Dr. Chris DeRienzo, System Chief Quality Officer, Mission Health
At the dawn of America in 1776, the everyday practice of medicine reached deep into citizens’ homes. Colonial physicians lived on house calls, and for the next two centuries the home environment served as the primary locus of the doctor-patient relationship.
That’s all changed in just two generations, as the rate of doctor-patient interactions taking place in the home fell from 40 percent for our grandparents to near zero for those born in the 1970s and ‘80s. The shift has been driven by a number of factors, including:
• How Medicare, Medicaid, and most commercial insurance companies reimburse for care,
• The movement to increased specialization among physicians and surgeons, and
• Technology-enabled advances that have increased overall demand for care
"Yet the world awaiting healthcare’s return into the home environment looks much different than the world it left just two generations ago"
Yet the wave that drove healthcare out of people’s homes is about to recoil. While we will always need hyper-specialized places for patients with the most serious conditions to engage with care, the recoil is being driven by the shift in healthcare’s core focus from treating disease to preventing disease and nurturing health. This is a once in a generation shift, and in its wake the practice of medicine is marching by necessity out of doctors’ offices and hospitals and back into people’s homes.
Yet the world awaiting healthcare’s return into the home environment looks much different than the world it left just two generations ago. Today’s world lets us buy airline tickets, choose seats, check-in and board a flight, track frequent flyer miles, and respond to an experience survey all from the comfort of our smart phones. At least three companies that all begin with an “A”(Alphabet, Amazon, and Apple) are spending billions right now to figure out how to do the same in healthcare, and both government and private payers are actively experimenting with how best to pay for it. When they do, brick-and-mortar based entities are at risk of being on the wrong end of the healthcare equivalent of a Blockbuster/ Netflix-level disruption.
While the train has clearly left the station, there are many, many challenges that remain to be solved as the population health engine changes how we engage in and pay for care, including:
• Can all health systems manage population risk as well as the small minority of those doing so today?
• Will the reimbursement system – both commercial and governmental – transition fast enough to push the pivot to population health but not so fast that safety-net providers fail?
• Can we facilitate enough real interoperability among the myriad dark corners of our health IT infrastructure to actually manage population outcomes on a national scale?
These are significant challenges, though largely solvable with time, energy, and resource. The biggest remaining question though isn’t solvable with time, energy, or resource, and it’s the one that as a nation we haven’t really asked... Will Americans really accept it?
While Americans have granted Facebook, Google, Apple and Amazon nearly universal access to everything we do everywhere we do it, will we be just as open when Alexa is telling us to take our beta-blocker and auto-reorders a week’s worth of kale instead of laundry detergent and ice cream bars?
When you really get down to what it takes to prevent disease and nurture health, you reach both incredibly complex social issues (like medication affordability, transportation, and housing) along with relatively basic decisions we make each day. Decisions like whether to eat a carrot or a bag of chips, walk the dog or smoke a cigarette, go for a run or go back to sleep. To truly improve population health outcomes, we must unleash the creative power of disruptive innovators working with providers to actually make America healthier, and that means accessing and influencing these kinds of everyday decisions.
Until the Obama administration, healthcare providers largely measured outcomes under their control inside the four walls of a hospital. A classic example is CLABSI (central line bloodstream infections). CLABSIs happen for the most part inside the walls of a hospital and are nearly 100 percent preventable when doctors, nurses, and other caregivers follow well-proscribed insertion and maintenance bundles. To drive success on other metrics, like surgical site infections and unplanned readmissions, providers by necessity have learned how to extend their reach beyond their walls through care management and better connectivity among inpatient and ambulatory physicians.
The great ACO experiment has gone a step further. Meeting a metric like “attributed beneficiaries with controlled hypertension” requires not just seeing a patient, diagnosing hypertension, prescribing the most appropriate therapy, and following up at the appropriate intervals. Instead, it means making sure each patient fills his prescription, takes his medications as prescribed, and doesn’t do other things that could make the medication either not work at all or work too well. It also means repeatedly documenting that his blood pressure improves and stays improved, meaning continual assessment, reassessment, and tweaking of his management plan over time.
With accountability for actually achieving this level of control over chronic conditions, ACOs have become increasingly creative in accessing and influencing patients where the opportunity to do is greatest - in their homes. Mission Health’s Caramedic program is one example, bringing care coordination literally and physically into a patient’s house via a community paramedic to directly impact the social determinants of health that really drive population health outcomes.
And yet here’s the rub-on the whole, how far will a nation of generally independent people allow the healthcare system into the parts of their lives that until now have remained generally private?
Like all things, better population health outcomes will come a price-making and keeping America healthier will require a level of personal, technology-enabled daily interaction with accountable parts of the healthcare system in ways unimaginable to our grandparents. It will mean balancing incentives and penalties that go far beyond paying a higher health insurance premium for choosing to smoke, and trading intimate access inside our homes for the opportunity to live longer, healthier lives.