Lesson 10: The Roadmap for Change from the National Academy of Medicine

Remember, the National Academy of Medicine produced a stinging indictment of our failure to address chronic diseases more effectively in Crossing the Quality Chasm. They did not stop there. They told us how to fix it. Their specific recommendations  follow: “Given the magnitude of the change that is required, the committee believes that leadership at the national level is required to initiate the process of change by taking two important steps. First, a short list of priority conditions should be promulgated by the Department of Health and Human Services, and all health care stakeholders should then focus attention on making substantial progress toward the establishment of state-of-the-art processes for these conditions…” They are describing our systems and protocols.

Step One: Bring Together the Stakeholders

No one entity can improve health and reduce costs at scale. We are bringing stakeholders together to begin that journey. These resources in combination result in better clinical and financial outcomes.

Step Two: Identify Fifteen Priority Conditions for Initial Focus

“Based on their prevalence, expense, or policy relevance: cancer, diabetes, emphysema, high cholesterol, HIV/ AIDS, hypertension, ischemic heart disease, stroke, arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimer's disease and other dementias, and depression and anxiety disorders.”

The conditions in bold type are the ones we will begin with because they are the ones for which best practices are most firmly established. Obesity, chronic kidney disease, other arterial disease, and congestive heart failure are also part of our list. In the 22 years since Crossing the Quality Chasm was written, we have learned that aging and most chronic diseases are related and that optimal medical therapy for the conditions in bold type reduces all-cause mortality.

Step 3: Executive

Health care organizations, clinicians, purchasers, and other stakeholders should then work together to

(1) organize evidence-based care processes consistent with best practices. I have written 800 articles on Substack about optimal medical therapy. Our protocols and related education programs like CME are all available in this same space. Much of the care for chronic diseases can be done remotely. The SouthCentral Foundation in Alaska is the best example. They do 85% of their visits remotely and have quality indicators in the 75^th to 90th percentile while providing care at half the cost.

2) organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions. We have patient education programs with 10-15 lessons each that patients with hypertension, type 2 diabetes, and depression can take any time at their own pace. Go to my Substack home page to find those.

(3) develop the information infrastructure needed to support the provision of care and the ongoing measurement of care processes and patient outcomes We identify the high-risk, high-cost patients from Third Party Administrator claims data claims or electronic medical record data automatically and introduce them to a team member automatically to begin building a trusting relationship. We automatically identify the patients who are not on OMT, identify the gaps in care, and produce the solution to close the gap. We automatically collect baseline clinical and financial data and report it every three months with a dashboard. We can identify the percentage of patients on OMT and changes in the cost of care automatically. Everything is designed to scale at the lowest lost.

(4) align the incentives inherent in payment and accountability processes with the goal of quality improvement. We are most successful in value-based models. The payment model is designed to support steps 1-3.

Multidisciplinary teams are critical to the success and efficiency of this model. Quality is a systems property. Optimal medical therapy is a product. Everything in our design is aimed at making standards of care standard and getting everyone on the team on the same page. Everything I have ever accomplished has begun by putting forward the best solution that we can identify, rolling up our sleeves, and getting started. We will learn how to improve it as we go, and it will always be changing.

The proof that OMT is dramatically better than the care most of us receive is beyond dispute. The investigators in the type 2 diabetes Steno trial in Denmark believed that the huge difference in outcomes between OMT and usual care was so great that continuing to treat patients with usual care had become unethical— They could no longer defend it. Isn’t that where we find ourselves and doesn’t that push us to make changing the way we manage chronic diseases a national priority.

If you have gotten this far in this article, it probably means that you are interested in healthcare reform, or you are a healthcare leader. Maybe you are a county administrator or a city manager. Maybe you are a healthcare benefits advisor. You are probably a stakeholder who can influence this change in some way. Let’s work together to protect the people we care about!