HJAR Jan/Feb 2023

HEALTHCARE JOURNAL OF ARKANSAS I  JAN / FEB 2023 15 medical decision-making. Is it any surprise that 10 to 15% of patients are reportedly misdiag- nosed, resulting in adverse clinical outcomes 17% of the time? It’s enough to cause moral injury to providers and actual injury to patients! In addition to epidemic rates of provider burnout, people leaving the profession in droves, problems with access to care, variable patient experience, and unacceptably high rates of misdiagnosis, healthcare in the U.S. is also not exactly known for being universally affordable. Indeed, about the only category where the U.S. healthcare system clearly leads the way compared to the rest of the world is that we are the most expensive. The cost of healthcare is a major concern for nearly all Americans, and healthcare costs are the lead- ing cause of bankruptcy, with one study find- ing 66.5% of all bankruptcies tied to medical issues. The exorbitant cost of healthcare might be a price worth paying if we were the high- est performing health system in the world, but there is no objective evidence of that. According to the Commonwealth Fund re- port, “Mirror, Mirror 2021: Reflecting Poorly,” compared to other high-income countries, U.S. health system performance is woefully lacking. Out of the 11 countries featured in the report, we rank last in health outcomes. The report builds upon many prior studies that highlight the discordance between the price we pay for healthcare and the quality of health outcomes we get in return. This relationship between price and outcomes denotes value. Although many healthcare definitions of value exist, I think the best one comes from the co-author of the book “Redefining Healthcare: Creating Value-Based Competition on Results,” Eliza- beth Teisberg, PhD. She defines healthcare value as the health outcomes that matter most to patients divided by the cost of delivering those outcomes across a full cycle of care. We are in desperate need of changes that create value. The good news is that it is pos- sible. With very few exceptions, providers go into healthcare because of their genuine desire to help care for those in need. When we suc- ceed in helping people become healthier, it brings us joy. It gives us meaning, a sense of be- longing to a cause greater than ourselves, and it renews our sense of purpose as to why we en- tered the profession in the first place. And when we successfully improve the health of those we serve, it reduces healthcare costs, both finan- cial and emotional. One of the great myths in healthcare is that excessive healthcare spend- ing is driven by inexorable forces, and that only by rationing beneficial care will we be able to reduce the total cost of care. The simple fact is that improving health reduces health expen- ditures. These two variables go hand in hand. ACKNOWLEDGING THE MISTAKES OF THE PAST One of the major hallmarks that differentiated the people working on NASA’s “moon shot,” was striving for a cause greater than them- selves. Less than a decade following President Kennedy’s famous declaration, we heard anoth- er world-changing quote from Neil Armstrong, “That’s one small step for a man, one giant leap for mankind.” Like any big, bold mission, mistakes along the way are the norm, and in improving the health of humanity, we certainly have committed our fair share. One of our big- gest mistakes thus far has been a failure to un- derstand the true drivers of health outcomes. Traditional clinical care only accounts for about 20% of outcomes. Our physical environment, like the air we breathe, accounts for another 10%. But socioeconomic factors and unhealthy behaviors (40% and 30% respectively) account for the majority. We will not solve the challenge of affordable care for all or deliver the world’s best outcomes until we address and incorporate these factors into our approach to clinical care. There are at least four other major mistakes that have impeded our progress toward im- proving health. The first of these is the failure to adequately define health. And the second is failure to explicitly measure and hold ourselves accountable for health outcomes. How can we adequately manage what we don’t mea- sure? The third is that somewhere along the way, we divorced mental health from physical health. Instead of understanding that health is more than just the absence of infirmity or disease, we must acknowledge that health is a complete state of mental, emotional, so- cial, and physical well-being. And the fourth is to ascribe moral judgments around an indi- vidual’s unhealthy behaviors, without attempt- ing to understand the “why” behind them. Health behaviors certainly include voluntary choices. But we also know that the prevalence of uncontrolled chronic conditions is causally linked to a history of adverse childhood trau- matic experiences. Likewise, mental health im- pairments can be both genetically acquired as well as influenced by impaired coping mecha- nisms in response to stressors during child- hood and adolescence, through no fault of an afflicted individual. And socioeconomic factors that are beyond an individual’s control are not simply the result of life choices. Indeed, there is an aura of judgmentalism that still abounds in healthcare, where we sometimes lack em- pathy and demand patient compliance. Some caregivers still view their role as one of “telling” patients what to do and educating them on the perils of doing otherwise. But behavior change is hard and requires more than expectation of compliance. Studies consistently show that commanding compliance does not work well — not in education, not in management, and not in healthcare. The better approach is coaching with compassion. Compassion is the action arm of empathy, where our job is to understand the reason behind behaviors, how they evolved, and then working together to overcome the challenges that stand in the way of changing them. Tightly integrated behavioral health, care coordination, nutritional support coun- seling, and health coaching become essential to facilitate progress toward a shared goal. CHARTING THE COURSE If we emerged from history’s deadliest pan- demic — the 1918 influenza — to lead the way with discoveries that led to antibiotics and immunizations, thus saving lives of countless children and young adults, then we can also emerge from this one by better managing the true drivers of today’s health outcomes. If we can lead the world in automobile manufac- turing to create the largest expansion of the middle class in the history of our country, then we can figure out how to make healthcare af- fordable for all. And if we can put a man on the moon less than 70 years after learning to fly, then we can figure out how to deliver the best health outcomes in the world. It will take heal- ers and leaders who are bold enough to dream the impossible and then focus all the energies and efforts of their organization on transform- ing that dream into reality. We will make plenty of mistakes along the way, but we will learn from them, constantly refining and improving our efforts until we get to a place where we measure our success based on how well we de- liver the health outcomes that matter most. n