2 renowned leaders offer 2 very different plans for ‘Fixing Healthcare’

In the first two episodes of Fixing Healthcare, co-hosts Dr. Robert Pearl and Jeremy Corr had the opportunity to interview two very different types of healthcare leaders. Here’s Dr. Pearl’s analysis of their plans to transform U.S. healthcare.

As guests on our show, Dr. Zubin Damania and Dr. Halee Fischer-Wright vied for the highly coveted (and totally fictitious) title of “Leader of American Healthcare.” To earn it, they needed to paint a convincing portrait of a healthcare system that’s far better than what exists today.

Call it a case study in contrasting leadership styles, the duo came to their respective interviews armed with data, decades of experience in medicine and very different recommendations. Asked to achieve five key outcomes, here are a few of their proposed fixes and plans to return U.S. healthcare to its position as a global leader:

1. Increase life expectancy in the U.S. from last among the 11 wealthiest nations to at least the middle of the pack (according to the Commonwealth Fund Report)

As an internist, a hospitalist and founder of an innovative primary care startup called Turntable Health, Dr. Zubin Damania (known to his fans and followers online as ZDoggMD) called for healthcare providers to double down on preventive medicine, education and primary care, approaches he said have been proven to “keep patients out of trouble.”

“If we’re going to increase life expectancy,” he began, “we need to address the actual problems. Those are the non-medical determinants of health: genetics, your zip code, socioeconomics, nutrition, education, etc.,” adding that medical care accounts for only 10 to 30% of our nation’s life expectancy.

By contrast, Dr. Halee Fischer-Wright focused on two systemic obstacles standing in the way of progress: “administrative complexity and regulatory burden.” As president and CEO of MGMA, a premier membership association for administrators and medical group leaders, Fischer-Wright believes we need to trust that “every player in the healthcare industry is making decisions with the same goals in mind.” She acknowledged that trust doesn’t exist today.

However, were American healthcare to relieve itself of burdensome regulations and complex insurance processes, we as a nation would, “rapidly save hundreds of billions of dollars, reduce physician burnout, improve frontline satisfaction and free up amazing time and resources that can be used to improve life expectancy and improve the health of people, leading to quality outcomes.”

2. Increase the quality of patient outcomes by 20% (as publicly reported by organizations like the NCQA).

Fischer-Wright pointed to a recent AMA survey showing that practices spend 14.6 hours per physician per week on prior insurance authorizations.

“If I gave every physician back 14.6 hours per week,” she said, “I guarantee you we would increase life expectancy and improve quality outcomes.”

Dr. Damania, again trumpeting the virtues of primary care, believes in creating a quality-improvement culture that ignores the “hype” (i.e., pricey technologies and complex interventions) and, instead, seeks to ensure doctors do the little things correctly, something he believes doesn’t happen today.

“We must realize that 50% of what we do (as a medical profession) not only doesn’t work, but causes harm. We must focus our research and implementation efforts on getting rid of that 50%. You know what works? Washing our hands.”

Here, Damania is referencing dozens of studies that show hospital-acquired infections are the third-leading cause of death in America, largely because doctors and nurses fail to wash their hands between patients.

3. Decrease the cost of healthcare by 20% (according to federally reported data)

Damania believes that the savings generated from more efficient and effective primary (and preventive) care can ultimately fund the kinds of education, nutrition and violence-prevention programs that will benefit both public health and our society at large. To ensure the right incentives are in place for primary care physicians, Damania would replace the perverse incentives of fee-for-service medicine with capitation, a form of prepayment that discourages doctors from providing unnecessary tests and treatments. In other words, rather than rewarding care delivery systems from fixing what’s broken, doctors should have more incentives to prevent serious medical problems from happening in the first place.

“The first thing we’re going to do is invert healthcare from a sick-care, reactive system that puts band aids on problems … to a focus on actual healthcare,” Damania said. “We have too many specialists, hospitals, and not enough primary-care prevention: OB/GYN, geriatrics, pediatrics, family medicine, internal medicine, etc.”

Fischer-Wright, who works with many health insurers, says that “since 2011, the direct costs for managing claims, billing and collections for primary care practices have increased by 74%, which is ironic since we’re supposedly at a time where technology and electronic transactions are supposed to be making everything more efficient. A journal article put the total cost of billing and claims at $471 billion in 2012. If we saved just 50% of that, that gives us our decrease in cost.”

In addition to simplifying the care-delivery process, she believes patient “consumerism” will lead to better and more informed healthcare choices, ultimately lowering costs at the patient level.

