Last week, I wrote about population health and gave scenarios for four people: Andrew, Brenda, Charlie, and Denise. They represent:

1. Healthy people who only need education to remain that way, preventative services to help keep them healthy, and health screenings to identify risk factors that need to be addressed to keep them from becoming patients;
2. People who feel well and may not be receiving medical attention, but who are at high risk of developing serious health problems in the future;
3. Acutely ill patients who need high-quality, state-of-the-art care to reduce the potential for complications and restore them to good health; and
4. Those who are chronically ill, often with multiple illnesses, that require care coordination and management of care transitions.

What does a health system need to be able to offer all people high-quality, reasonably priced, appropriate care, the kind of care we all want and deserve? 

Integration of the pieces of the healthcare system

We must address the fragmentation of healthcare delivery in America. Everyone has experienced this one way or another: having to register at multiple sites; having to repeat medical history over and over; all physicians and caregivers not having all records and current information; multiple indecipherable bills. 

Fragmentation refers to the fact that things don’t seem integrated for your providers or seamless to you. It’s the sense that the pieces of your health care are all operating independently and without coordination, and they probably are. 

It’s crucial to have an integrated delivery system with a single, electronic medical record. This is what St. Luke’s is becoming. 

Reduced healthcare costs, not just prices

It makes no sense to become an integrated delivery system and to provide accountable care if no one can afford the services. But it’s not just unit prices – the price of each particular service — that count.

No health system can lower prices enough to stem healthcare spending to the degree needed and survive in the current fee-for-service environment. If we truly want to get healthcare spending down to where it makes a dent, we must:

• Find ways to keep healthy people healthy. It is just too expensive to wait until they are patients to begin addressing their health needs. Preventing a heart attack or cancer is far less expensive than treating it.
• Reduce the 30 percent to 50 percent of healthcare spending that is waste and that adds no value or provides low-value services for patients.  The evidence supports that roughly half of healthcare spending confers no appreciable value to patients, and not infrequently, hurts them. Two examples of the no-value form of waste are prescribing antibiotics to patients with viral illnesses and ordering back scans for patients with back pain who don’t have signs of neurologic complications. The first question needs to be not whether another organization can offer a procedure at a lower unit price, but whether a patient will benefit from, and needs, the procedure in the first place.
• Focus our efforts on the 10 percent to 15 percent of patients that consume 75 percent to 80 percent of healthcare costs. We can concentrate our resources on a narrow segment of the population and achieve tremendous return for the effort.

Team-based care

Focus on that 10 percent to 15 percent requires a new model of care: team-based care. High-risk patients must receive coordinated care from a team of doctors, nurses, therapists, nutritionists, patient educators, care coordinators, patient navigators, social workers, and many others, depending upon the patient’s particular health conditions. 

There are not enough physicians to provide all care under the old model, and the care will not be as high-quality if all these important members of the care team, in concert with the palliative medicine team, are not involved.

Patient-centered care

In each of the cases I described, there were examples of patient-centeredness, i.e., care that is centered on the desires and needs of the patient, instead of being designed around the convenience of caregivers.  

In Andrew’s case, examples were the availability of an app to help him find and select a physician, the access to his medical records online through myChart, the ability to check his lab results online or on his app, the ability to email his physician and schedule appointments online, the information provided to Andrew around his health status and vitality score, the electronic notice/confirmation of his laboratory appointment, the patient reminders, and the opportunity for an e-visit. 

In Brenda’s case, the health coach and special classes, the provision of a pedometer, and the weekly follow-up are all examples of making care patient-centered. 

In Charlie’s case, it was the use of technology that made it possible to avoid a flight to Boise away from his family, and a treatment and therapy plan coordinated by all his therapists and doctors that ensured his maximal recovery. 

For Denise, patient-centered care involved access to her medical records online, the ability for her daughter to be updated and involved in her mother’s care through the electronic patient portal even though she lived out of town, the integration of her care among all her physicians so that her care was coordinated, a patient-centered approach to patient education, the electronic monitoring of her blood sugars and weight from home, the proactive approach to adjusting her medications as her healthcare providers monitor the electronically updated data, the team-based care for her heart failure, and the respect for Denise’s wishes as to end-of-life care.

Alignment of the business model with the care model

This is the most significant limiting factor as to when health systems like St. Luke’s can get to the future state. In today’s fee-for-service model, keeping people healthy is bad for business and is unreimbursed. 

But we won’t find people like Andrew and Brenda in physicians’ offices or hospitals. We have to go to their homes, businesses, and schools. And until the payment system changes to reward improving health or to allow providers to assume risk for managing these populations, St. Luke’s and other health systems must undertake these very important, logical, and needed activities without being reimbursed. We are doing what we can, and our affiliation with the Saltzer Medical Group was undertaken with all of these population health aims in mind, but the model must change.