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Prescription for the Future
The Twelve Transformational Practices of Highly Effective Medical Organizations
Read by David De Vries
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Prescription for the Future identifies some standout medical organizations that have achieved higher-quality, more patient-focused, and lower-cost care, and from their examples distills twelve transformational practices that could transform the entire healthcare sector.
Ezekiel J. Emanuel looks at individual physician practices and organizations who are already successfully driving change, and the specific practices they have instituted. They are not the titans everyone seems to know and assume to be the “best”; instead, Emanuel has chosen a select group — from small physician offices to large multi-specialty group practices, accountable care organizations, and even for-profit companies–that are genuinely transforming care.
Prescription for the Future shines a bright diagnostic light on the state of American healthcare and provides invaluable insights for healthcare workers, investors, and patients. The book gives all of us the tools to recognize the places that will deliver high-quality, effective care when we need it.
The healthcare system is dynamic. In part, this is because of the election of a new administration, its commitment to repealing and replacing the Affordable Care Act without much specific detail, and the consequent uncertainty about what policies will ultimately come out of Washington. This dynamism is partially the result of the ongoing changes currently occurring throughout the healthcare system. Nevertheless, we have reached and exceeded the tipping point of care delivery transformation. Although the direction of change is now clear, the pace at which it will occur in different locales—and whether there might be some temporary setback along the course—remains unclear. For now, all the information is accurate up until the words were set in the book during the spring of 2017.
This book contains many stories. All the patients' names have been changed to protect their privacy. A few physicians' names—such as my primary care physician's name—have been changed, again, to protect their privacy. The names of the physician leaders and executives at the various practices, multispecialty groups, and health systems that I visited as part of my research and case development are real.
Finally, I have several conflicts of interest to disclose. I teach at the University of Pennsylvania and describe some of the innovations at my home institution. Over the years I have given scores of speeches for fees, including at some of the organizations profiled in the book: Kaiser Permanente, Anthem (owner of CareMore), and Advocate Health Care. More importantly, I mention the work of several private, for-profit companies innovating and transforming the system. I work for a venture capital firm, Oak HC/FT, which has investments in 3 of the companies profiled: Aspire, Quartet, and VillageMD: I also sit on the boartd of VillageMD. Oak HC/FT and I have no financial relationship with nor have I received speaking fees or other compensation from other companies and medical organizations profiled in this book, including Aledade, Certify, ChenMed, Dean Clinic, Iora Health, WESTMED, Main Line Oncology, and Hoag Orthopedic Institute.
Is Exploring Transformation of the Healthcare System Still Relevant?
WITH THE ELECTORAL VICTORY of President Donald Trump, it seems reasonable to ask whether this book is still relevant. Have current events overtaken a book advocating reform and transformation of the American healthcare system?
The short answer is no. In fact, the ideas that form the core of this book—ideas aimed at showing how we can develop an innovative, value-driven healthcare delivery system in America—are probably more relevant today than ever.
That might seem counterintuitive. Whereas a burst of healthcare reform zeal fueled the 2008 election, the results of the 2016 election can be interpreted as a backlash against the Affordable Care Act (ACA) and the changes it unleashed throughout the healthcare system. Indeed, Republicans' most explicit and fundamental battle cry during the 2016 election was "repeal and replace." To some degree their victory hinged on their pledge to dismantle Obamacare. Many people might logically deduce that further efforts to transform the delivery of American healthcare are misguided and mistaken.
Wrong. Reforming the healthcare system is about more than just the latest battle over the ACA or any particular healthcare regulation. Two fundamental problems plague the American healthcare system: (1) it underperforms on almost every conceivable metric, and (2) the public, small businesses, corporations, and governments all find it unaffordable. Improving the American healthcare system is something every patient, every small business owner, every corporate executive, every physician, nurse, and other practitioner, every politician and policymaker should care about. The system desperately needs to be fixed.
This book is a transformation manual, a guide to updating the health system's core: caring for patients both sick and healthy. It will help medical organizations that want to transform their care but need guidance on the right steps to take and the right sequence in which to take them.
