American healthcare is moving towards value-based care—better care at lower cost. The train has left the station, but its final destination is far from clear. We have been talking about better at lower cost for decades. Healthcare in the US costs twice as much and the citizens live longer in other developed countries. It’s a problem, and our efforts to make progress have failed. According to an article in Forbes magazine, there are three critical components to value-based care: excellent clinical quality, affordability, and convenient access. Historically, provider groups could only achieve two out of three of these elements which made the third element worse. Until recently, our system lacked the new science, new systems, and new payment models to achieve success. Now we understand what a comprehensive solution or “system-ness” looks like.
A comprehensive solution is the key to value-based medicine. If any one element of the system of care is missing, it is like a chair that lost a leg. If you try to use it, the chair falls over. It fails. Chronic diseases like back pain, heart artery disease, and diabetes generate the most health care cost. Best practice care for chronic conditions is less expensive care. Optimal medical therapy (OMT) for heart artery disease makes it ten times more likely you will be alive in five years, and it costs $20,000 less per patient per year. OMT for diabetes over 20 years reduces hospitalizations for congestive heart failure by 70% and that is the source of most cost. OMT produces excellent clinical quality most consistently in chronic diseases.
Convenient access is part of the system required to produce OMT. Barriers like cost, travel, and time away from other responsibilities reduce the number of patients who achieve OMT. The greatest gains will be achieved by advanced outpatient primary care teams focused on related chronic conditions in the outpatient setting. These chronic conditions can be managed remotely. Only fifteen percent of visits occur face to face at the Southcentral Foundation clinics in Alaska. I have experience managing patients remotely. People can easily measure their sugar and blood pressure at home. Nurse practitioners or pharmacists can adjust therapy over the phone or computer very effectively using a protocol without checking with the doctor. Claims data can identify all patients with a high-risk condition for nurse coaching and education. A population health tool identifies members who have not been seen, have not had a test, or are not at goal. Direct contracting lowers the cost of hospitalization, imaging, and ER visits. A comprehensive system aimed at delivering OMT consistently provides big dividends in people with chronic diseases.
The Forbes article is right. Systemness is the key to value-based medicine. They are betting that massive systems like Geisinger or Kaiser Permanente will be the answer to better health at lower cost. Other possibilities are large retailers like Amazon, CVS, or Walmart. That could work but it will be much slower than focusing on advanced outpatient primary care where systems are equally important. Walmart is the most promising retailer because of their focus on value in other operations. Dr. David Carmouche leads their clinic effort, and he understands how it all ties together as well as anyone. If a retailer successfully leads the charge, my bet is on Walmart. Retailers generally are not patient-centered. Their priority is stockholder and company executives’ interests, not patient interest. Another possible path forward is a collaboration of stakeholders called Health Direct Partners. They are focused on outpatient primary care and OMT and they bring together an equally comprehensive solution.
If you do not have a comprehensive advanced primary care operation that combines new systems, new science, and a new payment model, you cannot scale your results no matter how good they are. Quality is a systems property and without systems you cannot scale it. If you apply these principles in advanced primary care, hospitalizations fall by 80% compared with usual care and ER visits fall by 2/3. The path forward doesn't have to be through giant health systems or pharmacy chains. A much faster approach can come with clinics like Vestra Health.
The new science is as important as the new systems. If you do not incorporate that into your model your results will not be as good as they could be. The new science shows that our system focused on risk factors and organ is outdated. The same genetics, epigenetics, and molecular biology cause more rapid aging and chronic disease development. Chronic diseases are whole body diseases. We understand this science well enough now to protect every organ and cell in a coordinated, integrated manner with specific systems and protocols.
"However, regardless of how their actions are envisioned, it is now critical for physicians to reconceptualize SGLT2 inhibitors as organ-protective agents rather than glucose-lowering drugs. The antihyperglycemic action of these drugs represents a tiny fraction of their broad portfolio of effects, which (when fully exercised) cause an adaptive reprogramming of stressed cells in a manner that promotes homeostasis and survival." In other words, Jardiance slows kidney disease and heart failure progression dramatically. Not because it lowers the sugar, but because it switches on a master metabolic genetic survival switch that prevents cardiovascular disease and cancer. Jardiance protects every cell and organ in the body. So do lisinopril, losartan, spironolactone, statins, and metformin.
Systemness is required for value-based care. The Forbes article describes it like this: “System-ness is the effective and efficient coordination of healthcare’s many parts: outpatient and inpatient, primary and specialty care, financing and care delivery, prevention and treatment.” Advanced outpatient primary care can get us there more quickly. By more consistently producing OMT it reduces hospitalizations, specialty referrals, and fragmentation. It requires less coordination. It keeps us healthy longer so we don’t need those things. Let’s get started.
We're heavy into a "Pandemic of Labetalol Protocol" at my hospital. Everyone is walking around scratching their heads...maybe it's 5G...? All the while, the NICU stays full of pre-term babies and crying mamas. God, please help us!
Thank you for such amazing critical news in how we can improve our medical care. Appreciate this information so much.