Make America Healthy Again: Taking the First Real Steps

A Guidebook to Better Health At Lower Costs

Let’s begin to examine the first concrete steps. The National Academy of Medicine of the National Academy of Sciences advises major medical stakeholders in the United States on healthcare policy. Twenty-two years ago, they recognized that we had not changed our approach to chronic diseases so that we manage them more effectively. They wrote a guidebook called Crossing the Quality Chasm. The name was no accident. In my last post, we looked at the problem from 30,000 feet. Now let’s look at the specific concrete steps the National Academy of Medicine laid out in their guidebook for healthcare leaders.

“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…”

When I read that report 25 years ago, I had already been treating patients with chronic disease for 2 decades and I had begun working on the systematic approach that the National Academy of Medicine was recommending. I recognized immediately the validilty and power of their recommendations. I was working already on a systematic approach to one third of the priority conditions: high blood pressure, diabetes high cholesterol, heart attack, and stroke.

Step One: Bring Together the Stakeholders

My colleagues and I have a long history of collaborating with other stakeholders to improve the care of patients with the chronic disease that I mentioned just above. We recognize this fact. No one person or entity can even begin to address the huge challenge of changing out healthcare system to identify and treat patients with priority conditions earlier and more effectively. We cannot begin to move away from treating the catastrophes like heart attack and stroke late in the disease process in huge hospital systems. We cannot begin to move toward preventing heart attack and stroke by systematic care in the outpatient setting. We alone cannot Make America Healthy Again. The problem is just too big. Only those with the greatest stake in changing the system and the power to force the change can make this happen. These are those who have lost and suffered the most under the current dysfunctional system.

These stakeholders have the power to force the change. Those who have suffered the most are payers who pay the exorbitant cost for much poorer results. These include federal, state, municipal, and county governments, school boards, unions, and self-insured employers. These non-medical entities control 80% or the economy and they should come together to force change in the medical system that controls 20 percent. The money and power people should not dictate all of the changes. American patients, hospital systems, employees, and clincians should be included as well. Bringing stakeholders together is an absolutely essential first step for Making America Healthy Again.

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.”

You could make a very strong case for adding obesity, other arterial disease,congestive heart failure and chronic kidney disease.

The conditions in bold type are the ones we have begun to address with other stakeholders because they are the ones for which best practices are most firmly established. They are also related in their root causes and management. One outpatient primary care team can address all those conditions using an integrated protocol. I led a team like that myself. A major employer was very happy with our work. In the 24 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 while reducing costs.

Step 3: Execution

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

(1) organize evidence-based care processes consistent with best practices,

• We have worked with other stakeholders to develop the protocols and care processes for the cardiovascular and related conditions in bold type in the priority list above. You can find them on my Substack home page.

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 on my Substack homepage that cover these issues.

(3) develop the information infrastructure needed to support the provision of care and the ongoing measurement of care processes and patient outcomes, and

• I have been working with a team at Congruity Health to develop an advanced platform that integrates through artificial intelligence a cardiovascular risk factor registry, a patient engagement tool, a population health tool, a clinician encounter documentation tool, with robust clinical and financial and financial analytics. This integrated platform is designed solely for chronic disease management. Electronic health records do not serve this function. They were developed to document patient encounters for billing purposes. They were not designed to support treating chronic diseases. The most effective chronic disease management requires a platform designed for the work.

(4) align the incentives inherent in payment and accountability processes with the goal of quality improvement.

• Chronic condition management will never improve without a change in payment. If you really want to Make America Healthy Again, you cannot have a payment system that pays large hospital systems more for the same service. That is unfair, counterproductive, and it is a barrier to progress. Rather than paying independent outpatient primary clinicians less than those employed by big hospital systems, they absolutely must be paid equally or better. I have worked in several settings on improving chronic disease management. I have never seen management improve without a change in payment. One way to go would be to pay these independent primary care clinicians the same as hospital system primary care doctors with an opportunity to make 25% more by meeting their best practice chronic disease management targets. You will save money all day long by preventing very expensive hospitalizations, ER visits, tests, interventions, and specialty visits.

Making America Healthy Again is an important and achievable goal. I have been advocating for that goal for three decades. If the administration is serious about making progress in that worthy pursit, they will begin the steps above immediately. If they don’t do that, you will know they are not serious. It is all hot air. Slogans and talk won’t make Americans healthier again at lower cost. It is time to stop talking and do something.