HJAR Sep/Oct 2023

HEALTHCARE JOURNAL OF ARKANSAS I  SEP / OCT 2023 21 failure to achieve adequate blood sugar con- trol may be placed squarely on the patient, and both the microvascular complications (ampu- tations, blindness, and kidney failure) and the macrovascular complications (stroke and heart attack) are the inevitable consequence of the patient failing to do what they have been told to do. And even if an effort is made to under- stand the social or emotional factors contribut- ing to the barriers, obstacles, and challenges standing in their way to adopt a healthier diet, exercise regularly, stop smoking, or take their medications, very little effort is usually devoted to helping patients overcome them. Concomitantly, insurance coverage of anti- diabetic drugs may be preferentially focused on the cheapest generic drugs that may help a patent achieve the short-term benefits of ade- quate glycemic control but that do not address the root cause of insulin resistance. Meanwhile, pharmaceutical companies have created a host of new drugs (including two relatively new classes of medications known as SGLT2 inhibi- tors and GLP1 receptor agonists) that better manage the underlying pathogenesis of the disease. Unfortunately, but somewhat under- standably, the pharmaceutical companies have priced the drugs using a pharmacoeconomic model that projects potential future cost sav- ings if these branded drugs were more widely adopted (meaning that the price of the drug is partially determined by how many hospitaliza- tions will be avoided, or how many cases of kid- ney failure, amputations, or heart attacks will be averted). These drugs may cost several hundred dollars per month. But commercial payers, who typically have members cycling in and out of their products every few years, may be hesitant to pay for drugs that will allow future savings to be accrued to their competitors over the long term but with the short-term expense incurred by themselves. And none of these consider- ations even begins to include the role of phar- macy benefit managers and financial rebates that come into the picture when drug manufac- turers start striking deals with the commercial payers and health systems. Complexity reigns supreme and no single entity bears the ultimate clinical or financial responsibility for outcomes, except the patient of course, who may eventu- ally find themselves disabled, blind, and bank- rupt, with their body ravaged by complications. These interactions among the different play- ers are predominantly financed by a transac- tional economic model. But you see, transac- tions don’t heal people — relationships and teamwork do. No matter how much we try to avoid it, transactional care leads to fragmented care. And fragmentation leads to challenges in delivering high-quality care that improves health outcomes. Failure to deliver high-quality care leads to moral injury for providers, actual injury to patients, and contributes to not just our epidemic of diabetes and obesity-related complications but to provider burnout as well. Lessons from one of the early systems that deliver health: HealthPartners and the Pursuing Perfection program HealthPartners, based in Bloomington, Min- nesota, is an early example of an integrated delivery system that embraced a transforma- tive journey around delivering health. Health- Partners, comprised of both a health plan and a medical group with several hospitals, oper- ated in a state that was known for innovations in healthcare delivery, with Minnesota boasting some of the best overall quality and lowest costs of care in the country. Minnesota’s health- care costs ran about 30% below the national average for Medicare patients, and Health- Partners own costs ran about 10% lower than that. Despite their already very favorable cost and quality metrics, HealthPartners engaged in transformative work in primary care, placing emphasis on achieving what was then known as the “Triple Aim” initiative — improving the health and health outcomes of the population they served, improving experience of care, and making care more affordable for everyone. HealthPartners became one of only seven organizations in the U.S. to be selected for participation in the Institute for Healthcare Im- provement’s Pursuing Perfection program, in- tended to help healthcare organizations “make dramatic improvements in performance.” Beth Waterman, their chief improvement officer, and other leaders were not at all comfortable with the reactive, visit-focused, transactional model of care. They adopted and implement- ed Edward Wagner’s (MD, MPH) Chronic Care Model, which emphasized the importance of delivery system redesign, self-management support, prepared proactive provider teams, and the role of an informed, activated patient. Wagner had identified a series of key deficien- cies in chronic disease management, includ- ing clinicians too rushed to spend the time needed with each patient, the failure to reli- ably apply evidence-based care, the failure to follow up, the failure to coordinate care, and the failure to train patients how best to care for themselves. Overcoming these deficien- cies would require transformation of how care was delivered, from a system that is essentially reactive — responding mainly when a person is sick — to one that is proactive and focused on keeping a person as healthy as possible. Applying the Wagnerian Chronic Care Model process to the treatment of diabetes, in 2004, HealthPartners transitioned away from their old model of hierarchy and autonomy. Instead, they developed prepared proactive provider teams comprised of doctors, nurses, pharmacists, di- etitians, diabetes educators, and others. They had to undergo a cultural change where pro- viders learned to let go of sole responsibility for outcomes and embrace their important role as a member of a team all working together to- ward a shared goal. They increased coordina- tion of care and focused on standardizing care processes to foster redundancy and reliability. They designed reliable systems and process- es and then, and only then, customized care around individual patient preferences, values, or changes in clinical guidelines. Along with implementing multidisciplinary primary care teams, they also created what became known as their “optimal diabetes measure” to hold themselves accountable for their health out- comes. This measure was comprised of five metrics, each with a specific target: hemoglo- bin A1c < 8.0, low-density lipoprotein level < 100, blood pressure < 140/90, non-tobacco user, and regular use of aspirin when appropri- ate. The measure set a high bar, because the only way to get credit for the measure was to achieve all five measures concurrently, meaning that even if they were able to successfully con- trol blood sugar, blood pressure, and achieve a targeted LDL cholesterol level in a person taking aspirin, but who was still smoking ciga- rettes, the team got zero credit for the measure.