The current national healthcare delivery model is devoid of efficiency, empathy, or—for that matter—care. With silos for the sake of silos and a transactional system in nature, focus, and orientation, the contemporary practice of healthcare consignment is defined by reimbursement and compensation methodologies and perpetuated by legacy processes.
Patient focus—what is that? If we examine the U.S. healthcare system under a microscope focusing on effectiveness and desired outcomes, we find that the molecular structure of the model—the very foundation of what was designed to ensure our happiness, stability, and wellbeing… the actual base of our existence—is at best flawed, fragile, and fraught with danger. Under the guise of innovation (read “profit’), we encourage a malady that seemingly has no treatment, no cure, and—worst of all—no functional reason.
Simply stated, American healthcare delivery is fragmented because the owners of the system have accepted that return on investment (ROI) is the desired outcome rather than patient-centered care across the continuum. While we can certainly offer arguments for ferreting cost-saving measures that drive down the cost of delivery in the name of affordability for all, common sense and history clearly show that the cost of health care will never be affordable. It will only continue to skyrocket. We left the launch pad long after the mission should have been scrubbed. Care is costly; lack of care is even more costly.
The consequence of coupling myopic measures with metrics that drive incentives (under the veil of quality) and reimbursement is that the two only conspire to perpetuate and serve the thieves of fragmentation and silos that prop up the shaky U.S. healthcare delivery model.
The Genuine Care of Humanity
Today, the objective of that construct must be to devise a model that broadens the lens and seeks an orientation on clinical outcomes and the genuine care of humanity—not the support of voluminous transactions that reward the indiscriminate consumption of services and further fragment care. Where does that leave us?
We must take an unusual approach, but one that can, or should, parallel the labyrinth that has become our contemporary U.S. healthcare delivery system: quantum theory. In our construct, quantum theory connotes the philosophy and psychology of a world in which we are a single wave, all connected and entangled, such that what one does affects and contributes to all that preceded and all that follows our individual interactions. It is an understanding of the universe and the interactions among us. The premise is to translate the philosophy and principles of quantum theory and apply them as a framework by which we transform the model of healthcare delivery in the United States.
Certainly, quantum theory is, by nature, a complex assumption. In short, when viewed comprehensively, it is nearly incomprehensible. At a high level, however, bit by bit and particle by particle, the argument slowly falls into place. The same is almost true for the healthcare delivery quagmire—almost. In theory, whether we deliver care preventively or reactively, we follow the trail from examination to data gathering to diagnosis to treatment and, hopefully, to continued wellness and/or cure. We take everything in a measured, systematic approach; however, as opposed to quantum theory, the delivery journey is where we diverge into chaos. A humanitarian need to stay the course or to correct the course drives the practice of health care itself.
On the other hand, ROI, relative value units (RVUs), and corporate bureaucracy have bastardized the delivery of health care. That is not delivering health care; it is delivering one-size-fits-all profit. As a result, physicians are neither aligned nor engaged in value-based care.
Continuing with our “quantum leap,” the practice of medicine is a complex, adaptive system similar to quantum theory. From the minute units that work synchronously to communicate, human physiology and our humanity are together a quantum system. Cell processes happen on a micro, or quantum, scale in which matter displays the sort of counterintuitive characteristics that are largely found in quantum mechanics. The deployment of quantum theory in medicinal practice could conceivably detect diseases in early stages or expose risks of disease prior to those diseases exposing themselves.
Our quantum framework eliminates silos and fragmentation and replaces them with a continuum of care “wave theory”—that is, preventative care, incidents, rehabilitation, and maintenance via acute care hospitals, ambulatory care, or long-term care facilities. Quality care (as defined by achieving desired patient outcomes) relies on an effective continuum of care in which the components appreciate the entanglement. In essence, they affect the action/encounter on the previous and future encounters toward outcomes rather than transactions and RVUs. The concept of physician autonomy (and thus engagement) is to personalize care using evidence-based best practices as available. Pilfering from Thaler and Sunstein, “Our goal, in short, is to help people make the choices that they would have made if they had paid full attention and possessed complete information, unlimited cognitive ability, and complete self-control.”1
Industry leaders largely agree that the predominant method of paying for care—fee-for-service—is unsustainable. The cost of care rises annually, even as patients pay more out of pocket for services. A system that incentivizes high-quality care at low cost is imperative.2
Generating Action
Consider Don Berwick’s “Breakthrough Series Collaborative Model,” which, in most estimates, is the premier approach to synergistic learning and action.3 The theory is anchored by the premise that people generate action by working together; in essence, learning by trial and error and improvement cycled by innovation. We are better together than as individuals. Thus, Berwick’s “evidence-based care bundles” initiative was born.
