Focus on the Patient — The Rest will Follow.
Why only a Patient-Centered Approach Can Heal our Ailing Health Care.
Views from a Patient & a Physician in the Fourth Part of this Series: Growing the Collective Value-pie in Health Care.
This article is written by Hanna Boëthius, a patient, and Verena Voelter, a physician, in the form of a narrative about their recent conversation after the SHS public event in Lausanne, 26th August 2020: “Collaboration of the 5P Leaders for Effective Health Care Delivery. What Does it Take?”
It is commonly recognized that the cost explosion in our health care systems battles patients’ premiums & out-of-pocket expenses. We have heard stories of patients in the US who sold their house in order to afford cancer therapy. We have read that even in a relatively wealthy country, such as our homeland Switzerland, on average 1 in 5 residents have to pay as much on their monthly health plan premiums than on housing & rent [REF].
Furthermore, we have as much of a quality issue in health care as we do have a cost issue. Both hamper the positive innovation cycle in medicine & science, leading to a slow-down of what was a previously tangible prolongation in longevity. If we want to shift the needle on health care, we must collectively move towards a novel system that encourages value over volume. So, you may ask: That sounds nice, but what does value really mean in health care?
“People don’t want to buy a drill. They want to buy a hole in the wall!”
This is a theme that Harvard Professor Theodore Levitt was teaching nearly some 50 years ago. To this date, it illustrates perfectly what we mean by customer-centricity, the customer experience and — what value truly means to a customer. This concept has been widely explored in various sectors leading to successful renewals in the travel & hospitality, retail business and tech industries. In health care, however, the concept of customer-centricity & the importance of the customer-experience has been late to show. Here, the customer being the patient. Over decades, a health care system that has notoriously focused on selling services & products, on increasing number of patient visits per time-unit and on return-on-investments has eventually disconnected itself from its primary purpose:
Serving the patient and the health of the patient.
As a consequence today, and for different reasons, all 5P leaders painfully resent the frustrations that this perpetual fee-for-system created. Providers, Pharma, Payers, Policymakers & Patients alike suffer from what essentially is a broken balance between medical innovation & affordability. Patients are frustrated over excessive waiting times, redundancy of care and over feeling unheard & not understood. Physicians don’t feel empowered to contribute to system changes and repetitively are burning out over backbreaking administrative burden & bureaucracy. A phenomenon, which is often being described as Dr Burn-out or as doctors turned into visit-vendors.
Interestingly, what both patients & physicians want is more time. More time for observing, sharing & thinking. More time to build lasting relationships with each other. More time to deliver and receive quality care.
Listening & responding to patients’ needs as well as improving the patient experience is what it means to create value for patients. ‘Focus on the patient and the rest will follow’ is what Dr Valerie Kirchberger, Head of Value-Based Healthcare at the Charité hospital in Berlin, recently said at the HIMSS & Health 2.0 European Digital Event 2020. In other words, only if we accelerate a fundamental Paradigm Shift from Volume to Value (as one of the event sessions was entitled) will we be able to restore the balance and ensure that we can keep the great progress in medicine & science while keeping it affordable to patients & society.
Luckily now, the concept of patient-centricity — as a cornerstone of value-based health care — is increasingly coming back into focus as we are collaboratively striving to rebuild a more humanized, empathic & value generating health care.
In this article, we are taking a closer look behind the curtain of patient-centricity. We discuss the central role it plays not only for the ‘Tango for Five’ but also for the transition toward a value-based health care model and the responsibilities it equally puts both on patients & physicians. We, this is Hanna: a Type 1 Diabetes patient with 35 years of experience of first-hand relationships within health care. And Verena: a passionate internist & oncologist with extensive experience both at the patient’s bedside and as a business leader in biopharmaceuticals.
#1: WHY THE PATIENT FOCUS IS IMPORTANT?
Choosing the right treatment for the right patient at the right time. This is a core principle of value-based health care. However, the reality still looks very different in many places.
What is the value for a hip replacement surgery if the patient 3, 6 or even 9 months later still cannot walk? What is the output value for a diabetes patient whose HbA1c continuously is floating above the norm on the chance of suffering from complications and secondary diseases such as heart & kidney failure? What is the value for a patient being taken a battery of blood, urine & lab testings if no one ever follows up, providing results, let alone drawing any treatment recommendations? (All happened to us or our families recently.)
The reality today more often than not is that we have an issue of operating in a system that is built on the wrong incentives. You get what you reward. If you focus on (reducing) cost, you will raise cost, as Michael Porter elegantly said years ago. That is, if your system only pays for the hip replacement but it doesn't look nor incentivize what happens before or after. Today, there is mostly no built-in reward to whether a patient can actually walk again, is pain-free and can resume their work or daily activities, such as providing day care for their grandchildren.