No matter how you measure it, the American healthcare system continues to underperform. Tens of millions of people are still uninsured. Health expenditures remain astronomically high—27% higher per capita than the next highest spending country, Luxembourg. Despite these exorbitant expenditures, health outcomes in the United States are not 27%, 10%, or even 5% better than in other developed countries. Although we arguably exceed the rest of the world in a few health outcomes—and even these are contentiously debated—such as cancer survival, trauma, and organ transplantation, we lag behind in most health and healthcare domains. On even some basic measures of health system quality—life expectancy, infant and youth mortality, immunization rates, behavioral health, asthma survival, and control of diabetes—the United States falls well below other developed countries. And there are endless complaints about impersonal care, hospital-acquired infections, rushed office visits, excessive admissions to the ICU, and too many high-tech interventions at the end of life. Such inconsistent and relatively poor performance at such a high cost should infuriate any responsible corporate executive. It rightfully infuriates the American public.
Unfortunately, this underperformance is nothing new. It did not begin with the ACA. In fact, the ACA narrowed the gap. Since its enactment in 2010, 22 million Americans have become insured, healthcare cost growth has slowed to an historic low, and by modestly reducing hospital readmissions, hospital-acquired infections, and other preventable errors, quality has improved.
Nevertheless, the public remains unconvinced that the ACA has improved the situation. Ironically, polls reveal that the public likes much of what the ACA enacted—the no preexisting disease exclusion, allowing young adults to be on their parents' health insurance plans until age 26, no annual or lifetime limits on insurance coverage, limits on insurance company profits, coverage of preventive services without deductibles, and subsidies to buy private insurance. Yet the ACA became a scapegoat, the nidus for all Americans' lingering anger about the healthcare system.
Today Americans are primarily angry about the affordability of health insurance and healthcare. Drug costs have skyrocketed, as epitomized by the 56-fold price increase for Daraprim by Turing Pharmaceuticals, the $600 for EpiPens, and $1,000 per pill for the hepatitis C drug Sovaldi. A visit to the emergency room, even for something as simple as a few stitches, can cost $5,000 or more. And insurance premiums have increased for most consumers while their plans have grown skimpier with ever-shrinking networks and ever-increasing deductibles. Although coverage gaps and preexisting condition exclusions were the big concerns in 2008, today the public is demanding reforms that focus on affordability.
The American healthcare system thus remains ripe for transformation. While some fret that the uncertainty surrounding the Trump administration's desire to repeal and replace the ACA will stifle innovation, that uncertainty is ultimately transitory. The system's underperformance and excessive costs are fundamental and structural. After the rhetoric and heat of the moment dissipate, addressing these issues will re-emerge as the primary locus of concern. Fundamentals provide the surest foundation to weather the vicissitudes of uncertainty.
Rather than focusing on the latest rumor about repeal and replace or the ups and downs of Washington political maneuvering, it is prudent to aim for what will necessarily be important both 5 and 10 years from now. For healthcare, that means achieving high-value care. That is where the system is ultimately headed. And that is where smart money, lots of it from venture capital and private equity, is investing. Although there may be some twists and turns off a direct course, high-value care is the eventual destination. That is where the best medical organizations are also headed. They are not, like inexperienced hockey players, converging on the puck but, like seasoned pros, skating to where the puck will be. Although there are many medical organizations currently making healthy profits who are skeptical of the need for change and resistant to innovating in the delivery of care, as the system evolves they will become less and less relevant, the Kodaks of healthcare.
The only way to simultaneously address the underperformance and unaffordability of the system is to transform care delivery. To address underperformance, we must improve the quality of care and outcomes—reduce preventable complications and errors, ensure patients are consistently prescribed the right tests and treatments, and create support networks and systems to ensure they actually adhere to them. This can only be done by transforming how physicians, hospitals, and other providers deliver care.
To address unaffordability, we must sustainably moderate healthcare cost increases—keep per person healthcare cost increases to no more than growth in the GDP. This requires eliminating waste in the widest sense—namely, eliminating unnecessary services that do not improve health yet increase costs, reducing the per-unit cost of delivering each medical service, and prescribing lower-cost but clinically equivalent services. This too can only be achieved through delivery system transformation.