Reliably implementing a care bundle produces better results (outcomes) than implementing interventions separately. Imagine that! A system that depends on cooperative efforts—quantum mechanics, if you will—produces beneficial consequences. It actually works. The respect of individual learning and best practices work simultaneously to effect optimum outcomes; humanity working together to benefit humanity.
Paul Keckley agrees that our current healthcare system—key word: “system”—is unsustainable.4 Policy rules the industry, and the “complex system” into which health care has evolved is a quagmire that is “essential, complex, fragmented, inefficient, unsustainable, and change-averse.” Keckley agrees that “systemness is needed in healthcare now more than ever before.”
Today’s healthcare climate merely mimics the actual intent of systemness—the parts give the illusion that they are working together, but the results show otherwise. Keckley goes on to reference the Kaiser Permanente Institute for Health Care Policy, which characterizes the systemness that defines the U.S. healthcare arena: governance, strong physician leadership, organizational culture, clear and shared aims, accountability and transparency, physician-centeredness, and teams. The organization concludes that the missing piece is the manner in which those elements can collaboratively improve the system.
Quantum theory is the manner in which things influence each other or, in the view of many in the physician community, a patient outcome. We must demonstrate that in the continuum of care and health of a population there is value that no individual can create or accomplish alone. Quantum theory thereby establishes a culture of collaborative medicine supported by quantitative evidence that “it works.” By so doing, we inaugurate the purpose of improving health and providing the right metrics and pure analytics that allow us to learn and continuously improve and support the idea.
Ground Subzero
Where to start? Let us agree that strong physician partnership is ground zero. Ground subzero, however, is physicians understanding, embracing, and sharing in the incentives of the new care model. In his 1934 book, I, Candidate for Governor: And How I Got Licked, Upton Sinclair wrote, “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”5 Physician autonomy, then, becomes specific to patient care as we shift from a “problem” orientation to an “outcome” construct. Such comprehension is integral to the profession’s effectiveness toward humanity in the new group/entanglement paradigm. Autonomy is possible, and largely achievable, only on rejecting entanglement.
The worldwide population expects that the practice of medicine be founded on physician adherence to and respect for the architecture of society, not regulatory compliance, prohibitory laws, administrative nonsense, or human resources tripe. First, do no harm. The first, foremost, and primary duty of the physician is the care of patients. Everything else is clutter. Period.
Value-based care isn’t a new concept. Michael Porter, Ph.D., has been advocating for the model since at least 2006, citing value-based health care as one of the most critical topics in healthcare transformation.6 Dr. Porter rightly contends that value-based approaches are the key to improving patient outcomes and to reining in uncontrolled healthcare costs. He defines value as “outcomes that matter to patients and the costs to achieve those outcomes.” (See “Sound and Simple Outcomes.”)
If the concept sounds familiar, it should. Decision theory has been around for millennia and derives from determining the expected value of an outcome. The resulting action is the one that will produce the highest expected value. As opposed to normative decision theory, which supposes that the decision-maker can calculate with optimal accuracy and is largely rational, descriptive decision theory describes observed behaviors assuming that decision-makers are complying with consistent rules. In our case, the rule that the physician’s acts underscore the patient’s best interests.
Peter Senge’s The Fifth Discipline: The Art and Practice of the Learning Organization presents five theories for developing three root learning capabilities: fostering aspiration, developing reflective conversation, and understanding complexity.7 The fifth discipline, systems thinking, integrates the preceding four—personal mastery (objective view of reality), mental models (personal assumptions and generalizations), building shared vision, and team learning—by attempting to make sense of the world by looking at it from a holistic and relationship-centered approach rather than by breaking it down into parts. We are back to the rationale for quantum theory providing a framework for a transformed model of care.
That framework was best defined in Becker’s in “Saving the Art of Medicine.” Author Riz Hatton’s sage inquiry, “When their autonomy is taken away, what do physicians become?”8 elicits an equally sagacious response from Vikas Patel, M.D., executive vice chair of University of Colorado Medicine in Denver: “The biggest threat facing physicians right now is the business of medicine. Medical care for physicians has become much more of a business from every aspect, compared with what used to be the ‘art’ of medicine.”
