A letter from the editor-in-chief of The American Journal of Accountable Care®.
It would be difficult to make the argument that health care in the United States was designed with the patient in mind. A statement like that is inherently controversial and would likely be viewed as heresy by many entrenched in the medical establishment, but I firmly believe it to be true. It is not the fault of anyone per se, but instead the product of an amalgamation of policies, laws, regulations, and funding streams that have created what is often called the American health system. Congress passed the Hill-Burton Law in 1946 providing funds for communities to construct acute care hospitals, nursing homes, and other facilities in exchange for a commitment to provide care to anyone in the community who needed it. We ended up with lots of hospitals—too many, arguably—yet still had many Americans without insurance and therefore too many had limited access to care. In terms of insurance, our history has tied coverage to employment for those of working age and their families, while in 1965 creating the Medicare and Medicaid programs to cover seniors, those with lower income, and the disabled. Yet these investments still left 48 million Americans uninsured despite the United States spending about 17% of gross domestic product on health care, which was a major motivator for the Affordable Care Act and its provisions that over a decade have reduced that number of uninsured Americans to about 28 million. The fields of medicine and public health have a long history of being at odds and competing for funding, with the disease and treatment focus of medicine often winning over the more basic activities of surveillance and prevention, much to the surprise of the population that looks for coordinated leadership when faced with a public health crisis such as the COVID-19 pandemic. The phrase “social determinants of health” seems to be the rage in policy circles these days as many are discovering for the first time what we’ve known for decades: Safe housing, food security, access to transportation, and other basic needs can greatly affect one’s health—often more than hospitals, doctors, drugs, and devices—yet for those needs we have created a whole additional patchwork of programs outside of the many health care programs described above.
Rather than to be too critical of our republic or to hope that our democratic country—founded on pluralistic ideologies and governed by a federalist model—will quickly convert to a European-like planned society that can quickly and swiftly address a myriad of health and health-related challenges and needs, I would argue that our best hope is a different path— innovation and real-time learning. Innovation is something valued and respected in America, and it plays well in the political halls and in the economic marketplaces. The innovation needed in health care is in theory simple: Put the patient at the center of everything, and add value relative to the status quo. And with all due respect to those including myself who have invested years in education to earn PhDs, or MDs, or PharmDs and the like, the innovation needed in health care also requires those who understand our patients as customers and consumers: the app developers, the supply chain specialists, the information technology gurus, the team building coaches, and those who may be more comfortable operating in a virtual world rather than one restricted to bricks and mortar. Yes, I’m simplifying things a bit, and we don’t want to lose the strength of our clinical science enterprise, but we desperately need more systems science in addition to basic and clinical science, and we also need to utilize the behavioral and social sciences to better understand what motivates and nudges our patients. And of course, all of this needs to be done while creating value, which means it can’t cost more and in fact we’d like it to extract more value from the significant monetary investment we collectively make as a nation in medicine and health-related programs.
The articles in the December 2021 issue of The American Journal of Accountable Care® (AJAC) include multiple examples of attempts at innovation in different health care settings attempted in real time by various stakeholders. Yeager et al focus on how using case conferences in a primary care setting, involving physicians, social workers, and community public health workers, may help connect the dots on the social determinants needs of patients and potentially help to steer patients and families to resources that may be available for assistance with housing, food, transportation, and other basic needs. Lee et al report on a formal assessment of the pandemic-induced and unexpected rapid shift to the use of telemedicine in a cardiovascular specialty clinic, with the goal of understanding how it went from the patient and provider perspective and how it can be improved. I’ve heard clinical colleagues tell me that the pandemic catalyzed the adoption and use of telemedicine and related nontraditional approaches to providing care decades forward relative to what likely would have happened absent the pandemic. This is good, but the need to rapidly adapt means there is a lot to be learned and that can be improved, including better understanding the benefits, as well as the limits and acceptability of these innovations. In their commentary, Sherman and Klepper discuss how value can be created by purchasers directly contracting with health care providers, possibly eliminating to some degree the “middle parties” such as third-party administrators, which often extract dollars while providing services that are sometimes of marginal value in the supply chain. Being innovative involves being efficient in the way care is produced, and these authors suggest that much more is possible if provider organizations systematically assess their own production functions and have direct discussions with the payers who “feed the pig” by supplying dollars to the health care enterprise. And finally, the commentary by Jennifer Bright entitled “Patient Value Is the Root of a Learning Health Care System” reminds the reader that just as individual learning should be a lifelong endeavor, so too should be systems learning. Yet in the frenzy of our daily health care transactions, literally years can go by before organizations meaningfully stop to assess if there is a way to operate with less chaos. That is because while we require and invest in individual-level learning—such as continuing medical education for physicians—there is no commensurate requirement for health care organizations to dedicate time and funds for systems learning, which could help to better understand if and how the myriad component parts of the health enterprise function together for patients. Bright cites the National Academy of Medicine’s definition of a learning health care system as “one in which science, informatics, incentives, and culture are aligned for continuous improvement, innovation, and equity—with best practices and discovery seamlessly embedded in the delivery process, individuals and families as active participants in all elements, and new knowledge generated as an integral by-product of the delivery experience.”1 That sounds like utopia to me, and I don’t pretend for a moment that most of the health care systems that I know or have studied can get there any time soon. Instead I’d be thrilled if these systems, often created by market-driven mergers and acquisitions and investor-led attempts to block competing systems from gaining market share, would simply add the above definition to an agenda at a board meeting and take 30 minutes to discuss the concept and honestly assess if in fact their own system is on a path to truly becoming a learning health system.
As I close, I want to thank our readers and many contributors for their contributions to AJAC during 2021—including authors, peer reviewers, and the editorial staff. At the risk of using this platform to pontificate, I will suggest an idea for those individuals and organizations that might be inclined to set “resolutions” or goals for 2022. My suggestion is to strive to innovate and learn in real time with the goal of making things better for patients and adding more value for the resources you’ve been provided to deliver health care. And if you decide to set goals, make certain to collect some data and objectively assess if what you are doing is making a difference, which is a basic principle of a learning health system!
Dennis P. Scanlon, PhD
1. NAM Leadership Consortium: collaboration for a value and science-driven health system. National Academy of Medicine. Accessed November 12, 2021. https://nam.edu/programs/value-science-driven-health-care/