4. Improve patient service and convenience by 20% (according to patient satisfaction reports)

Ironically lost in 21st century medical culture are two important areas that can improve patient satisfaction, according to Damania. We need to address patient convenience and the doctor-patient relationship.

“Let’s go where the patients need us,” he says.

And accomplish that in the most convenient way for patients, Damania suggests, “Telehealth visits, phone, email, Skype. That’s where our patients want us, but instead we’re stuck behind a clunky EHR that looks like it was built in the ‘90s or worse. Also, not everybody needs a doctor. Sometimes a health coach, a licensed clinical social worker, the team—the nurses, the respiratory therapists—those are the people on the front lines.”

Interestingly, both Damania and Fischer-Wright pointed to the need for better end-of-life care in America.

Fischer-Wright, drawing on her past experiences as a chief medical officer, noted that creating a palliative care service line in her hospital resulted in higher satisfaction among patients.

“As physicians, we view death as the competitor,” she says. But instead of viewing end-of-life through that lens, Fischer-Wright says doctors need to have conversations that ask the patients about their expectations and preferences, then find ways to fulfill them in the most comfortable ways possible.

5. Improve professional satisfaction for clinicians by 20% (according to physician surveys)

With physician burnout at an all-time high, both healthcare leaders spent a good deal of time focusing on ways to improve professional satisfaction. Fischer-Wright spoke of empowered partnerships.

“I believe that empowered partnerships, in which the right people have the right amount of control over the right decisions, are crucial to building a culture of excellence in the whole industry. If we all trust that every other player in the industry is making decisions with the same goals in mind, we’ll be more collaborative in decision-making and contributing to that progress, and we’ll be more willing to share ideas far and wide.”

Damania spoke about the frustrating process of obtaining health-plan approval in order to simply do the right thing for patients and the “moral injury that occurs when we feel like we have to treat patients differently because of their insurance status.”

He believes the entire process contributes to ‘burnout’ in physicians.

“That’s not a sustainable thing.”

My $0.02 On These 2 Plans To Fix Healthcare

I was inspired by both leaders and their perspectives, but for different reasons.

Damania’s emphasis on prevention resonated with me. As former CEO of The Permanente Medical Group (TPMG), once responsible for the health of 5 million Kaiser Permanente members, I saw firsthand the power of prevention. With hospital costs accounting for 30% of all healthcare expenditures, preventing problems is a powerful way to raise quality and lower cost.

With our focus on reducing medical errors – and preventing heart attacks, strokes and cancer from happening in the first place – we were able to cut hospital utilization in half. Using this same strategy, our mortality rates from cardiovascular disease and colon cancer were 30% less than patients receiving healthcare anywhere else in the nation.

At the same time, I nodded in agreement with Fischer-Wright when she spoke of trusting clinicians to do the right thing for patients. Doctors and nurses are mission-driven and dedicated to the people they treat. In the right context and culture, they can achieve world-class outcomes. I saw it at TPMG and in other integrated healthcare systems (multispecialty medical groups and hospitals paid through capitation) that embrace information technology and reject fee-for-service payments.

The power of these two visionaries’ plans should be evident to hospital leaders and boards of directors.

Either leader’s approach could successfully lower the number of hospitalized patients and both would require a shift in resources from inpatient to outpatient facilities.

In the future, hospitals will need to focus on operational excellence, rather than trying to swallow up physician practices as a means to gain market control and raise prices.

Both leaders spoke of the recent Amazon-Berkshire Hathaway-JPMorgan Chase joint venture as a warning, a clarion call for change in a broken industry. The CEOs of these mammoth companies understand the importance of creating efficiencies in any industry. Therefore, they aren’t currently shopping for the best health plan – they’re looking to replace insurance companies altogether. What’s more, they won’t be contracting with all hospitals and physicians, only those achieving the best outcomes. Finally, their pursuit of better healthcare won’t end with their 1 million employees. They want to enroll employees at all of the nation’s biggest companies – for starters.

Today’s healthcare leaders will benefit from expanding their primary care base, moving away from fee-for-service and rewarding doctors and hospitals that achieve the highest levels of prevention and the lowest percentage of medical errors, readmissions and chronic-disease complications.

In future months, other leaders will step forward to offer their ideas and recommendations on “Fixing Healthcare.” I predict all will be different in design, but none like the healthcare model of today.

Fixing Healthcare is a part of the New Books Network (NBN) and a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via iTunes or wherever you find podcasts. Join the conversation or refer a potential candidate to us by following the show on Twitter @fixingHCpodcast, liking us on Facebook and visiting our LinkedIn page.

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