Transformation does not happen spontaneously. It requires the right financial, legal, and practice environment to occur. Fortunately many of these factors were introduced by the ACA and are likely to live on given their general lack of public controversy. First, even as payment remains largely fee-for-service, the system is inexorably moving toward alternative payment models such as bundled payments and capitation. This transition has incentivized physicians, hospitals, and other healthcare providers to start delivering higher-value care. Second, the ACA introduced accountable care organizations (ACOs), the Center for Medicare and Medicaid Innovation, and policies penalizing hospitals that have high rates of readmission and hospital-acquired infections. These reforms, along with the bundled payment experiments, reinforce and amplify the drive to transform care delivery. Finally, in late 2015 Congress enacted the Medicare Access and CHIP Reauthorization Act—better known as MACRA—that institutionalized the government's drive to change how it pays for care while further encouraging physicians to adopt alternative payment schemes. This combination of policy changes has pushed the American healthcare system past the tipping point on transformation. The genie is out of the bottle; there is no turning back now.
Importantly, the reforms created by the ACA are necessary but not sufficient for transformation. The critical next step is for physicians, hospitals, and other healthcare providers to comprehensively rethink the processes of care delivery—from simple processes like scheduling office visits and rooming patients to more complex clinical decision-making processes like building out standardized care protocols, implementing effective chronic care coordination, and integrating behavioral health services into routine office flows. This book is meant to help medical organizations that want to be in the right place in the near future—near the high-value puck—focus their energies on the right issues and change their practices in the best ways.
The case studies in this book portray medical organizations that are transforming how they deliver care to improve quality and patient experience while simultaneously lowering costs. Delineating these practices will also help physicians and hospitals transform their practices to deliver higher-value care. Lastly, the insights about transformation can help Americans choose better physicians and practices for their own care.
This book aims to nudge—even push—medical organizations toward that better delivery system. It shows how, by adopting the 12 transformational practices delineated in Chapters 4, 5 and 6, physician practices and health systems can get there.
Finally, this book offers enduring advice to practitioners that is not tied to any particular piece of governmental legislation or regulation or to any debate among politicians about healthcare proposals. One election or one more piece of legislation does not render irrelevant the guidance about how to transform the delivery of care to patients. Although the next few years may be rocky, the American healthcare system will ultimately become better performing and more affordable in the long run. This book provides lasting insights for medical organizations on how to realize those goals and consistently improve care and patient experience while controlling healthcare costs. Its advice will not go out of style or be superseded by any particular election or the vagaries of Washington; indeed, the case studies, transformational practices, and lessons in this book will help position medical organizations for the future regardless of the momentary vicissitudes created by the 2016 election and related political upheavals.
FAILING MISS HARRIS
IT WAS A HOT SUMMER DAY in 2014 when, suddenly, Miss Paige Harris passed out in her sister's living room. Her sister called an ambulance, which rushed her to Mercy Philadelphia Hospital a few blocks away. The emergency room physicians determined she had suffered neither a heart attack nor a stroke and diagnosed her with sick sinus syndrome, which intermittently prevents normal electrical impulses from going throughout her heart and beginning the process of pumping blood. The ER physicians transferred Miss Harris to an affiliated hospital, Mercy Fitzgerald Hospital, where a cardiologist placed an automatic implantable cardioverter defibrillator (AICD) in her chest. The AICD serves as both a pacemaker, electrically stimulating Miss Harris's heart if it is beating too slowly, and a defibrillator, shocking her heart if it stops beating altogether. Yet Miss Harris is confused about the AICD. She calls it a pacemaker, yet she cannot describe what it actually does. She cannot recall anyone asking her for consent but does not believe she could have refused the procedure.
Miss Harris, in her full-length, pink zip-up dressing gown and black do-rag, is an adorable 95-year-old African American woman who, because she is stooped over, looks even smaller than her 5-feet-1 height would suggest. She has a lovely open face that always seems to be smiling, even when she is describing her pains and the frustrations of managing her medications and physician appointments. Her living room has a large TV pushed up against one wall, with a few pictures and knick-knacks decorating the other walls. One piece of artwork is a particularly striking blue primativist picture of a church interior, with 2 dried-out palm fronds draping the frame.
