HJAR May/Jun 2023

CHANGING HOW CARE IS DELIVERED 32 MAY / JUN 2023 I  HEALTHCARE JOURNAL OF ARKANSAS   to embrace changes regarding their own roles, especially with regard to evolving concepts in professionalism, interprofessional education, and leadership. As outlined by former Supreme Court Justice Louis Brandeis, characteristics of a profession include the following: 1) possess- ing a special set of knowledge and skills that it is responsible for maintaining, improving, and for passing on to the next generation, 2) putting others’ interest ahead of its own, and 3) self-regulation, where financial return is not the accepted measure of success. Considering the woeful performance of the U.S. healthcare system compared to other economically devel- oped countries, I think a good argument can be made that our profession needs to acknowl- edge these failures and lead the way forward to a better future. Doing so will require physi- cians to reconceptualize the notion popular- ized in traditional culture as “doctor knows best.” Abundant evidence from the manage- ment literature illuminates the shortcomings of autocratic leadership, while highlighting the benefits of many other forms of leadership, such as humble leadership, relational leader- ship, or empowerment leadership. While we will always rely on physicians to apply hard- earned tacit knowledge in solving complex unstructured problems or to apply technical skill in performing life-saving surgeries and procedures, the knowledge and skills needed to manage chronic conditions and many of the other problems plaguing healthcare are vastly different. And chronic conditions are where the majority of avoidable costs in healthcare can be found. Better managing of those con- ditions requires flattened hierarchies, humble leadership, relational coordination, and team- work. Physicians must ask the question, “What can I do to help make these people better,” referring to both their patients and the care teams they will lead. And care teams will be comprised of both a healthcare and social care team that will work and learn together with the object of cultivating collaborative practice around providing truly patient-centered care. It is through this interprofessional education where it all gets tied together and where physi- cians will both lead and learn at the same time. General Martin Dempsey, former chairman of the Joint Chiefs of Staff, saw the need for precisely this kind of mindset shift in what was historically the most autocratic and hierarchi- cal of places, the U.S. Army. Dempsey, in his one of the world’s most valuable companies. In that same article, we mentioned how Iora Health, a company of only 600 employees — comprised solely of primary care physicians, behavioral therapists, health coaches, and sup- port personnel serving approximately 38,000 Medicare beneficiaries — sold for over $2 bil- lion by creating and capturing value very differ- ently than traditional health systems. The com- pany that purchased them was One Medical, a novel primary care company that first began exploring alternatives to traditional fee-for-ser- vice financing mechanisms as far back as 2007. In 2020, a study was published in JAMA about how One Medical worked directly with a large innovative, self-insured employer in southern California to deliver care to that company’s employees very differently than traditional transaction-based primary care. Utilizing a dif- ferent economic model to capture value, One Medical deployed reinvented team-based pri- mary care to create value. Predictably, the cost of care for that employer went up modestly in three areas: primary care, behavioral health, and physical therapy. However, total cost of care for that employer went down 46% over- all, with decreases in spending on emergency room visits, hospital admissions, surgeries, and specialty visits. Measured health outcomes improved considerably as did experience of care for both patients and providers. In a move that should raise the eyebrows of every healthcare executive in the country, Amazon reached an agreement to acquire One Medi- cal in July 2022, and that deal was finalized in February of this year. I’m quite certain many healthcare executives will immediately cast doubt on the ability of Amazon to disrupt the healthcare industry. I’m also quite certain that the executives of the motion picture industry never dreamed that a company that started as a small online book seller would one day be making Oscar-nominated motion pictures. CHANGING THE CULTURE For this third article in this series, we stay at a very high level but at least come down into the stratosphere. Changing the fundamental economic model of healthcare is an essential prerequisite to achieving the most efficient, equitable, and effective healthcare system pos- sible but is far from the only change that needs to take place. A culture change in healthcare will be equally necessary. Physicians will need In the first article of this series, we began with a view of the world — specifically the world of healthcare — from the 240,000-mile level, quite literally a view from the moon. From that view we explored our “moon shot” and imagined a different world of healthcare where the un- relenting focus of our healthcare system is to improve the health and health outcomes of the patients we serve, while measuring and hold- ing ourselves accountable for those results. We envisioned a world where healthcare is af- fordable for everyone and no longer the lead- ing cause of bankruptcy in this country. We dreamed of a future where the experience of care for patients will be as seamless and fric- tionless as ordering a purchase from Amazon, while simultaneously cultivating an environ- ment where patients can spend enough qual- ity time with their physician or care team to have their questions answered, their concerns addressed, and where the focus of each inter- action is aimed at helping them achieve the health goals that matter most to them. And lastly, we looked forward to a day when all pro- viders and care team members come to work every day to connect with the deep sense of purpose of why they entered healthcare, expe- rience all the joy that our profession can offer, while also strongly recommending it as a ca- reer path to idealistic youth without hesitation. In the second article, we came down to more of a 240-mile view of the world — about where the International Space Station currently or- bits — and explored the economic models that have resulted in current U.S. healthcare system performance falling dramatically short of the idealism expressed above. Indeed, our current U.S. healthcare system is wildly expen- sive, does not produce anywhere close to the best health and health outcomes in the world, and is too often characterized by poor experi- ence of care for patients and providers alike. While economies of scale will continue to ex- ist in healthcare, business model reinvention will intervene with increasing frequency, of- ten driven by economies of scope. Business models oriented around scope-driven solu- tions seek new ways of creating and captur- ing value by starting with the customer and then working backward to figure out how to deliver value propositions that alleviate pain points, solve problems, and meet customer needs. This newly envisioned way of delivering value has been exactly how Amazon became