Comprehensive Primary Care+ Failed Because Key Elements Were Missing
No Heart, No Brain, No Courage
If you want to maximize health in your community while reducing costs, you must follow the National Academy of Medicine playbook I presented in the last post. If you don’t include all of the elements, you will not realize the maximum benefit. Success requires a truly comprehensive solution. If any element is missing it is like a stool with one leg ripped off. It doesn’t work. If you try to sit on it, it falls over.
The Wizard of Oz is a perfect allegory for the journey to a better healthcare system. Dorothy on the yellow brick road is our journey to advanced primary care. Your familiarity with this story may bring the key points home more effectively and help you feel them
The Scarecrow Lacked a Brain
Moving to effective advanced primary care for everyone requires a brain. It is high tech. It requires reason, data, clinical and financial analytics, a population health tool, and an ability to review the evidence without conflicts of interest. The brain connects the dots found in the new science, new systems, and new payment models to form a new comprehensive, integrated model of advanced primary care. Adaptability is equally important. In a large primary care practice, the entire team can be housed within the the organization. A single nurse practitioner in a rural community can do this work as well as anyone, but she needs remote support from a single hub. She needs a patient engagement tool with a worksheet that has the pertinent diagnoses and medications listed along with a place for the latest blood pressure, LDL cholesterol, and hemoglobin A1c levels coupled with an ability to see trends for all three values easily. Spaces for smoking status and aspirin use complete the criteria for achieving optimal medical therapy. The central hub can interact with the insurance company or health record to identify patients with the high-risk, high-cost conditions and provide a list to the nurse practitioner. The hub can provide nurse coaching, nurse case management, direct contracting, and the ability to identify patients who are not engaged, have not had a test, have not had a visit etc. At baseline and quarterly, the hub provides information on the percentage of high-risk patients that have achieved optimal medical therapy along with comprehensive cost information. Information is available on the number of patients seen in the ER and hospitalization. Telemedicine support can make care more convenient for members and support the clinician. The hub provides updated protocols for priority conditions. You don’t need to reinvent the wheel. Small rural communities can have the very best care.
The Tin Man Lacked a Heart
The scarecrow’s new brain is critical, that is the high-tech part. The Tin Man’s new heart may be even more important. That is the high-touch part. The brain is important for care delivery, but the heart is critical for care efficacy. Chronic diseases generate most premature death, premature disability, and costs but recommending the right care and having the systems to support it never works without empathy. Patients will not care what you recommend until they understand that you care. Effective care of chronic diseases depends on longstanding personal relationships. Nurse coaches are the team members that are most able to establish those relationships. Establishing trusting relationships takes time.You may have a large practice and you may have nurse coaches on your own teams. Nurse coaching can be provided from the hub. Either way, nurse coaching and case management to establish long trusting relationships are required for successful chronic disease management. A very wise man once said that friendship is about common interests like making quilts, stamp collecting, or fishing. Is there a better thing to be friends about than staying healthier longer? Most of the patients I worked with became my friends. Empathy and the ability to form relationships are critical for your chronic condition team members.
The Lion Lacked Courage
A lack of courage may be the greatest barrier to bringing advanced primary care to all Americans. It seems to me that great wealth, influence, and power are the things that Americans value most. No? Can you think of a single celebrity who is not extremely wealthy? I can’t think of one. We used to have other heroes like Mother Teresa or Dr. Albert Schweitzer, but no more. That seems to be the leading aspiration too. Many of us want to be wealthy, powerful, and famous. Too many are willing to lie, cheat, and steal to achieve it. Our own opioid epidemic has its roots in a healthcare company that promoted pain as the 5th vital sign and told us we could not become addicted if we have real pain. I always knew that was BS, but that is what people are willing to do for money and power. They lied to get more money and more power. They won and despite the settlements they still have more money than they would have had—billions of dollars.
And that is the problem. The businessmen who run healthcare control one fifth of our gross domestic product. They are extremely wealthy and powerful. They view what I am talking about as a threat. A healthcare system that helps you live longer at lower cost is a threat to the people running one fifth of our economy. They are actively fighting to keep their advantage. They will do anything to keep their advantage and that is why it takes courage to work towards what we all need.
Very large health systems, drug companies, device companies, health insurance companies and drug store chains are all threatened by what we are working to achieve together. They understand that if we are successful, they will make less money. They understand they may lose power and influence. They will do whatever the can to defend their advantage. I believe that the organizations that get grants to help with these big federal improvement initiatives must be not for profit. Remember that not for profits get money from the winners in our current system like drug companies. Companies like those that promote adoption of new brands of drugs help not-for-profits with their K Street lawyers and they are coached in how to get the grants. Employees of the drug company ally help lead execution of the major initiative with the funding that they get. I was a regional medical director for one of these big federal improvement initiatives. I met my obligations under the grant and I was a strong advocate to all the changes I have recommended. I also continued to work with independent health reformers and I had begun to explore some independent initiatives because I could see that I would not be allowed to promote optimal medical therapy for chronic conditions. The head of the drug company ally told me that I could not work with them if I continued to work with real health reformers. I kept working with health reformers and they fired me. That is the price that you must be willing to pay.
The price is worth it. You need to understand when they lose, everyone else wins and you win most of all. But to overcome their power and money we will need courage perhaps most of all.
The Wizard Was a Fraud
This scene from the Wizard of Oz is a beautiful metaphor for the people at the very top—the insurance company executives who want you to think they have all the answers. Dorothy, the scarecrow, the tin man, and the cowardly lion have have killed the Wicked Witch. The Wizard promised that he would see that the scarecrow got a brain, the tin man got a heart, the lion got courage, and Dorothy made it to her destination— home. Now they have accomplished the mission and they have appeared before the Wizard. Of course, he tries to delay because he does not have the answers. He is the master of illusion and special effects. He projects an intimidating image of himself with smoke and a big booming voice. He continues to project the image of the all powerful, all knowing Wizard, but the dog pulls back the curtain and he is exposed. We don’t have the best medical care in the world. The current leaders don’t have all the answers. In fact, they only have answers that work for them and for no one else. Like the Wizard, they are frauds, and they will never get Dorothy home.
But here is the best part of the story. The lion, the scarecrow and they tin man had what they needed all along and that is where we find ourselves. CPC+ failed but that only helps us understand that we already have what we need. We know about the advanced primary care teams and the protocols that can produce better care for chronic diseases. We have identified the fifteen priority conditions. We have brought together the stakeholders who can provide the support required for your community to have better health at lower cost. Your community has proven they have the firepower to develop and run a community water supply. Now all we need to do is bring the stakeholders and your community together to get started. That is the prize we will find over the rainbow.
We have just been through the season of feasting and celebration. Now we are entering the season of determination and resolution for the New Year. We are entering the season of fixing what is broken. The stakeholders I work with are ready. If you are a small town with a primary care nurse practitioner seeing your people, we can help them bring you the best healthcare in the world. We can help your town be a leader in the struggle to protect your family’s health at a reasonable cost. Let’s get started.
No more data cherry picking, gaslighting of people, and the diabolical “late-stage-sickness-seeking-profiteering-kabuki-dance-theatrics” big pharma sponsored racketeering! Let’s put out the dumpster fires 🔥 and build a new world where people can enjoy a healthy life without being forced into bankruptcy and dying from a weaponized system which monopolizes their own personal data.
MCG Technology is leading the way as the tip of the spear to usher in a new era of true innovation for the good of humanity! Stay tuned!