The failure of the president and House Republicans to launch a credible process to “repeal and replace” the ACA creates a moment of opportunity for those who would like to contribute to the search for a better future state for healthcare. The challenge of providing affordable, quality care to all Americans has flummoxed politicians, healthcare policy experts, clinicians, healthcare administrators, insurance executives, employers, and the public for more than seventy five years. The ACA brought us closer to the goal of universal access to sustainable, affordable quality care than any other single piece of legislation since the passage of Medicare and Medicaid more than fifty years ago. Jost and Lazarus recently reviewed the intent Congress when it passed the ACA. Their New England Journal of Medicine article “Trump’s Executive Order on Health Care—Can It Undermine the ACA if Congress Fails to Act?” says:
Congress explicitly indicated that its priority in adopting the ACA was to “provide affordable health care for all Americans,” primarily by expanding access to health insurance and Medicaid for consumers with low or moderate incomes or preexisting conditions.
For many years I have tried to stress the continuing wisdom expressed by Dr. Robert Ebert, Dean of the Harvard Medical School, in 1965 when he wrote:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
This remarkable statement requires some dissection to fully appreciate what time and experience have clearly proven.
- Despite decades of effort and investment in highly trained personnel and possessing fabulous facilities full of technology, the problem of sustainably affordable universal access to care, has not been solved. Training and investment are probably necessary but insufficient components of the ultimate solution.
- He stresses the importance of systems engineering in solving the problem. Since the statement was made we have made great strides in the science of continuous improvement and have a better understanding of how to create systems that produce quality. Healthcare is behind other industries in adopting these principles that have a proven ability to create efficiency in production and improve distribution of products to larger markets.
- Long before concepts of population health were commonly considered in practice design, Dr. Ebert recognized the benefit of solving systems issues for the individual by recognizing the unique needs of the population from which the patient came, and the necessity of applying solutions that considered all populations. In other writings Dr. Ebert expressed particular concern for the urban poor and rural populations.
- It is important to note his reference to finance. He was clear that finance influenced processes of practice. He frequently spoke about and wrote about the conflicts of interest and the process limiting realities of financing healthcare through fee for service payment schemes.
Dr. Ebert surmised that care delivery could be improved through the methodology of the scientific method. His writing also suggests that he believed that a better system of care would require significant shifts in how doctors were trained, and the evolution of a culture of collaboration that elevated our attention to ambulatory care and prevention, and capitalizing on the explosion of possibilities with more effective collaboration between doctors, nurses and other providers of care. Dr. Ebert was asking multiple “what if” questions and knew that it would take great organization and focus to hold the experiment together in an environment of resistance.
The journey begun by Dr. Ebert and similar thinkers at Kaiser and other like minded organizations continues and has not yet reached its desired destination. It is the belief of many people who have spent all or part of their professional lives working at the legacy organizations of Dr. Ebert’s dream that what has been learned and proven is foundational to the dream of the Triple (Quadruple) Aim.
…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.
When that better future comes, and I believe it will, many of its foundational ideas about quality, as well as value based reimbursement, will be traced through to Kaiser and the exceptional medical leaders in the Permanente Medical Group and then on to the legacy practice of Harvard Community Health Plan and other organizations like Group Health in Seattle (now Kaiser in Washington State). The Institute for Healthcare Improvement arose from these same creative forces and has been effective in spreading best practices from these pioneers to other interested and forward looking organizations that see the wisdom of aligning with the Triple Aim.
Perhaps it is simple minded to say that the distillation of several decades of this work in these innovative organizations was the Institute of Medicine’s famous book, Crossing the Quality Chasm (2001). Given the fact that after thousands of years the wisdom of the world’s religions as recorded in the scripture and literature of the various faiths has been frequently ignored, misinterpreted, never been understood by many, or forgotten by leadership, and has not led us to the realization of a perfect world, it should be no surprise to us that at this confusing moment in the search for solutions in healthcare, the wisdom and experience of what has been learned over the last 75 years in healthcare is rarely mentioned by those who have, for the moment, the responsibility to lead. All they can say is, “Who knew healthcare was so complicated?”
Dr. Dan Burnes, former CEO of Harvard Vanguard Medical Associates has put out a call inviting the “sons and daughters” of Dr. Ebert into a collaboration with the objective of making a clear concise statement of the values and key principles that are the building blocks of a world class healthcare system. The collective experience of these organizations was effectively captured in Crossing the Quality Chasm. To lower the cost of quality care so that it is sustainably available to all Americans, we need for all of healthcare to accept the six systems assertions that Don Berwick outlined in his 2002 article, “A User’s Manual For The IOM’s ‘Quality Chasm’ Report.”
