HJAR Jul/Aug 2023

HEALTHCARE JOURNAL OF ARKANSAS I  JUL / AUG 2023 27 netic resonance imaging (MRI), thus enabling superior capability to diagnose and treat acute conditions or the downstream complications of chronic disease. Other innovations included advances in the field of surgery or the devel- opment of new procedures like cardiac cath- eterization and coronary angiography, followed by angioplasty and stent placement as life- saving therapy for acute heart attacks. These new practice-changing, life-saving advances brought us into a new era of modern medicine with resultant increases in life expectancy. And the technical and procedural knowledge/skills of these advances became increasingly con- centrated in the minds and hands of specialists like radiologists, surgeons, and proceduralists. Meanwhile, the domain of primary care con- tinued to rely on thinking and relationship build- ing. Primary care’s most advanced tool was the time they spent with patients while performing a history and physical. A history and physical starts by obtaining a history of the present ill- ness — usually an acute presenting complaint such as chest pain, back pain, headache, or malaise — followed by eliciting past medical and surgical history, family history, and social remaining laser focused on their why — the pa- tients we serve — while innovating the future. We will change not only how we create value but also how we capture value, all the while holding ourselves accountable for what we deliver — our measured results and outcomes. HOWDIDWE GET HERE? Recall that when Medicare and Medicaid first came back into being in the 1960s, transaction- based payment rates were initially determined by a group of physicians — comprised mostly of specialists — that ultimately decided surgi- cal, procedural, and advanced imaging services should demand much higher levels of reim- bursement than cognition and spending time listening to patients, earning their trust, and building relationships with them. It probably made some sense at first, especially since pre- dominant medical expertise of that time had evolved mainly around diagnosing and treating acute conditions. It also made sense because the biggest innovations in healthcare delivery were typically related to the development of new advanced imaging modalities like com- puted axial tomography (CAT scans) and mag- In previous articles, we have kept it at a very high level, starting with our aspirational “moonshot” and then subsequently looking at some of the macrosystemic, macroeconomic, and broad cultural principles that will be nec- essary to transform the current performance of U.S. healthcare to a level that our patients, pro- viders, and care teams deserve. In this article, we come all the way down to Earth and start looking at how things work at the ground level. In subsequent articles, we will begin to look at how these changes impact both individuals and specialized populations like older adults. But for now, we will begin to explore how we can bring the concepts of the first three articles to- gether and coalesce them around better man- agement of chronic conditions, starting with high blood pressure (also known as hyperten- sion). Doing so requires integration of every- thing we have discussed so far. Changing the fundamental economic model is essential to enabling better management of chronic condi- tions, and the objective evidence for that as- sertion is both overwhelming and indisputable. The barriers to change are due in large part to traditionalists being constrained by their exist- ing business models and financing mechanisms without a direct line of sight in how to move forward. Innovating the future requires design- ing new methods of creating and capturing value and development of new operating and performance metrics. To that end, the tradi- tionalists have become so engrossed in what they currently deliver and how they currently capture value that — in the words of noted author Simon Sinek — their why gets “fuzzy.” That is why you will see the traditional health systems attempt to deal with the currently unprecedented conditions of dramatically in- creased labor costs by attempting to cost cut their way out. They may reduce the number of employees in their workforce. They may demand much higher rates from the payers, attempting to generate sympathy for their cause by asserting that society is not paying enough for healthcare. They may even try to substitute less expensive sources of labor by rationalizing to themselves and their boards that quality of care will be unaffected. Mean- while, systems that deliver health will deal with the adversity of these economic conditions by “When you adequately manage and control chronic conditions effectively, you can reduce the risk of consequent cardiovascular complications, like heart attack and stroke, along with their associated costs to society.”