Patients, physicians, nurses & other providers alike suffer from the inherent fragmentation of a hypercomplex health care system. Further, when talking about affordability & resources, a recent anonymous survey of US physicians revealed a staggering 1 in 4 physicians admitting unnecessary (over)testing and wasteful (over)treating [REF]. Why is this? Well, the underlying reasons are reflecting the complexity of the system. We mentioned fragmentation leading to duplication. Another reason certainly has a cultural dimension. Cultural when it comes to malpractice: real or the fear thereof. And cultural when it comes to patient expectations towards calling doctors only good doctors if “they do something.” Verena concluded in an earlier essay:
We do not have an issue of shortage of resources. We do have an issue of resources in the wrong place.
Now, the good news is:
Since long, scholars & practitioners around the world concur that only a fundamental shift from a fee-for-service system towards a model that incentivizes health outcomes in well defined patient populations can unlock the quandary of health care. In a few key words, this model puts the patient at the center and rewards all participants in the health care ecosystem — providers, payers, patients & policymaker alike — for how healthy a population is. Nobody claims that this is an easy task. It takes years & years and multiple stakeholders to agree on new regulatory frameworks that enable the successful transition to a system that will enhance efficiencies by eliminating unnecessary care & wasteful care delivery.
In sum, there are three key ingredients that most successful modern value-based pilot projects have in common.
1. Measuring health outcomes,
2. in clearly defined patient populations,
3. and, putting a concrete time frame around these measurements.
Then, once the outcome data are collected & analyzed within multidisciplinary teams; insights & conclusions are drawn; there will be a review & readjustment of outcomes definitions, patient population characteristics and time window set for the next round of measurements. In brief, we have been impressed by the two following stellar examples that have pivoted from volume to value incentives, solely rewarding health outcomes:
Moving on, it almost intuitively raises the question: What can the patients contribute themselves? And what can treating physicians do to return & carve out more time with patients rather than with administrative bureaucracy?
#2: HOW PATIENT (SELF)EMPOWERMENT CAN INFLUENCE VALUE GROWTH?
Within the overall movement of the health care transformation, a cultural shift from passive & reactive to more pro-active & strategic behaviors is needed. This does not only apply to providers, policymakers, payers & pharma. But foremost this also applies to the patient themselves.
Here, Hanna shares a unique perspective from her own journey to become an “empowered” patient. She wasn’t always the well-self-educated patient she is today, but rather an “enfant terrible” of diabetes during her teen years, with her biggest wish being like “everybody else.” Her years of roller coaster blood sugars and HbA1c levels 2x or 3x that of a healthy individual left her exhausted, wishing for a change. That change didn’t come until she started seeing her health care providers as partners rather than being intimidated by the authoritarian behavior they sometimes portrayed.
Interestingly enough, Hanna feels she only became an “empowered” patient once she went her own way, finding solutions outside the norm that happened to suit her condition & lifestyle. Things such as nutrition, movement, hydration & stress management, helped her do better than what the conventional toolbox alone prescribed. Hanna has worked with many (many!) providers throughout her diabetic career, and those that have stuck as bright stars in her mind have some simple commonalities: they have listened to her and taken her — and her concerns — seriously. For example, she learned to inject herself with insulin as late as the age of 10, and was accompanied by a wonderful nurse who didn’t just scoff at her fear of needles and tell her to “get over it,” but rather spent two afternoons a week working with Hanna to help her overcome the fear.
Co-creating the goal together with the patient. Hanna’s goals became the providers’ goals. Or, before she was as empowered of a patient as she is today, they helped co-create achievable & timely goals. They saw her as a human being, an individual who happens to live with diabetes. Not just as DIABETES. Her doctors have been willing to let her try new & perhaps even unusual management tools, in the hope that it works for her as an individual.
Creating this space for co-creation isn’t done in one appointment. It requires both trust and a growing relationship between patient & provider. This, in turn, can actually make health care more efficient, and would help patients to find what the right course of treatment is for them as individuals.
· What we need is a novel kind of partnership.
Partnerships where both patients & doctors feel they have the trust & the tools to collaborate. Imagine if patients & providers are given the space to work closely together? Couldn’t it create the very powerhouse that is needed in order to, as Verena says, move the needle on healthcare?
This, naturally, requires the patient to be highly engaged in their own care and act as an empowered patient. What does that look like? When is a patient empowered? In Hanna’s opinion, this happens once the patient has fully understood their diagnosis & treatment. In short, when they have accepted their condition or illness (REF). The following step is for the patient & their providers to determine the correct course of action for that given patient. The way to get there can be multifaceted, ranging from an appropriate level of health literacy, mutual respect, as well as assessing the extent of therapeutic inertia. Furthermore, empowerment is an ongoing process and is heavily driven by personality styles, where not every patient wants to be involved in making decisions about their care, and not every doctor always having the time & involvement needed.
· What we also need is a new care coordination model anchored in trust.
Hanna’s vision of the empowered patient entails that they’re sitting at the center of a proverbial round table. Next to them, they have whatever entrusted health care professionals they need. For example, for a person with diabetes, they may need an endocrinologist, a diabetes educator, a nurse, a podologist, ophthalmologist, therapist, personal trainer, coach, and so on; depending on individual needs. All these professionals around the table need to be informed of, and aligned with, the patient’s goals. This means that the patient is co-creating goals they believe are worth working on for them.
