During college and medical school, my summer employment acquainted me with members of organized crime families. Now, reflecting on my full career as a primary care clinician, geriatrician, and researcher on health care delivery improvement, I have discovered that several insights from organized crime could guide medical professionals’ responses to our country’s health care crisis.
Organized crime and the U.S. health care industry have more in common than might be immediately apparent. Both provide goods and services for which there is high, mostly inelastic demand—conditions ripe for profiteering. Both market sectors have been subjected to tight regulatory controls, which likely provoked their matching supply-side consolidations to a few big players. And with such massive profits at stake, competition among the few remaining players escalated corruption in both sectors to previously unimaginable extremes — corruption is now estimated to consume a third of U.S. health care’s waste, the sum total of which is greater than the entire amount devoted to health care in 90 percent of countries globally.
So allow me to introduce Tony. A paragon of organized crime, Tony was an international union leader, an invited speaker at an Ivy League university and a candidate for a United States Cabinet position. Tony was laser-focused on maximizing financial gain, but his ambition never reached a level of greed that would have attracted too much attention or inflicted excessive damage on his host. Tony was eventually found guilty of extortion, bribery, and tax evasion, but he had cultivated friends in high places who submitted supportive requests for leniency to the authorities, and with this brand protection strategy, Tony served only three years of his 20-year sentence. Nonetheless, Tony’s indictment signaled the need for new methods and personnel, and the simple, cash-based money laundering and bribery of Tony’s day were aggressively adapted to the large-scale, untraceable currency transactions of today.
Considering Tony’s experience along with my medical training, clinical practice, and research, I suggest that U.S. health care could be guided by the following three lessons:
1. Don’t damage the host,
2. Protect the brand, and
3. Lead necessary adaptation.
With the total cost of U.S. health care approaching 20 percent of GDP, we all know that the holy grail in contemporary clinical practice is reducing costs while improving outcomes. As a clinician, looking at the enormous sums dumped into new initiatives and institutions that would never reach patients, I felt for a long time that I couldn’t do anything to stop the fiscal hemorrhaging. Like clinicians nationwide, I struggled to deliver continuity of care in a professional environment characterized by rapidly shifting alliances among professional guilds, hospitals, pharmaceutical interests, political entities, and investors.
But in 40 years of clinical practice, I observed that patients who lack confidence in their ability to manage their health concerns use a great deal of expensive care that they don’t actually need. So several years ago, my colleagues and I began designing and testing a simple method of leveraging health confidence to assess health risk and deliver the care our patients want and need, when they want and need it. We found that five patient-reported measures reflected our patients’ quality of life and were as accurate at risk stratification as computer-generated predictive analytics. These few measures also minimized our guesswork about what mattered to our patients and effectively directed our interventions. We called the five measures — low health confidence, bothersome pain, emotional problems, multiple medications and the sense that the medications are causing illness — the What Matters Index (WMI).
My colleagues and I have since found the WMI to be a feasible and ethically sound basis for care delivery. In line with what I learned from Tony, the WMI limits damage to the host, reducing the total cost of care by eliminating the insane patchwork of complex process and regulatory measures used to define health care “value” in favor of just five simple, easily remediable, cost-effective, patient-reported items. The WMI’s emphasis on what matters to patients also alleviates U.S. health care’s image problem among the general public. Moreover, the WMI’s aggressive adaptation of chronic care management away from the inscrutable algorithms that currently fail to identify many at-risk patients results in more effective and equitable care delivery.
To illustrate a WMI application that improves care and reduces costs, consider adapting treatment for the common chronic condition of high blood pressure. Currently, pharmaceutical interests ply a confusing array of products to clinicians who schedule more than 40 million visits each year for hypertension. As summarized by a commentator on a very large controlled trial: “Fixed-dose combination (polypill) therapy … is an effective, scalable strategy that improves adherence, and thus [blood pressure] control. This therapy also can be efficiently incorporated into multilevel interventions through simpler supply chains, fewer pills, and ultimately fewer outpatient visits.”
However, despite the advantages of polypill therapy, only 15 percent of poor hypertensive patients and 30 percent of the non-poor are health-confident and engage in regular self-monitoring of their blood pressure. For the vast majority of hypertensive patients who lack confidence that they can manage their health problem(s), our clinical experience has shown that improving their health confidence is the most effective motivation for patients to engage in regular self-monitoring. Thus, and for a broad range of chronic conditions, my colleagues and I have found that understanding what matters to all patients and helping them to become more health-confident improves care while reducing costs.
Of course, our profession needs to adopt other practices to reduce damage to the host and protect our brand. For the first goal, we could redirect hospitals’ public relations budgets into the education of medical students to reduce or eliminate the debt burden that pushes those students toward lucrative specialties and questionable billing practices, and we could accept the reality that many costly educational and training practices are based on irrelevant traditions and restrictive guild barriers. Toward the second goal, we need to work towards ending kickbacks, such as those that supported the current opioid epidemic, and we must report corruption.
In many ways, whether we recognize it or not, medical professionals benefit from the current system’s faults, as frustrating and exhausting as those faults can be. But if we are to maintain the respect our patients have generally afforded our profession over the years, we all need to get involved in developing better methods for delivering health services. So I hope you will encourage your patients to participate in WMI-based care delivery.
John H. Wasson is a geriatrician.
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