Miss Harris has a long history of high blood pressure and congestive heart failure, leading to severe shortness of breath. Consequently, she sits most of the time: "Anything I do now is hard work." Most days Miss Harris simply sits in an easy chair a few feet from the TV; the chair electrically tilts forward when she wants to get up. Game shows or gospel music play in the background, keeping Miss Harris company as she works her way through thick word-search puzzle books. She shuffles around her small living room–dining room area with a walker.
After her fainting spell Miss Harris moved in with her 93-year-old sister, Mrs. Lilly Johnson, because her shortness of breath made it too difficult to care for herself. At first, Mrs. Johnson did all the housework and helped Miss Harris bathe, dress, and climb the stairs. Six months ago, however, Mrs. Johnson was diagnosed with gastric cancer. Standing in her purple blouse and jeans, Mrs. Johnson appears energetic, but upon closer inspection one can tell that the cancer is taking its toll. The numerous skin folds on her arms attest to the weight and muscle mass she has lost. Mrs. Johnson no longer has the strength to help Miss Harris up the stairs to use the house's 1 restroom located on the 2nd floor or to take a bath. Instead, when Miss Harris needs to use the restroom or go up to bed at the end of the day, she maneuvers her walker to the bottom of the stairs, clutches the bannister, then crawls like a toddler on all fours up the 14 stairs. This self-reliance has been difficult: she is unsteady on her feet, and 2 months ago she fell while getting into the bath. Fortunately she did not break anything, but this episode left Miss Harris fearful. She has not bathed since, instead settling for washing herself off in the sink. Obviously what would be most helpful for Miss Harris is not her high-technology AICD or an office visit to her board-certified cardiologist but rather an aide who could help her climb the stairs and help her bathe.
Miss Harris hardly ever goes outside. She often feels sad and frustrated that she cannot go to the local Sharon Baptist Church. This is at least somewhat alleviated by monthly visits in her home from a church member. A few women from the church also bring Miss Harris sermons recorded on a DVD, an act that Miss Harris is grateful for: "It's not the same as being there, but I do like hearing the sermon."
As Miss Harris describes her situation, sadness clouds her face and her eyes begin to well up:
I'm no good to myself and nobody else. Can't do nothing for myself. Lilly's [Mrs. Johnson's] sick herself, and I'm a burden on her. I can't do nothing I want to do. I don't want to be a burden to her. Lilly says I'm not a burden, but I don't want her to do my washing and everything. I've always been independent. Always been the one helping everyone else. Now I can't do nothing for myself. I don't want to burden her.
Miss Harris then begins to talk about her wishes: "I want to be comfortable. But I'm ready, I'm ready ever since I had my heart attack. Ready whenever the Good Lord is ready to do His work."
After her discharge from the hospital a visiting nurse was assigned to check in on Miss Harris once a week. Surprisingly, after 2 years the visiting nurse, Trina, still comes once a week. Trina's tasks mostly involve taking Miss Harris's blood pressure and weight along with filling all 28 compartments in her plastic pill organizer to ensure Miss Harris has all her medications for the week. This includes vitamins, minerals, and 10 different prescription medications, amounting to 19 pills each and every day. In the 2 years since her fainting episode, Miss Harris has avoided any hospital admission, though she did go to the ER once for abdominal pain that was diagnosed as a urinary tract infection and was treated with antibiotics.
One of the few things Miss Harris still looks forward to are her monthly visits from McKenzie, a nurse practitioner (NP) from a palliative care company called Aspire. Aspire specializes in providing home care for patients who are not yet in the last 6 months of life, at which point they might qualify for hospice. Using a predictive algorithim, Cigna, her Medicare Advantage managed-care company, identified Miss Harris for palliative care. Although Miss Harris did not exhibit many of the "red flags" Cigna uses to identify the terminally ill, such as repeated hospitalizations or having cancer, she is a frail 95-year-old with serious congestive heart failure and qualified by the more qualitative metric often used by Aspire: "Is she a patient that you would not be surprised to see die within the next 12 months?" For Miss Harris the answer was "yes," and so, about 1 year ago, they assigned McKenzie to her.
