We know what happens when the health care system fails.
But what happens when it works?
That’s the subject of this edition’s One Big Question.
The United States spends more on health care than in any other country. Add to that, this: nearly half of American adults suffer from chronic disease.
It’s pretty easy to find parts of health care system that aren’t working.
But what does a working health ecosystem look like? REthink asked members of the Dell Med community to give us their take — and they, in turn, challenged colleagues and family members to do the same.
Kellee is the co-founder and director of Mama Sana/Vibrant Woman, which works to facilitate access to culturally appropriate, quality pre- and postnatal care for women of color. She is also a member of Dell Medical School’s Community Strategy Team.
“A working health care system would be truly family-friendly. Women would be able to take their babies with them to doctors’ appointments without a hospital turning them away for liability reasons, and delivering a child wouldn’t feel like treating a disease, with a cascade of interventions that aren’t always medically necessary. The midwifery model — which provides personalized support before, during and after pregnancy for both mom and baby — would be more common, with medical intervention only when necessary.”
“In a working system, doctors would make money based on outcomes, not volume of patients, and physicians would be trained to be mindful of the health inequities that exist in the system. Doctors’ offices would be offered government support for processing Medicaid and incentives for serving vulnerable populations. The doctors who are trying to do these things now should be part of the norm, not outliers in the system.”
Kellee challenged ...
Priscilla A. Hale, MSW
Priscilla is a seventh-generation Austinite and the executive director of allgo, which fosters vibrant queer people of color communities in Texas through cultural arts, wellness and social justice programming. Priscilla is also a member of the Community Strategy Team at Dell Medical School.
“If health care worked, my doctors would be as invested in my wellness as they are in my sickness. Patients wouldn’t have to spend the valuable face time they get with doctors re-explaining their medical history. A working health care system would encourage physicians to take the time to refresh themselves on my history and my life before attempting to provide me with care, and spend time with me discussing my health — not trying to diagnose and ‘fix’ me.”
“As a caregiver for several of my family members and an active participant in my own care, I keep all of our medical histories organized and readily available for each doctor. Despite this, doctors often forget important details of my family members’ conditions, or have tried to prescribe me a medication that I’m already on.
“I have received frustrated answers and outright anger when asking doctors questions or choosing a course of action that is different from what they prescribe. A working system would reward patients who take an active role in their care, and allow people to have agency in their own health. Doctors would welcome discussion and contradicting second opinions, all in the pursuit of better care.”
Chris Moriates, MD
Chris is Assistant Dean for Healthcare Value at Dell Medical School and the implementation director at Costs of Care, a global NGO which curates clinical insights that drive better care at lower cost. Chris co-authored the book “Understanding Value-Based Healthcare” with Neel Shah.
“If health care worked, the system would be coordinated around the needs of each patient, with seamless handoffs to the best providers for a given condition. The patient would be able to see and understand the process on her own, perhaps through a digital ‘dashboard’ that illuminates the path she is expected to take and compiles the progress and results along the way.
“Test results would be communicated to patients — and interpreted for them — in real time.
“If health care worked, you wouldn’t have to be a personal health navigator for your family members, and you could instead concentrate on the important work of supporting them in sickness (and in health).”
“Many of us who work in health care often feel that we need to wield our expertise to help family members get the care they need. In fact, I once heard a prominent health care leader remark that he will know health care is working when he feels he can trust his adult child to navigate the system without him. To me, this reveals the fundamental failure of our system — when those who are ‘in the know’ can’t trust that their loved ones will be treated safely, effectively and efficiently without need for an advocate.”
Neel Shah, MD, MPP
Neel is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. He is the founder and executive director of Costs of Care, and he co-authored “Understanding Value-Based Healthcare” with Chris Moriates.
“If health care worked, you could step away from a conversation with your doctor feeling reassured that the treatment options you are considering are not only effective and safe, but affordable. Prices could be pulled up with a swipe of a finger.
“Things that might end up on the bill could be previewed, and discussions about whether they are actually worth it would be routine. When care is both expensive and necessary, the doc might even point you toward a plan that makes you better without breaking your bank.”
“For the average American, health care is the least affordable it has been in half a century. In 2017, cost can no longer be an afterthought. Foreclosures have become side effects, and too many of us are vulnerable.
“Alleviating illness at the expense of personal security is not a choice anyone should be forced to make.”
Chelsi West Ohueri, PhD
Chelsi is a research project manager at Dell Medical School, where she focuses on health disparities. As an anthropologist, she has conducted intensive fieldwork in Albania and southeastern Europe.
