Many Americans seem to expect politicians or lawmakers to provide a new model for how health care is delivered. The competing political chants of “Repeal Obamacare” and “Medicare For All” represent the vastly different opinions about how to do this. But the answers may instead come from places other than the inner corridors of Washington, D.C. That should not be surprising, given the partisan gridlock sentiment that permeates the capitol. The real solution is too complex to be reduced to simplified campaign slogans.
A core element of the solution is the transformational concept of value-based care, in which health care providers are compensated for the health and well-being of their patient population rather than for services rendered. On paper, this seems like a rather simplistic concept; in reality, it requires a major pivot on the part of health care providers that too many continue to resist.
The resistance is predictable, because the concept is counterintuitive but essential. Historically, hospitals have focused on filling their beds and offering the latest high-tech procedures. But that drives up the cost of health care without necessarily improving overall health.
The good news is that change is starting to happen. According to a report from the U.S. Department of Health and Human Services, the percentage of health care payments tied to some type of value-based care reached 34% in 2017, increasing at a steady pace from 23% over a two-year span.
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Intermountain Healthcare, a not-for-profit healthcare system based in Salt Lake City, where I am president and CEO, is making the pivot very quickly and seeing it work well. This new transformational model has five core principles.
1. The enemy is disease, and we must speed up the connection between science and patient care. The goal should not be political victories but rather improving public health. Science in that regard is key, and the ways to improve public health should be based upon and responsive to the best science we have to offer.
At Intermountain Healthcare, we’ve formed an international collaboration with a global leader in analyzing and understanding the human genome. With our partnership with deCODE genetics of Iceland, the HerediGene Population Study will focus on discovering new connections between genetics and human disease that could save lives. The study will analyze, within five years, the genetic blueprints of 500,000 people in our patient population, all of whom will be volunteers. It will be the largest, most comprehensive, DNA-mapping effort to date in the United States from a single population. It will speed up the time between research and application, and it will look at a wide range of chronic diseases — such as heart disease, diabetes, and high blood pressure — exploring genetic commonalities and combinations to reveal new insights and understandings.
2. We must be willing to disrupt the traditional for-profit model of pharmaceutical production. Some drugs have become unjustifiably expensive or scarce. We’ve seen a 5,000% price increase by Turing Pharmaceuticals, for instance, for one tablet of generic pyrimethamine, which is used to treat a rare infection. In another instance, we’ve seen a 2,800% price increase in a single year for digoxin, a commonly prescribed heart medication.
Intermountain Healthcare has joined with three philanthropies and numerous health care organizations that represent more than 1,000 U.S. hospitals to found Civica Rx, a not-for-profit company whose mission is to ensure that essential generic medications are accessible and affordable. Civica Rx rolled out in October its first generic drug, Vancomycin. It expects to have 14 generic drugs available to participating hospitals by the end of 2019, with a target of 40 drugs available by the end of 2020. The impact of this initiative will be vast as it scales further.
3. We must link health care providers and health insurance providers, so that they — and patients — jointly benefit from improving the health of a population. If a person is healthy, a hospital will not benefit unless the hospital is closely linked to the insurance provider. Providers and payers should work together in increasingly close collaborations, so that they share the risks associated with poor health and the benefits associated with good health.
At Intermountain Healthcare, we are developing a range of such collaborations. We are an integrated system, in that we have our own health insurance company, SelectHealth, with a 900,000-member health insurance plan, working cohesively with our 24 hospitals and 215 clinics. SelectHealth has worked with our medical providers, for instance, to offer low fixed insurance rate increases for employers and to lower exchange plan premiums for individuals by 2.7% in 2019. Health systems do not need to be completely integrated with insurers, but they should develop strategies for sharing risks and benefits with them.
4. We must reduce the cost of health care while at the same time improve care. That again may seem counterintuitive, but it shouldn’t. It only appears that way, because traditional incentives are wrong. Hospitals should benefit from better care rather than more care, and that is possible when providers share risks and benefits with insurers, as we do with SelectHealth.
At Intermountain Healthcare, we focus relentlessly on continuous improvement and are developing more and more cost-saving initiatives. In addition to conceiving Civica Rx, we have developed a team-based care model called “Reimagined Primary Care” with 31,000 patient members (and a goal of 100,000 by the end of 2020) that focuses on preventive care to keep patients well. It has already generated a 60% decrease in hospital admissions, a 35% decrease in emergency department admissions, and a 20% decrease in per member per month costs. We have also integrated mental health care into clinics, making it 3% less expensive and producing higher patient satisfaction.
In addition, we are reducing unnecessary emergency department visits by increasing access to appropriate care in lower-cost settings such as urgent care clinics, physician offices, and telehealth visits. A recent study of our neonatal telehealth program, which began in 2012, evaluated the effect of video-assisted resuscitation on the transfer of newborns from eight community hospitals to newborn ICUs in Level 3 trauma centers. The service produced a 29.4% reduction in a newborn’s odds of being transferred, which corresponds annually to 67 fewer transfers — and estimated savings of $1.2 million for affected families. Overall, through the implementation of evidence-based best practices and a commitment to continuous improvement techniques, we have improved care, reduced the cost of medical procedures and treatments, and will put $35 million back in the pockets of consumers this year.
5. We must work with the public to confront the social determinants of health. Much of health is influenced by preventable conditions like obesity, poor nutrition, smoking, lack of exercise, inadequate housing, lack of education, and access to transportation or technology. We must engage the public in changing lifestyle behaviors and living environments and assist them in achieving that goal.
At Intermountain Healthcare, we are leading a new collaborative called the Utah Alliance for the Determinants of Health that has been formed to promote health, improve health care access, and decrease health care costs. The Alliance, which has started with two demonstration programs in two Utah counties, involves city, county, and state government agencies and other community-based organizations. It seeks to improve health by focusing on non-medical factors that affect health such as housing instability, utility needs, food insecurity, interpersonal violence, and transportation. This approach includes screening SelectHealth members for social needs and assisting with coordination of those needs. It will also include working with community partners to ensure that services are aligned with the needs of community members.
This emerging model of health care delivery is not one that can be designed by politicians. It must be created through innovation in the field and a shared commitment by the many stakeholders in the complex network of health care: hospitals, clinics, physicians and other caregivers, and representatives from the pharmaceutical, insurance, and medical device and supply industries, and the general public.
We must revive the pioneering spirit that used to be pervasive throughout the nation. It will require us to look not to the corridors of Washington, D.C., but to each other and pivot to a new model of care. If we combine that pioneering spirit with goal-oriented practicality, our nation’s future will be healthier and promising.