When McKenzie arrives for her monthly visit Miss Harris's face lights up in a smile. And throughout McKenzie's visit Miss Harris repeatedly asks, "You ain't going to stop coming?" McKenzie always promises that she will not. When reassured, Miss Harris responds, "Oh good. I'd have a fit if you stop coming."
One of the initial things McKenzie did when she first met Miss Harris was to talk about her end-of-life care wishes. Miss Harris made it pretty clear that she did not want to go back to the hospital or get anything "new" done, proclaiming that "If my heart stops, I don't want to change it." When pressed, Miss Harris openly states her preferences: Resuscitation? "No." Being put on a ventilator? "No." Dialysis? "No." Hydration and artificial nutrition? "No. I only want comfort measures, and certainly not the intensive care unit."
McKenzie helped Miss Harris document her wishes by filling out a Physicians Orders for Life-Sustaining Treatment (POLST) form—a kind of expanded Do Not Resuscitate Order. The two also filled out an Advance Care Directive appointing Mrs. Johnson as her power of attorney for these healthcare choices. Miss Harris keeps these forms right on her smoky-gray glass dining room table. As she talks, Miss Harris runs her fingers over them, almost as if she is caressing a rosary. When McKenzie asks whether the forms should be kept somewhere safer, Miss Harris insists that the dining table in the house's main room is fine—it is the best place to ensure the forms' availability should anything happen.
When asked whether there is anything she wants to do before she dies, Miss Harris says, "I'd love to see my great-nephew grow up. I want him to graduate high school, go to college, and make something of himself. I didn't finish school. Wish I'd gone back to school, so I always tell him to go to college. Don't put off going." If she could see that, Miss Harris explains, "then I would be ready for God to do what He wants to do."
McKenzie has tried to get Miss Harris additional assistance to help her cook meals and bathe. But even for an educated, health-literate nurse practitioner, the process of applying for Miss Harris's home assistance has been tortuous. A few months ago, McKenzie and Miss Harris filled out the extensive paperwork necessary to apply for a home aide. Weeks passed, yet they heard nothing. Finally, someone from the Department of Public Welfare came out and evaluated Miss Harris's needs. The official was certain that Miss Harris would qualify but said it would take at least 2 more weeks for the paperwork to be processed and approved and then probably a few more weeks to schedule an aide to start coming to help Miss Harris at home. Yet even after this visit another set of papers was sent to Miss Harris from the Department of Public Welfare. This 11-page document was to assess Miss Harris's assets in order to ensure she qualifies for, as they called it, "County Assistance, Medicaid or Long Term Care." She did. The process has, in short, been both confusing and frustratingly inefficient for McKenzie.
During one visit McKenzie weighs Miss Harris—no increase to indicate worsening congestive heart failure—and notes that her breathing is clear and that oxygenation of her blood is normal. Although Miss Harris's blood pressure is elevated, this is not that unusual. Still, McKenzie arranges for Trina to retake Miss Harris's blood pressure early the following week to make sure nothing is amiss. McKenzie also reviews the pill organizer to see if Miss Harris is taking her medications properly. The pills seem poorly organized, and the day's bedtime pill container is unexpectedly empty. "I have them pills in my pocket," Miss Harris explains, and she pulls out of her pink dressing gown a small wad of tissue tied together with a black rubber band. She opens the tissue packet to show McKenzie the 3 pills, explaining, "That way I'm sure I have the pills when I go up and lay down at night." McKenzie notices that one pill bottle is empty, so she calls the pharmacy to make sure it is refilled and sent to Miss Harris's home.
