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This blog is part three of a six-blog series on "US Healthcare: A Bureaucratic Quagmire Needing Disruption". If you haven't read the first two blogs yet, please read them from the link provided at the end of this blog.
Strategic management is the process of developing and implementing plans to help organizations achieve their objectives. It has four basic elements:
Creating a shared vision (strategic plan)
Aligning stakeholders toward this shared vision
Energizing stakeholders to move in that direction
Measuring key outcomes and adjusting elements of the strategic plan until the objectives are met.
The process sounds simple but is not always easy to execute. Not all organizations and industries are the same. The U.S. healthcare industry is plagued by two fundamental challenges when it comes to executing this paradigm: (1) there is no shared vision, and (2) there are multiple stakeholders who are not well aligned or engaged. Let us explore these two issues more closely.
No shared vision
It is generally accepted that the overarching objective of a healthcare system is to improve the health and well-being of individuals and populations, but it is not always clear exactly what this means. What key metrics should be tracked to ensure that it is delivering on this promise? How do we measure them and who is responsible for doing so? And who is accountable when metrics are not met?
As so often happens, we focus on the outcomes that are easiest to measure rather than the most meaningful ones[1], reminiscent of the so-called “streetlight effect.” For example, longevity (length of life) is a commonly used outcome to measure the success of a healthcare system because it is dichotomous (you are either alive or not) and easy to measure.
But is it meaningful? Should the goal of healthcare be to have all persons live to be 130 years old? What if this goal is met, but the quality of life is so poor that most individuals over age 90 are confined to bed and unable to recognize their loved ones? Does this constitute success?
In addition to quality of life, what other factors should be considered when trying to evaluate the success of a healthcare system? What about cost, equity, and access? And should you adjust for social determinants and cultural factors? You don’t have to dig far below the surface to recognize that there is no consistent definition of success and no shared vision for healthcare.
Multiple stakeholders
The challenge of multiple stakeholders (customers) and misaligned incentives has been highlighted previously[2]. Patients are concerned about accessibility, affordability, and choice; providers are concerned about equity, pay, and working hours and conditions; regulatory agencies are concerned with quality; for-profit payors and drug companies are concerned about profits; politicians are concerned with population-level outcomes and cost to the taxpayer.
The end result is that stakeholders are constantly pulling in different directions, each trying to extract as much money as they can from the $4.5 trillion U.S. healthcare lottery.
All too often patients find themselves on the outside looking in, wondering how a system that is primarily designed to serve their needs has become so dysfunctional, so self-serving, with so little self-awareness.
Patient engagement
Patient engagement describes the process of actively involving patients in their own healthcare. This includes shared decision-making, self-management, and partnering with providers to improve their health. After all, 40% of healthcare outcomes are driven by patient behavior—things patients do (or things done to them) such as smoking, drinking, illicit drug use, being obese, or being a victim of gun violence or motor vehicle accidents—compared with 30% driven by genetics, 15% by social circumstances (such as living in poverty), and 5% by environmental exposures. That leaves just 10% of healthcare outcomes determined by medical care—the work that doctors, hospitals, and other providers do[3,4].
How patients behave has a huge impact on what diseases they are going to get, when they are going to die, and what they are going to die of. Providers have a responsibility to educate, inform, promote, and support the adoption of healthy lifestyle changes and other strategies to prevent disease, but the onus ultimately is on the patient to take advantage of this advice. Americans share a number of common traits—their rugged individualism, optimism, and skepticism of government[4]. They want to have the right to make their own decisions. That is entirely reasonable, so long as they are also willing to own the consequences.
Provider engagement
In addition to ‘sliding down’ to engage their patients, providers must also ‘slide up’ to engage the wider healthcare community. They must keep abreast of the latest publications in their field, updated committee opinions and guidelines from national/international consensus bodies, new drugs and therapeutics, and they must remain in compliance with ever-changing regulatory and licensure requirements. The end result is that physicians now spend less than a third of their workday providing direct patient care, with much of the rest of the day spent on clerical and administrative tasks[5,6].
"If we look at the total clinic day, less than a third of that time a physician is actually giving direct patient care …. despite spending half of the work day on EHR/clerical work, physicians are still taking home one to two hours of data entry work at night."
-- Christine Sinsky --
(VP of Professional Satisfaction at AMA, 2019)
This has led to widespread disenchantment, disengagement, and burnout, which has only been exacerbated by the COVID-19 pandemic. Lack of engagement has consequences for both patients and providers. Given the overwhelming expectations and flood of new information coming their way, only about half of physicians adhere to practice guidelines[4], which is not in the best interest of patients. And more and more providers are stepping back, working fewer hours, taking off more time for work-life balance, with many leaving the profession altogether, either through early retirement or to pursue other careers. This is true of physicians, nurses, and members of allied health professions[7,8].
There is one trend that appears to be moving in the other direction. Applications to medical schools in the U.S. have increased dramatically[9]. The drivers are unclear, but some speculate that the COVID-19 pandemic has increased awareness of the importance and value of the medical profession. We applaud the efforts of the millennial generation, stepping up to save the healthcare industry. May they work smarter, not harder.
Note: If you haven't read the part one and two of this blog series, we recommend you to read it from our official website: https://www.cognitivecare.com/post/us-healthcare-misaligned-incentives and https://www.cognitivecare.com/post/why-is-us-healthcare-expensive
Authors: This Blog is Co-authored by Dr. Errol Norwtiz and Venkata N. Peri
References:
Muller JZ. The Tyranny of Metrics. Princeton University Press, 2018.
www.cognitivecare.com/post/us-healthcare-misaligned-incentives
McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93.
Garson A, Holeywell R. Exposing the 20 Medical Myths: Why everything you know about health care is wrong and how to make It right. 2022 update. Rowman & Littlefield Publishers, London. 2019.
Landi H. Physician survey: EHRs increase practice costs, reduce productivity. Healthcare Informatics Magazine, 2016. www.hcinnovationgroup.com/policy-value-based-care/news/13027535/physician-survey-ehrs-increase-practice-costs-reduce-productivity
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