Читать книгу Transforming Healthcare - Morey Menacker - Страница 5

I have had the past good fortune on several occasions of meeting certain persons for the first time, who, after hearing them speak cogently for only a few minutes, have become my instant and durable friends. One such colleague is Dr. Morey Menacker, former President and Chief Executive Officer of the highly successful New Jersey‐based Hackensack Alliance Accountable Care Organization, and well qualified author of this brave new book, Transforming Healthcare. Given his very extensive experience as a master geriatrician and seasoned senior healthcare executive, the best three words I can think of to describe Morey are as “The Doctor's Doctor”.

More than twenty years ago, the Institute of Medicine (now known as the National Academy of Medicine within the National Academy of Sciences) published an urgent “call to action” for the American Health System in its seminal Crossing the Quality Chasm. This consensus‐based work defined quality of healthcare through six very important aims: Care that is simultaneously Safe, Timely, Efficient, Effective, Equitable and Patient‐Centered. In this regard, Transforming Healthcare continues to fire on all of these cylinders as the vision of the future is presented.

One of these aims is “Efficiency”, which the IOM originally defined as “avoiding waste, including waste of equipment, supplies, ideas, and energy”. I emphasize this definition often when discussing the time‐honored topic of “Cost of Care”, because it helps gets at heart of the economic mindset that is necessary for realizing what's at stake throughout this book. Yet, today's determinations as to what constitutes optimally efficient healthcare depends on which lens the many diverse stakeholders among the US healthcare system use for their own internal deliberations. And, as Dr. Menacker rightly points out, major challenges to overcome this resultant inertia stand in the way to achieving timely consensus‐based solutions for improved health status, such as redirecting resources towards improved patient‐centered primordial prevention efforts and away from our traditional delivery of downstream “sickness treatment”. Yet, at the end of 2021, the market cap of the healthcare industry exceeds $5 Trillion and per capita healthcare costs total $4.5 Trillion. Unfortunately, the Cost Curve is bending in the wrong direction, i.e. concave up, not convex down.

An important and illustrative example to denote in the context of Transforming Healthcare is cardiovascular disease (CVD), which is the leading cause of death, not only in the US, but for the entire world. CVD (including acute myocardial infarction, heart failure and other patients with coronary atherosclerosis), when combined with stroke account for four of the top 10 expensive conditions treated annually in US hospitals. Most major local and regional US hospitals provide comprehensive acute care services to patients with major acute cardiovascular events (MACE), including well‐staffed medical and surgical intensive care units, sophisticated state‐of‐the art technologies and procedure rooms for acute high‐definition imaging and multimodal revascularization interventions, and specialist physicians, nurses, pharmacists and other healthcare professionals with advanced training credentials. Well paid and incentivized traditional health system service line senior executives skillfully juggle day‐to‐day operations, complex and interdependent supply chains, ever‐evolving information technologies, challenging workforce requirements, managed care negotiations and increasing capital allocations. Chief Executive Officers and their governing boards prioritize the “strategic” intention of these service lines in order to realize substantial future revenue growth through increased market share and reimbursement and competitive advantage for being recognized regionally as “cutting edge and ahead of the curve”.

In contrast, High Blood Pressure (HBP), a major risk factor for MACE, results in billions of dollars of waste from reduced worker productivity and absenteeism as well as significant increased per capita healthcare costs. Clearly, reducing the risk of major cardiovascular events by controlling HBP, and thereby improving health‐related quality of life, can significantly lower attributable excess annual per capita health costs. High quality scientific evidence from large scale population‐based studies published in the 2017 Hypertension Clinical Practice Guidelines of the American Heart Association (AHA) and the American College of Cardiology (ACC) documents the significant blood pressure lowering effects from six specific critically important lifestyle modifications: tobacco cessation, regular physical exercise, restriction of dietary sodium, dietary intake of potassium, moderate alcohol consumption and a “healthy heart” diet. Assessments of Social Determinants of Health (SDoH), Shared Decision Making (SDM) conversations between patients and their physicians, and Team‐Based Care (TBC) delivered by nurses, pharmacists and other health professionals are now known to result in significant improvement in BP control and other health risk reduction targets through effective, evidence‐based lifestyle modifications.

Nonetheless, recent data reveals that over 115 million Americans have diagnosed or undiagnosed HBP, and that more than half are inadequately controlled to guideline‐based BP targets published by AHA and ACC. Worst of all, blood pressure is almost always measured incorrectly, resulting in innumerable inaccurate readings obtained in both health care settings and at home. Inadequately controlled HBP is but one of many major unmet public health challenges that can be directly traced to the diffuse health system inertia so elegantly addressed by Dr. Menacker in Chapter 5 of Transforming Healthcare that is at the heart of this matter. No doubt, the healthcare delivery infrastructure for the care of major acute and chronic CVD is vastly different than what is needed to achieve health promotion, maintenance, and prevention necessary to reduce MACE and hence the need for acute care.

I recently asked some health system senior managers, governing board members and primary care physicians to informally describe the barriers to achieving optimal BP control. Their comments were remarkably consistent and focused on time and resource constraints, process limitations and a general lack of urgency regarding HBP as a top organizational priority. The clinicians described control of HBP as "just another metric" within constantly expanding externally imposed quality requirements. Administrative demands remain overly burdensome, leading to too many "clicks" to add home BP readings to the electronic health record (EHR). In addition, the team is understaffed and overworked, leaving no time to properly address Social Determinants of Health (SDoH) and effective lifestyle modifications. Traditional practices do not ensure consistent and accurate BP measurement technique with validated and certified devices in accordance with standardized guideline‐based scientific methods. Patients often present other pressing concerns, which can lead to deferment of BP control until the next annual examination or ignoring it altogether. Not surprisingly, control of HBP for patients and employees is nowhere to be found as a key performance indicator on any governance or managerial accountability “dashboards”.

Of course, it is certainly much easier for us to describe these “wicked” problems like control of HBP than to find and implement cogently clear pathways to solving them. And while Dr. Menacker's strong recommendation for global payments to health systems to simultaneously manage the associated clinical and financial risks is not new, it comes at just the right time in our history. What is urgently needed today to achieve the goals outlined in this book are stronger health system alliances and congruent alignment with insurers, employers, public health, community health safety net organizations, large and small biopharmaceutical and device firms, digital health Information technology companies and governmental health agencies. “Moving the Needle” of improved health status of the US population will require a major reprioritization of both capital and human resource allocation by all of these stakeholders. Transforming Healthcare is henceforth our Call to Action.

Principal & Founder, IPO 4 Health (Improving Patient Outcomes4 Health)Associate Professor of Medicine, Rush Medical CollegeSenior Associate Editor,
American Journal of Medical Quality	Donald E. Casey Jr MD, MPH, MBA, FACP, FAHA, CPE, DFAAPL, DFACMQ