,” she says. “All these benefits are only possible if the information is in an open network and everyone with permission has unfettered access,” she says.

Is Our Healthcare System Schizophrenic?
Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be unresponsive or withdrawn, and may have difficulty expressing normal emotions in social situations.

The above definition is really funny. Because it is exactly what is happening in healthcare today; 12 million people employed in the healthcare profession in the US; split into two camps; healthcare providers and management, but they are not talking to each other; physicians not able to distinguish what is real and what is imaginary about their profession, while management is unresponsive and withdrawn, and neither side is able to express themselves to the other in order to be understood.

In my work, I move fluidly between management and healthcare workers; interviewing them, working with them to solve problems, and collaborating with them to create strategic plans. There is one striking element about all of these conversations; a profound lack of trust between the two camps. And, the really sad thing about all of this is that no one seems to be addressing the gulf between the two camps.

What this is ultimately doing is creating a roadblock for achieving the "Quadruple Aim" Mr. Tersegni so eloquently outlined 14 months ago in that webinar. Whereas all of the "Aim" elements are well stated, there is yet to be a well defined and well thought out system to nest these elements under. This is the challenge for achieving a better than 37th place in the world healthcare system.


Next Week: Is There a Cure for the Schizophrenia in US Health Care?