“If health care was working well, policymakers and academics would be actively addressing structural and institutional racism as root causes of health and health care inequities. There has been a great deal of research on the subjects of discrimination — and, recently, implicit and unconscious bias — but rarely is structural racism explicitly named as a root cause for disparities.”
“This type of radical shift would involve new approaches to curriculum, training and interventions that address inequity and inequality. Moreover, there would be more multidisciplinary and cross-sector collaboration to best understand racism and its impact on numerous interconnected systems that shape health and health care (housing, education, employment and criminal justice, to name a few) in a concerted effort to address and reduce health and health care disparities.
“One way to begin is to introduce these concepts into the medical education and allied health professional curriculum. This would involve scholarship from a wide variety of disciplines. While in recent years there have been increased efforts to include more discussion of race, ethnicity and cultural competency, there is still a great deal of hesitancy to address structural racism, despite its prevalence within all U.S. institutions, including the health care delivery system. Redesigning curriculum and training would be one way to directly address inequities that continue to disadvantage marginalized communities in the United States.”
Janice Bacon-West, MD
Janice is a community physician working in Mississippi, where she specializes in pediatrics. She is also Chelsi West Ohueri’s mother.
“If health care worked, electronic health records (EHRs) would be standardized and synchronized for better use between agencies, such as clinics and entities like Medicaid.
“The single most revolutionary thing that could happen to the health care system right now, arguably, is standardizing EHRs. I’ve spent considerable time over the past decade learning how to best transition from paper files to electronic ones, and it’s especially difficult in federally qualified health centers (FQHCs) in medically underserved communities. FQHCs have certain requirements for using EHRs, but there is not enough support and training on how to integrate new forms of technology into clinical practices. Standardizing EHRS could lead to more (and better) integration of electronic record-keeping into medically underserved communities.”
Steve Steffensen, MD
Steve, the former chief of innovation for the Military Health System and former chief of the U.S. Army Surgeon General Office of Health Innovation, is now chief of the Learning Health System at Dell Medical School. He is a veteran of the U.S. Navy.
“Health care will work when care for a person extends beyond the walls of an exam room — making the title of ‘patient’ inadequate and role of ‘physician’ insufficient. Health is more than just the absence of disease.”
“When you think about what it means to work, the classic definition involves putting forth physical or mental effort to achieve a purpose. While it is tempting to apply this definition to health care and assume more physical and mental effort would result in improvement of health outcomes, history suggests otherwise. Many attempts have been made to think our way out of the current health care crisis and yet, despite the fact that almost 20 percent of U.S. spending is on health care, we still lag behind most developed countries in terms of improved outcomes.
“This problem will continue to get worse as long as our definition of value in health care is focused internally. Today, value is inappropriately defined as quantity of care over the cost of delivering that care. As physicians, we get paid more and are incentivized to do more to a patient than for a patient.
“I prefer the physics definition of work, which reminds us that work is measured by movement of an object through application of an external force. Moving health care forward will require a new way of thinking about where health happens and who has the power and greatest incentive to influence change. The most knowledgeable person and greatest advocate for an individual’s health is, of course, the individual. Focusing value on outcomes that matter to our patients will revolutionize what it means to care.”
Elizabeth Teisberg, PhD
Elizabeth wrote the book on value-based health care strategy, 2006’s “Redefining Health Care: Creating Value-Based Competition on Results,” authored with Michael Porter. She is executive director of the Value Institute for Health and Care at Dell Medical School.
“A health care system that works would wipe out health disparities. There would be no correlation between health outcomes and race, and one’s ethnicity or race or gender would not predispose worse or better care.
“Transformation toward a system without disparities can be accelerated by measuring outcomes for every person served — patterns in such data will clearly show systemic gaps. Measurement alone often inspires improvement, so attention to this issue will go a long way. Facts are friendly to transformation.”
“Unmasking disparate outcomes will create insight that helps to correct them, starting with unintended participation in disparate delivery, followed by design and redefinition of services that work better for everyone. Rather than presuming that access to currently defined services is the answer, services can be designed to help people achieve better health based on their real lives and specific medical circumstances.
“In health care, value is created in helping individuals improve health. Individuals with similar health challenges can be efficiently helped with services designed around their needs. Services thoughtfully and respectfully developed around the medical, cultural and social realities of a segment of patients can be delivered very efficiently.
“Unlike today’s systems that are defined around payment, in a health system that works, services will be defined around people. Patients and families, doctors, nurses and other caregivers will be better served by high-value, person-centered care.”