Healthcare must ‘systematize’ so the right care is easy to provide

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Atul Gawande, MD, the newly named chief executive officer of the non-profit healthcare venture started by Amazon, Berkshire Hathaway and JPMorgan Chase, contends that the objective of modern care is not to “rescue” patients from “catastrophic” health episodes—but an ongoing process that takes into account patients’ physical, cognitive and emotional life goals that clinicians never ask them about.

“To measure and manage that over time is going to be highly technologically enabled in order to make that possible,” Gawande said on Thursday at the 2018 AHIP Institute & Expo in San Diego. “We need to act through the data, tracking you with your life on how you’re doing against those goals, and when our treatments are benefitting and when they’re not.”

Gawande, who starts as CEO of the Amazon-Berkshire-JPMorgan venture on July 9, spoke at AHIP’s conference the day after the three companies announced they had selected the prominent surgeon, writer and public health innovator to lead their new healthcare firm.

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The as-yet unnamed firm, which will be headquartered in Boston where Gawande is a surgeon at Brigham and Women’s Hospital, is aimed at improving healthcare for the three companies’ combined one million-plus U.S. employees.

“System science and innovation is the next massive, major opportunity to advance human wellbeing in health,” he added. “Patient-reported outcomes are fundamentally important. In a world where people are accumulating chronic illnesses, if the only goal is that they survive longer, you can spend an infinite amount of money without ever knowing it is making any contribution.”

Gawande sees patient-generated information as critical to reporting what their “real outcomes are, such as how they are doing physically, cognitively, as well as emotionally” which will be measured against their goals. In that regard, he said that digital health tools are “going to be really crucial” to gathering the data, emphasizing that these tools “have to make it easy” for people to use.

At the same time, Gawande argued that work must be done to make it easier for clinicians to work together in that environment. Some of the solutions are “low tech,” such as checklists, he observed. However, it will also require communication tools as well as artificial intelligence to “substitute for parts of that” capability, according to Gawande.

“You need to connect the pharmacist, the primary care clinician, the cardiologist, and, so on,” he added. “Maybe there’s an AI tool for that, but mostly it’s about enabling people to communicate together, create plans and test those plans against what’s really happening—while understanding the costs that go along with those decisions.”

While Gawande spoke in a previously scheduled AHIP general session on end-of-life care, he told the audience that he recognized that his talk perhaps will “take on some greater significance” in light of his new job.

Gawande, the author of Being Mortal: Medicine and What Matters in the End, a book that addresses hospice care and the current state of care with regard to age-related frailty, illness and death, made the case that in researching the topic, it became painfully obvious that the “top-down” approach to healthcare is not succeeding.

Citing a 2012 National Academy of Medicine report, he noted that 30 percent of healthcare spending is wasted and is of no benefit. “I didn’t quite believe it then—but now I do,” said Gawande. “We often fail to deliver—on the right thing, the right way, at the right time—and are often doing things that are of no value whatsoever.”

The high cost of healthcare is the “symptom” of an industry plagued by inadequate systems, according to Gawande, who is a professor in the Department of Health Policy and Management at the Harvard School of Public Health and the Department of Surgery at Harvard Medical School. He referenced the fact that there are “more than 70,000 different ways that the human body can fail” as indicated by ICD-10 diagnosis codes.

“There’s no industry that has to do 70,000 different services in every community and do it well and without wasting resources and humanely—for everybody,” he observed. “How do you fix that? It’s hard. But, what I can tell you is it’s not working the way we want it to. Now that smoking is down and cardiovascular disease is the No. 1 killer in the country, controlling high blood pressure is the biggest opportunity to save lives.”

However, Gawande said that only 40 percent of Americans are having their blood pressure elevation recognized and are getting the appropriate treatment. In addition, when it comes to healthcare spending, he contends that two-thirds of major complications and deaths are avoidable.

“Overall, the lack of execution in delivering already existing medical discoveries is responsible for at least a third of deaths under the age of 75—not only in the United States but even in Europe,” according to Gawande. “We are still in a stage of very primitive thinking about how you create delivery, how you create performance—whether you’re an insurer, you’re a health system or you’re just a doctor trying to get it done.”

To solve this challenge, he believes that healthcare must transition from “delivering components for human beings to delivering outcomes, which require systems that utilize all those components to the best possible results.” In addition, Gawande said the industry needs to do a better job of educating and training medical professionals to deliver care.

“Modern delivery and performance depends on us systematizing the care, making it so it’s not just that you should do X—treat the blood pressure appropriately and so on—but that the norm is to do it,” he added. “That’s the puzzle for us in healthcare. It’s ultimately about making the right care the easy thing to do.”

Gawande emphasized that the kinds of changes he envisions are a “long target” for the Amazon-Berkshire-JPMorgan venture, with the “expectation that we’re going to take on the kinds of problems we’re talking about over the next decade,” marked by “gradual” progress, not “instant” solutions.

“I feel incredibly lucky in this role that I will get a million new patients,” he concluded. “We will come to a place where we can generate scalable solutions that change the practice of medicine anywhere. We, as a society, are headed towards being able to do that. It’s a long road, but it clearly is possible.”

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