HJAR May/Jun 2023

CHANGING HOW CARE IS DELIVERED 34 MAY / JUN 2023 I  HEALTHCARE JOURNAL OF ARKANSAS   healthcare business models almost exclusively favor the role of the physician because of fi- nancing mechanisms that fail to adequately financially value other very important roles. Under reinvented business models, teams of caregivers — typically coached and led by phy- sicians — will work together to help patients attain their health goals and optimal state of health, where the patient themself becomes the most important member of the team. Using a football analogy, the offensive team needs to make progress against an array of barriers, ob- stacles, and challenges — i.e., the defense — standing in the way of progress toward the goal line. The defense is composed of an array of elements that obstruct this drive to health suc- cess, such as the social determinants of health, mental health impairments, adverse childhood experiences, maladaptive coping mechanisms that underlie many unhealthy behaviors, acute injuries or illnesses, and the cumulative burden and complexity of many overlapping chronic diseases. The physician coaches and leads the team, with advanced practice providers, nurses, dietitians, behavioral therapists, phar- macists, data scientists, process engineers, physical therapists, fitness instructors, health coaches, and others, all working together as a team and doing plenty of blocking. But again, the most important member of the team is the patient, who in this analogy has the ball and needs the coordinated efforts of the entire team to make progress toward the goal line. And when the patient achieves their health- related goals, the entire team will celebrate together. When specifically considering the role of physician as coach, I particularly like this quote from Hall of Fame football player Ronnie Lott, “Great coaches lie awake at night think- ing about how to make you better. They relish creating an environment where you get more out of yourself. Coaches are like great artists, getting a stroke exactly right on a painting, ex- cept they are painting relationships. Most peo- ple don’t spend a great deal of time thinking about how they are going to make someone else better, but that’s what great coaches do.” Wouldn’t the world of healthcare be better if this mindset is how physicians saw their role in coaching patients and leading care teams? The fourth T, time , becomes a dependent variable that is a function of the mutually in- terdependent variables of talent, technology, and teamwork. In an update to the work of Østbye and Yarnall mentioned in the first ar- ticle of this series, a recently published study used very sophisticated analytical modelling to show that for a primary care physician with 2500 empaneled patients, it would now take 26.7 hours per day to adequately address all of their panel’s needs, quite literally a math- ematical impossibility. But by incorporating a team-driven approach to care, that time could be reduced to 9.3 hours per day. Unfortunately, the current relative undervaluation of primary care services afforded by traditional transac- tion-based financing constrains primary care physicians who don’t know anything other than the status quo. It doesn’t take much expertise to realize that older adults are more complex and derive significant benefit from having more time with their provider or care team. Likewise, medically and socioeconomically complex pa- tients may also require more time allocated to their care than what is afforded by prevailing reimbursement for primary care services. How- ever, by changing the fundamental economic model and reengineering how time, talent, teamwork, and technology are optimally uti- lized, it becomes possible to reallocate time spent with patients based on factors such as age and/or complexity. These new business models allow us to develop specialized clinics for older adults with much longer visits, more time spent with patients, and more time devot- ed to coaching them and leading care teams. However, we can also use these same vari- ables of talent, technology, and teamwork to save time and deliver care more efficiently and effectively. Indeed, one of the next frontiers of healthcare will become the exploitation of ex- plicit knowledge. Hypertension management is an early but classic example. Knowledge of the management of hypertension is so complete that it is has essentially become explicit and can therefore easily be converted into stan- dardized care processes and algorithms. Once knowledge for a given condition becomes ex- plicit, the reliability of the outcome no longer depends on the individual locus of knowledge and processes of a given clinician, but rather on the execution of a protocolized algorithm. Explicit knowledge can then be codified and turned into a digital solution, hence why our system’s digital hypertension programs achieve greater than 90% rates of blood pressure control even among socioeconomically disadvantaged populations. An additional benefit is that busy primary care physicians now have more time to devote to solving more complex, unstructured problems that require the application of tacit knowledge rather than explicit knowledge. Therein lies the real promise of technology in healthcare, to give clinicians more time to devote to other aspects of care as it relates to patients, like relationship-building and com- plex clinical problem solving. And eventually, technology will be used to speed up evidence- driven clinical decision-making, along with processes and workflows that correlate more with improving health outcomes than simply to support the coding and documentation functionality necessary for transactional billing. The fifth and final “T” is the most important in my opinion: trust . Trust is both the output of getting the right configurations of talent, team- work, technology, and time in place, as well as the input that enables the physician-led team to generate the best health outcomes pos- sible. And it is essential to both understanding and influencing patients to change unhealthy behaviors. Based on the exhaustive research of Frances Frei, Harvard Business School profes- sor and author of the book, Unleashed: The Unapologetic Leader’s Guide to Empowering Everyone Around You , Frei asserts that lead- ership is about empowering others, and that its focus shifts from elevating oneself to pro- tecting, developing, and enabling the people around you. This shift becomes a pivot in how a physician views their leadership role and forces them to see the full humanity of the people and patients they seek to lead, including a patient’s ability to evolve. Frei asserts that only when you can imagine a better version of someone can you play a role in helping to unleash them. This type of leadership is predicated on the idea that human beings can adapt and that we can play an important role in each other’s adaptation. This progression requires a leader’s willingness to both believe in someone else’s unrealized potential and to find ways to com- municate that conviction. And trust is the foun- dation of that leadership framework. If lead- ership is about influencing and empowering others, then trust is the emotional framework that allows the service to be freely exchanged. “I’m willing to be led by you because I trust you,” were words written by Frei, but that could have just as easily come out of the mouth of a patient. It is not the patient’s job to comply with what we tell them do. It is our job to earn their