This care coordination is becoming a core element for success in a value-based world. In the future, in addition to the empowered & pro-active patient, the role of GP’s (general practitioner) & hospitals will need to evolve into taking on more of this responsibility: coordinating preventative, episodic & chronic care towards optimal health outcomes.
Lastly, a successful relationship between the patient & the health care provider isn’t possible without trust. How do you build trust? How can you, as a patient, trust that your doctor has fully understood & carries your best interest at heart? And how can you, as a doctor, trust that your patient shows full commitment & that they won’t derail from your suggested treatment?
What Hanna would like to see in the future, in terms of health care for empowered patients, is relatively simple: it is to be taken seriously and to be considered as an integral individual. In brief, patients taking the time & effort to get highly involved with their own care — in her opinion —represents a hugely undervalued resource in health care.
Talking about trust, Verena recalls an enlightening moment during her fellowship. A breast cancer patient provided her with honest feedback after a discussion about a clinical trial of high-dose chemotherapy followed by stem cell transplantation. Usually, patients who trust their physician are likely to accept the suggestion to participate into a clinical trial, should they be eligible. So, she was reasonably surprised & disappointed when the patient returned & refused to take part in this study. The eye-opener for Verena was when the patient reported that she didn’t feel that Verena was convinced about this trial herself. Therefore, the patient declined. Indeed, she was right.
This example is testament to 2 things in our mind: First, patients do have a strong sensor. They observe & watch their doctor closely; verbally; non-verbally; body language. Second, we need to assume that patients are right. It is in their own bodies & minds that they live, feel and suffer; day & night.
Therefore, physicians & nurses need to get their time back with patients so that deep & meaningful relationships can unfold, creating space for a give-and-take in quality care delivery. We do strongly believe that this doctor-patient axis is a core element to sustain the reduction of wasteful care delivery and hence ensuring long-term efficiencies in health care. Allowing to choose the right procedure, the right treatment for the right patient at the right time.
#3: WHY ALL OF THIS MATTERS TO THE TANGO FOR FIVE & THE COLLECTIVE VALUE PIE
There is an increasing amount of literature demonstrating how the customer-centric transformation has long led to disruptive & efficient business renewals in other industries; and how these learnings could be transferred to the health sector. In our eyes, one of the most provocative & thought intriguing books is the one from Zeev Neuwirth: “Reframing Healthcare.”
“If the health care industry were to fully embrace a continuous customer-only, demand-side approach, it could literally transform health care delivery and health outcomes.”
This is how Dr Neuwirth summarizes a call for-action to drastically change the way we think about health care & reverting it back to a “humanized” discipline after all — by applying a deeply empathic approach to this novel kind of partnership.
We believe that by helping the patient to properly understand their diagnosis, disease & treatment, an immense untapped potential can be unleashed to drive efficiencies in our systems. Health is less expensive than illness. Based on this simple framework, the notion of rewarding & paying for how healthy a population is versus how much services & products have been delivered, brings a person’s health continuum into focus. Imagine if the provider network enhanced its processes, information flow and supply chain to the extent that more time is given back to physicians & nurses? Time that in turn can be repurposed towards direct patient care from prevention to acute & chronic care? Doesn’t this sound like a valid value proposition in itself?
Well, we conclude — based on our personal experiences & the reports in the current literature, coupled with the many real-life reports — that this reality is already at our doorsteps. Digitization is on its way to plow through & facilitate the complexities of provider circuits, payer landscapes & policy frameworks; value-based care is being taught & pilot projects being applied around the world. All we need to do is to encourage & share what’s working & what’s not, then step out of our comfort zones & make this change happen.
Restoring a close relationship between patients & their doctors, a bond anchored in trust, mutual respect & transparency will prove to become the center piece to the overall creation of value in the health care value chain.
An educated patient, and an educated doctor, will jointly determine what the right procedure and the right treatment are at the right time.
This also includes measures that can avoid treatment, such as preventative steps including lifestyle choices, movement & nutrition, which are critical components of successful disease management along the health continuum, especially in chronic conditions such as diabetes, and others. A very good example that struck us during our research is the Value-Based HIV Care project launched by the OLVG hospital in Amsterdam where outcome measures are jointly set by the HIV specialists and the patients.
Hanna is raising a critically important point, which is care coordination. She refers to how eagerly she is awaiting a better orchestration between the various specialists who are co-creating the care for her health — together with her. Also, social determinants such as job choices & work (re)integration are critical aspects to ensure a broad socio-economic winning value proposition for patients & society. This is particularly true in light of the 2 mega trends of the future: the increase of chronic conditions in an otherwise ageing society.
Overall, reducing waste in all dimensions will inherently lead to increasing efficiencies; then, collective value in health care can grow, as defined by better outcomes for patients per dollar, euro or franc spent. Not only providers within smart hospitals & networks, but also payers, insurers & policymakers will derive value from a healthier population in their scope of responsibility & jurisdiction.
Focus on the patient, and the reward will follow. This similar logic has been true in many other industries that have renewed themselves by focusing on the consumer experience and the customer value.