Factory Mentality
Patel continues: “What is even worse is the increasing trend of hospitals employing physicians. This, then, really becomes a business employment, and the primary goal of any business [for-profit and nonprofit] is to generate revenue. Physicians are then the focused to increase patient visits and pressured to do more procedures and surgeries. This becomes a ‘factory mentality’ with a tremendous focus on throughput.”
Hear that, healthcare executives? If we are looking for revenue, Patel’s words are business gold. The allowance of the practice of humanity-based medicine takes the profession back to basics, which in turn achieves the results for which medicine was created—not the purchase of second homes or a weekend in Aspen. However, if the latter is the goal, satisfied patients, fortified with the confidence that the physician acted in their best interests, beget referrals and, potentially, satisfied patients, which result in increased revenue.
The factory mentality permeates the modern healthcare delivery model. The juxtaposition is clear—“the modern healthcare delivery model.” Factories, regardless of the industry, are incentivized by mass production. Revenue increases as production increases, but production increases are based on analysis of past performance—innovation be damned. The goal is to increase production, which heightens revenue but leaves no room for innovation as a result of future thinking. Therefore, the modern healthcare delivery model is a rusty, sluggish, and antiquated piece of machinery methodologies that worked in the past. Physicians are forced to deliver care based on methodologies that worked in the past. But businesses survive not by paying homage to the past but by creating the future. The modern healthcare delivery method pays no mind to what lies ahead.
As scientists, we long ago abandoned bloodletting as nonsense. RVU-based and revenue-generating constructs deserve the same fate. They are not viable or sustainable. Data demonstrate that we are not realizing our foundational goal of patient-centered care as measured by clinical outcomes. Delivering care based on the resources to provide that care is a factory byproduct. We can continue to fatten the coffers by churning and burning, or we can actually deliver patient-centered care.
The Quantum Theory Framework
Upgrades to the Large Hadron Collider at CERN, the recent deployment of the Webb telescope, quantum computing, and other sciences will define the mathematics and precision of our understanding of the universe. But the quantum theory framework as described here, one of seamless connectivity with entanglement of each “point” on the wave, will remain its foundation. Starting with good intentions of healing the sick, the U.S. healthcare system has been perverted by the siloed success of its parts—which individually and collectively are enriched by the status quo.
It is time for us to articulate, support, and impose a new, shared vision of a healthcare delivery model that rewards clinical outcomes and quality. A lesson from the COVID pandemic is that physicians, care team members, and organizations have the capacity to work together to support the people we care for—and yes, it took government subsidies to support the crisis-oriented, focused approach to collaboration.
For their parts, federal and state government agencies and regulators must eliminate the black hole effect of special interest groups representing pharma, insurance companies, and others and facilitate a transformative model of care delivery for the people. We must eliminate bureaucracy and incentives not aligned with our goal to improve the health and wellbeing of people. Perhaps it is time for a “Big Bang 4 Health Care!” As Don Berwick wrote, “It is time to move from Care Compare to Care Collaborate.”3
Medicine is both an art and a science. Coupling the two supports our goal. Transition of the financial model from its current unsustainable transactional construct to one that supports value-based care will be difficult. Our leverage? Humanity.
Steven L. Delaveris, D.O., is principal, TheDelaverisGroup, LLC, Columbus, OH. Patrick J. Higgins is director of communications, TheDelaverisGroup
References
- R.H. Thaler and C.R. Sunstein. 2021. Nudge: The Final Edition. Penguin.
- Modern Healthcare; May 16, 2022
- D. Berwick. 2021. Berwick Looks Back: IHI Ideas and Innovations. Institute for Healthcare Improvement. Accessed October 27, 2022 at https://www.ihi.org/communities/blogs/berwick-looks-back-ihi-ideas-and-innovations.
- P. Keckley. 2022. Systemness in Healthcare: Pipedream or Possible? Accessed October 27, 2022 at https://www.paulkeckley.com/the-keckley-report/2022/3/7/systemness-in-healthcare-pipedream-or-possible.
- U. Sinclair. 1994. I, Candidate for Governor: And How I Got Licked. Ed: James Gregory. Berkeley: University of California Press.
- M. Porter. 2006. Value-Based Health Care. Institute for Strategy & Competitiveness. Accessed October 27, 2022 at https://www.isc.hbs.edu/health-care/value-based-health-care/Pages/default.aspx.
- P.M. Senge. 1990. The Fifth Discipline: The Art and Practice of the Learning Organization. Doubleday.
- R. Hatton. March 11, 2022. “Saving the art of medicine.” Becker’s ASC Review. Accessed October 27, 2022 at https://www.beckersasc.com/leadership/saving-the-art-of-medicine.html.