- Better systems for identifying best practices and ensuring that these best practices become organizational standards
- Better use of information technology to a) access information and b) support clinical decision making
- Greater investment in workforce training and skill development
- Better team coordination
- Improved care coordination across and within services and organizations, particularly for patients with chronic conditions
- Better performance measurement
Aligning with the principles of Crossing the Quality Chasm remains an enormous exercise that most healthcare organizations have not consciously undertaken and few have completed. A graphic from Wikipedia dramatically demonstrates the shifts in thinking and practice at the level of “microsystems” of care that experience has taught would facilitate better affordable care.
In a recent letter to potential collaborators, Dan collated a rough outline from many sources that I have organized below. How many of them must be generally accepted for progress to occur?
- Medical care is a right and not a privilege. Access to healthcare should be universal.
- High quality care is measured and defined by outcomes and patient and clinician satisfaction.
- Care should be patient centric, with continuous healing relationships, available when needed 24 hours a day, customized to the patient’s needs and values, with the patient and family involved in shared decision making.
- Care is best delivered within coordinated systems of care, preferably a multi group practice with or without hospitals, that is rewarded for value, and rewards its participants for their contributions to value. Reimbursement systems at every level should reward value and the health of individuals and populations rather than the volume or activities of care.
- The systems or groups should be at risk for their performance.
- Innovation is a critical success variable in any successful system.
- Transparency is necessary for trust, innovation, and efficiency.
- Decisions should be grounded in coordinated data driven systems with investments in cutting edge technology (AI).
- Physicians must be leaders and fulfill the expectations of patients by working with other healthcare professions to drive organizational development and performance.
- The delivery of healthcare is best when organized and focused at the level of the local community or region.
- Anticipation of need for both the individual patient and the community is fundamental to reducing the total cost of care. We must address the social determinants of health and illness.
- There must be cooperation among clinicians. “I to we” transitions must occur within practices, effective teams across practices, across systems and throughout the community.
- Financing should be coordinated at the federal level, and not at the state level to insure equity for citizens of all states. States and localities should have the stewardship responsibility for these resources.
Change is dependent upon some shared values. Atrius has recently articulated their core values:
Atrius Health’s Core Values:
Patient centered care: The patient is first in everything we do.
Quality: We are passionate about consistently delivering the highest level of safe, timely and appropriate care.
Compassion: We treat our patients, their families and each other with understanding, respect and empathy.
Service: We provide exceptional service to patients, their families and each other.
Innovation: We shape the future by innovating better ways to improve health.
Education: We are committed to teaching, research, continuous learning, and sharing what we learn.
Diversity: We value the unique needs and preferences of all individuals.
Stewardship: We hold ourselves accountable for managing resources responsibly.
Integrity: We demonstrate the highest standards of professionalism and personal responsibility.
Workplace: We create an outstanding work environment in order to recruit, develop, and retain talented clinicians and staff to enable Atrius Health to achieve our vision.
Finance mechanisms must be trusted, fair and equitable and promote and reward waste reduction and innovation. Finance can be public or some combination of public and private. Finance influences how care is delivered, but high quality care can be delivered through many different finance mechanisms and payer combinations if rewarding value is the goal.
Every system of care need not be exactly alike. Design should vary by population need and by the variable existence of resources in different localities. We need to measure every proposal or manifestation of local variation against the yardstick that was articulated in Crossing the Quality Chasm. Leading organizations have tested the principles and operate with them in mind. By necessity systems of care will be different, but all should offer in their own way:
- Care based on continuous healing relationships: Care should be given in many forms not just face to face encounters. The system should be responsive 24 hours a day.
- Customization based on patient’s needs and values.
- The patient as the source of control. Encourage shared decision making.
- Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians
- Evidence based decision making. Practice should not vary illogically from clinician to clinician.
- Safety as a system property.
- The need for transparency.
- Anticipation of need.
- Continuous decrease in waste
- Cooperation among clinicians. “I to we” within practices, across practices, across systems and throughout the community.
The public’s growing awareness that it is at risk if the ACA is repealed and replaced with an inferior program that does not defend the gains of the last seven years should be encouraging to all of us who believe in the Triple Aim. “Who knew healthcare was so complicated” is a statement of opportunity. Those of us who care and do understand healthcare should be working together to help those who have a desire to learn more recognize that the only way to be assured of the care you want for yourself and your family is to assure that the same care is available to everyone.
