I was sitting with a large group of people tasked with devising a plan to curb the problem of over utilization of the Emergency Departments. Chief Medical Officers, wellness professionals, insurance payers, company CEOs and data analysts were all present to lend their opinions and insights.
We pushed our focus to deciding how to stop the “Avoidable ED Utilizations”. These are the headaches, respiratory infections, low back pain, UTIs, and other minor acute conditions that could be treated more efficiently at a primary care practitioner or urgent care setting. Depending on the specific definition of “Avoidable ED Utilizations”, these conditions could range from 8% – 45% of all emergency department admissions.
At the conclusion of the meeting we were able to establish an action plan targeting all stake holders including health plans, employers, consumers, and health providers.
Conversations strike up after the meeting and a member says to me,
I have been in the health industry for 25 years working in almost every aspect of care and management. We have looked at the question of ‘How can we make care more affordable while improving quality and outcomes’ in every direction and nothing has changed in 25 years. Does anyone stop and think ‘Are we asking the right question’?
His comment hit me stronger than I expected. What is the right question?
Let’s break it down
The question broadly stated as, ‘How can we make care more affordable while improving quality and outcomes’ is viewed differently by the parties involved.
Employers create solution that lowers their healthcare expenses while allowing them to offer competitive healthcare packages to their employees. It needs to be comprehensive and easy for the employees to adhere to while promoting a healthy lifestyle.
Consumers find the best care possible and pay little to nothing for it. Many consumers do not know or even care what the costs are of the healthcare they receive as long as they don’t have to pay a lot for them. On the other hand, they are well aware of the accessibility and quality of what they receive.
Insurers devise the health plans that the employers and consumers buy. Their goal is to provide the best plans possible that allow them to be competitive, increase profits, and abide by the latest regulatory policies out there.
Health providers including hospitals, pharmacies, individual practices, and all health service organization want to provide the highest level of care and be the most sought-after health employer out there for nurses, doctors, etc.
Where is the sweet spot?
Let’s think of these 4 players as a 4 plated scale. Is there a way we can balance the scale to satisfy the needs of all the players which would achieve this balanced state of affordability, quality, and better outcomes? Spoiler, no or at least not easily.
Take a moment and imagine putting weights on the scale to measure the influence each member had on an individual’s health, public health, costs of services, quality of services, governmental regulation, personal incentives, and all other factors you might associate with achieving affordability, quality, and better outcomes.
Overwhelming isn’t it? You can keep adding more and more influences till the reality arises that answering the question posed earlier, ‘How can we make care more affordable while improving quality and outcomes?’, is a ridiculous task. All you do is add another weight onto the scale in a hope that eventually it will be balanced. That is what the member was referencing after the meeting about the past 25 years he has seen just more and more attempts of balancing the scale and nothing has worked. Obviously we are attempting to answer the wrong question.
So, what is the right question?
The first two questions that come to mind are: 1) Can we break/change/improve the scale? 2) Can we avoid the scale all together?
Question 1 could be answered through two options go to a type of single payer health system or change the influence of certain parties in the system.
Question 2 can be answered by an overhauled focus on preventative health.
The surprising thing is that the answer to question 2 actually answers both of the questions. It not only avoids the scale but also changes the dynamic of the scale. A single payer option would only transform the scale into a two plated scale but not directly address the second question.
After realizing these things it is evident that the better question to ask would be. “How can we prevent illness, empower patients, and keep them so healthy that they don’t need hospitals?”
I bet if for the last 25 years we only focused on that question we would have answered the question we have been battling all along. The struggle though has led to exponential progress in disease prevention, drug development, and understanding the human condition which now can allow us to better attack this new question.
Will the results we seek come easy? No
Will the results we seek come quickly? No
Will the results we seek come one day if all of our efforts and discussion revolved around the question of, ‘How can we prevent illness, empower patients, and keep them healthy and out of the hospitals’? Yes
It might be wishful thinking but I believe it can happen. If that question became the creed upon which insurers, health providers, and employers made decisions the actions of the consumers would follow suit.
You may argue that we have already attempted this or that this idea is another iteration of the original question posed. It may be similar in nature but it is rooted fundamentally in solving the larger problem.
We should not look at each problem in a silo but rather root them all in a single originator. That is the only way to break the scale and avoid it at the same time.
So I pose to you the question:
How can we prevent illness, empower patients, and keep them healthy and out of the hospitals?
If we all work to answer that question, just wait and see what comes next!