Towards Equity-Centered Care

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A “Health in All Policies” framework has been touted in the past few years as a strategy to illuminate the intersections between public health and other areas of civic life. It’s one way to incorporate health metrics into existing and proposed public policy – from education to transportation. But the question is, will it work?

It seems fairly obvious that health-centric framing may obstruct interdisciplinary collaboration. But at a more fundamental level, will replacing multivariate, silo’d interests with the singularity of health effectively capture the complexity necessary to create shared agendas across public sectors?

The short answer is no. Here’s why and how we got here.

The former structure of medical education and training was rooted in the idea that the greatest knowledge in medicine was best revealed through individual patient inquiry and the greatest challenges in the field were best understood and addressed through individual clinician excellence. So clinicians were evaluated based on their individual aptitude, patients were assessed based on their isolated symptoms, and each sector of the health and human service network operated in silos, training and treating pieces of the problem, without ever quite appreciating the inter-connected whole.

This paradigm of education and practice placed clinicians at the center of care and patients and allied partners at the periphery. Allied learners were taught separately and systems communicated poorly, both of which resulted in fragmentation – in how problems were evaluated and in how care was delivered.

A more recent iteration of this care ecosystem, like the “Health in All Policies” approach, now places patients and health at the center of delivery models and public policy strategies to treat disease and advance wellness. These patient-driven, health-specific metrics ensure that systems are oriented to serve and public policies are structured to mitigate health impacts.

However increased focus on individual patient outcomes may obscure population-level drivers of health disparities and unilateral dependence on health as the primary outcome, may ostracize allied disciplines, institutions, and learners whose work or study contributes to advanced understanding of human behavior and the complex relationships between structural environments and the pathophysiology of disease.

The bottom line is: the intricate problems that threaten child and community health will not be solved by the individual capacity of excellent clinicians or public servants, but rather by the ability of leaders to organize interdisciplinary teams that learn, work, communicate ideas, translate interventions, and are evaluated across shared infrastructures, in the service of shared outcomes.

If identifying health as the primary outcome of interest or individual patients as the primary drivers of systemic priorities, alienate important partners and dilute the input of minority populations, it is time for a new centering principle. In my mind, that principle should be equity.

Placing equity at the center of the care ecosystem ensures each sector of the health and human service network and each provider and recipient of care has a role and contributes to the shared societal realization of public safety, economic security, and wellness.

Shared values, like equity, are important foundations for building integrated public systems. And integrated public systems are important to create parity in resource dissemination and improve productivity through partnership with allied disciplines and institutions. Although the process of integration may generate new financial costs, it will hopefully save money on the back end by aligning incentives and improving efficiency.

In the end, equity will be the framework for the future of care and policy that aims to improve health. So as we move towards the future, let equity be our guide.

* In appreciation for their wisdom: I want to acknowledge Dr Rajiv Bhatia who’s novel work on The Civic Engine, and Dr. Damon Francis whose generously shared expertise, informed the ideas presented in this piece.*

Freeing the “Doc in a Box”

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The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.

The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.

To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.

Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”

But the baffling thing is, that is not what is happening.

Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.

But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.

Thinking outside the “doc in a box”

In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.

The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.

It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.

If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.

There will likely always be a need for physical care of patients with ailments that require  treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.

With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.

Sick Care: Is There Any Healing Left in Health?

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Incentive structures in healthcare have to change. Right now, we pay for services, or have a so-called, “fee for service” system. The idea is that the more patients doctors see, the more expensive tests doctors order, and the more patients doctors hospitalize, the more money clinics and hospitals make. This incentive structure has transformed our health care into sick care.

The reality is, in America, we are adept at caring for complicated medical problems that require multiple tests, specialists, long hospitalizations, and frequent clinic visits. We focus a lot of resources and attention on this part of medicine because it is what we are paid to do. And to further our efficiency in providing this model of care, many medical systems have adopted business practices, like Toyota’s Lean Strategy, to run our hospitals and clinics more like factories. We essentially increase the number of cogs, or patients in this case, on our conveyor belt, to increase profit margins.

Now, it is only fair to acknowledge that “Lean” and other strategies to improve healthcare efficiency also have real hopes of lowering healthcare costs. In fact, there may be evidence of that. And streamlining health services so that every patient gets a standard quality of care, will likely create equity in the system and reduce costly medical errors, preventing patients from receiving disparate care based on race, gender, or cultural affiliation.

But as we extol the benefits of these patterns of practice, we must also be critical of their overall impact. Is the way we are paying for medicine coming at the expense of delving deeper into the heart of our field? As care becomes more standardized and protocolized, with each patient treated with machine-like accuracy and precision, we do improve “quality” and efficiency in the system. But where is the healing? Where is the prevention? Where is the practice of medicine caring for the human condition and working to keep us well?

Being well isn’t simply having your diabetes under control, it is preventing you from getting diabetes in the first place. If we continue to commoditize patients, valuing their ailments over their wellness, we miss the opportunity to provide the very care we claim to offer, health.

So how do we re-organize the way we pay for care to build a health care system instead of perpetuating a sick care system?

First, if we recognize that social needs have profound and costly health impacts, then as we transform our payment structures under the Affordable Care Act (ACA), we have to support innovative models that address social inequity. That means, using healthcare dollars that are typically spent on clinic visits and hospitalizations to also pay for education, food, housing, and job creation in low-income communities of color. That also means that in the spaces where we provide medical care, we should also be equipped to address patients associated needs. There are models for this.

Second, we have to change the narrative about what it means to provide care. We need to think about the overlap between natural life processes, like birth and death and medicine, and learn the limitations or boundaries of the medicines we wield. When there are no quick fixes or magic pills, how will we care for the human condition? In the spaces where listening is better than treating and healing doesn’t come at the end of a needle, we need to foster the relationships in our communities that provide healing and build resilience.

Third, it is time to transform the physician-patient relationship, a dynamic historically limited to a clinics and hospitals, to team-based care. In team-based models, physicians use their trusted relationship with patients to lead a team of community health advocates to address patients’ health needs in the places where they arise. Sometimes those places are hospitals and clinics but more often they are in homes and neighborhoods. The future of care, if we are smart, will deploy complex networks of healers that extend the reach of the system into people’s lives, supporting their wellness as we address their disease. This will require thinking across sectors, partnering with unconventional liaisons in the social service and for-profit sector, to have a coordinated approach for health.

Right now, The Department of Health and Human Services (HHS) is doing historic work to re-design how we will pay for healthcare. With the guidance of the ACA, HHS is laying out a plan for a population-based payment structure that incentives providers to be efficient with precious medical resources. Doing less for more means we will have to learn how to keep people well. These new changes have the opportunity to shift the focus of our system, towards health. Looking down the pike, let’s be actively engaged in ensuring quality, efficiency, and equity guide how care and healing are provided.

This piece was co-authored by my friend and colleague, Dr. Jessica Schumer. Follow her on twitter @schumerj.