Then Miss Harris complains about pain, moving her hand to the right side of her chest. Although the dull pain is pretty constant, Miss Harris notes that, "It's not getting any worse." She seems to think it is related to going up and down the stairs, as holding onto the bannister strains her shoulder. McKenzie asks whether Miss Harris is still doing her physical therapy, so she demonstrates the physical therapy exercises for her right shoulder, saying, "Forty times I do them. Three times a day." To help cope with the pain, McKenzie also suggests using a pain-relief cream like Icy Hot.
As she talks, Miss Harris fingers through a stack of small medical appointment cards. Her old primary care physician has recently retired. When asked about her new primary care physician—who, fortunately, visits her in her home—Miss Harris says, "I don't know. She came, asked questions, filled out paperwork, and left." On October 26 she has an appointment with a nephrologist, and before that appointment she must fill out a form because the doctor wants her to get urine and blood tests. On November 2 Miss Harris has an appointment with the cardiologist who put in her AICD.
Her physician appointments are the only time Miss Harris goes outside, and each visit is a major undertaking:
I got to see if anybody nearby who has a car can drive me. But it's hard to get anyone who's free in the daytime. And I got to pay them to drive me.… There [at the appointment] I always got to go around to one place for the sheet, I got to go to another place for the test, and another for the doctor.
Her sister, standing next to Miss Harris, chimes in that her experience is significantly better than what Miss Harris goes through at Mercy:
I love it at Presbyterian [Hospital] 'cause there they got it organized. I only got to go to one place to register, and then they bring me back and do all the blood work and doctor visits in one place. I don't have to move around. Plus, with cancer they bring me, I don't have to get someone to drive me there.
When asked why she is going to the kidney doctor and what the blood and urine tests are for, Miss Harris says she doesn't know. Similarly, she is not sure why the cardiologist needs to check out her defibrillator, as it has not gone off and she has not fainted. And it is obvious from her voice and body language that Miss Harris is dreading all the effort it will take to make the arrangements she will need for each visit—asking the neighbors to drive her and moving around the hospital for the tests and office visit. But these appointments are scheduled, and she seems to think she must go. She wants to be a "good patient." Indeed, as a frail, kindly, elderly woman without a high school diploma or much health literacy, she hardly seems like the type of patient who would question a physician's recommendation, and certainly not for something he claimed was necessary to keep her heart beating or make sure her kidneys were working properly.
IN MANY WAYS Miss Harris is lucky. She is part of Independence-at-Home, a program that has primary care physicians conduct visits for frail, elderly patients in their homes instead of an office; she has a visiting nurse who comes and refills her pill organizer to ensure she is compliant with her medications; and she has a palliative care nurse practitioner who sees her every month and, more importantly, has gone over—and documented—her end-of-life care wishes in official forms that are readily available. Hopefully, if something goes wrong—should Miss Harris lose consciousness or have some other acute medical event—these forms will prevent her from being resuscitated and rushed to the hospital and into the ICU, where she does not want to be.
Too few frail, elderly patients actually receive these benefits.
- "Dr. Emanuel's Prescription for the Future is a sweeping, systemic, and optimistic practicum for the transformation of healthcare. It is a well-researched compendium of best practices from dozens of innovative providers. Prescription is a must-read, whether you care about whole system transformation-or finding your own best doc!"—John Doer, Chairman, Kleiner Perkins
- "Prescription for the Future is a detailed guidebook to achieve value-based care. Dr. Emanuel dives below the surface of politics and policy, focusing on concrete and effective changes clinics and hospitals can make to improve the quality and lower the cost of care."—Michael Leavitt, Secretary of Health and Human Services, 2005-09
- "Prescription for the Future is the playbook we have been waiting for. This is a must-read for anyone in healthcare. Dr. Emanuel's practical approach and compelling examples of what we need to do in healthcare is the path forward. It is our moral imperative to follow."—David Feinberg, MD, CEO, Geisinger Health System
- "Ezekiel J. Emanuel, perhaps the nation's most incisive healthcare expert, teaches us the path to better healthcare by leveraging the experiences of the best. He delivers key strategies that are primed for rapid adoption. It should be required reading for all seeking to elevate performance and achieve better patient experience and outcomes."—Harlan Krumholz, MD, Director of the Yale Center for Outcomes Research and Evaluation
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