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What is the Future State Vision for Health Care Delivery System Transformation?

“You’ve got to be very careful if you don’t know where you are going because you might not get there.”

– Yogi Berra

“Would you tell me, please, which way I ought to go from here?” said Alice.
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where —” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“— so long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

– Alice’s Adventures in Wonderland

The country is in the midst of an unprecedented transformation of the health care system and may even be at a ‘tipping point’, yet many of us find it astounding that we have no official (or unofficial for that matter) collective vision of where we are headed, thus how the heck do we know if we are on the right path to get there? Given the very high stakes and costs that extend far beyond financial ones, why is it acceptable to not have a future state in mind so that the current state can be quantified and a gap analysis roadmap can be created to address it? Sure, we have the Triple Aim as the overall goal but what are the ‘guardrails’ that help build the road to it?

The truly great news is that we actually have those ‘guardrails’, and in fact have had them for over a dozen years. It is just that most people have not been aware of this hidden time-tested gem, created by incredibly thoughtful health system transformation forefathers and foremothers back in 2001. This visionary team has overwhelmingly been praised for creating the powerful and gutsy call to action in their Crossing the Quality Chasm Institute of Medicine (IOM) report. What many have missed is that in addition to all the highly visible work, the group created a set of 10 key new rules to inform a future state for the health care system (see figure 1).

Figure 1 Source: Institute of Medicine, “Crossing the Quality Chasm,” p. 67, 2001.

Twelve years later, the chart in Figure 1 strikes many of us in two powerful ways: 1) How the ‘New Rule’ column has stood the test of time for the vast majority of its intended direction and spirit, and 2) how sad and disappointing that many of the 2001 ‘Current Approach’ column items are still entrenched even today.

Experts within the Accountable Delivery System Institute® (ADSI) have been privileged to have been involved in numerous IOM workgroup activities in recent years resulting in key published findings, while at the same time, we believe, creating important by-product position updates to the ‘Simple Rules’ table above in Figure 1.

Ideally the IOM would have specifically updated the ‘Simple Rules’ table directly in their 2012 update to the original Chasm report, Best Care at Lower Cost but unfortunately that was not the case. Therefore, we at the ADSI have attempted to carefully and thoughtfully update the original table to reflect a proxy for the most recent consensus IOM thinking in order to create a ‘straw dog’ as to what updated rules can inform an end game vision for health care system transformation. Figure 2 reflects ADSI’s proposed updates:

Figure 2 Source: Accountable Delivery System Institute (ADSI)

Ok – great (you may say), but how does that help us to collectively respond to Yogi Berra’s challenge and get us to know where we need to go? Current and proposed policy, business strategies and tactics at all levels can be evaluated against these rules to understand how strongly/weakly they support the 10 revised rules. These assessments can be made at all levels: national, state, regional, and organizational. Starting with these rules to create an informed high-level future state, entities can develop a contextual set of road map milestones along the journey that are specific to their situation, this gap analysis process provides the basis to arbitrate priorities within an entity and their related resource trade-off allocations. 

Figure 3 is shown for completeness to facilitate a cross-walk between the original baseline rules and the ADSI’s proposed updates. As you look at the updated rules, you will likely notice that we only suggested changes within each rule where appropriate and not the addition or subtraction of any of the rules – at this point we did not feel comfortable extrapolating that level of significant modification given the incredible amount of consensus effort that went into identifying these specific 10 rules back in 2001.

We welcome both the IOM to tackle this important update directly, as well as the health and health care industry’s feedback to the proposed revised 10 new ‘simple rules’ outlined above. The country and Alice cannot afford an ineffective and inefficient health care system ‘long walk’ and not knowing where we are collectively going.

Figure 3 Source: Accountable Delivery System Institute (ADSI)

Jim Hansen currently leads the Accountably Delivery Systems Institute. He is also active with the Institute of Medicine and other national policy workgroups.

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  1. The Future of Nursing: Leading Change, Advanc – ing Health,” this past October, nurses are featured and acknowledged by the IOM as the leaders and agents who will transform the health care system, ensuring care is patient centered, effective, safe, and affordable. This vision calls upon the entire nursing community to embrace this report as a blueprint for action, and requires each and every nurse to use evidencebased research and collaboration to improve health care. Thank you for this informative blog.

  2. Mighty Casey – Thank you for the thoughtful response. I am in year 22 of knowing all about ‘the lip service legion’, waiting for health care to change while keeping after it with the energy as if it is year one or two – with one exception where I just could not take it anymore and left the industry for a year and a half but returned with even more focus because I came to reluctantly understand that it was a calling. A friend at the time told me that trying to fix health care was just plain dumb, leaving and coming back is something only stupid and/or stubborn people would do – well … What gives me honest hope is that this time their is a different vibe and level of conversations that we have seen in talking with a wide variety of health systems, medical groups and health plans from across the country we have hosted at our Institute that have not been there before. Trust me, as somebody who has run an HIE for over 3 years, I know defensive participation when I see it from a mile away and there certainly is some of that but there is clearly a sense that we have exhausted our options and must finally be driven by this crazy notion of logical, value-driven health and health care. Jim Hansen

  3. The issue I see with your vision (which I applaud) is that, when it comes up against the calcified paternalism that’s still rife within the healthcare system, it will wind up with a flat spot on its forehead. Using government carrots and sticks can shift the system a bit, but I fear that it won’t shift the thinking in the health system C-suite, particularly when there are shareholders expecting dividends.

    As a healthcare writer/journo, I have the opportunity to talk to many bright lights in care delivery, but they still run up against what I call the Lip Service Legion (“Great idea! We’ll take it to the board and get back to you.”), which turns into the Great Waiting.

    Physicians and patients are still “product” in the US healthcare system, not customers. All the federal regs in the universe won’t shift that until both of those cohorts are fully empowered equal players. Since both are still in the dark about the COST of their shared decision-making … we ain’t there yet.

  4. Whatsen, Thank you for the post. For years you summary has been the fear of many of us in the industry – that we dehumanize the intellectual process to the point that the challenge of medicine for some of our smartest citizens and students will cease to exist.

    The great news that I want to share with you is that our experience in the Institute with hundreds of physicians operating under full risk along side a ‘collaborative payer’ who provides information transparency and the proper incentives over many years in what we call accountable care 2.0 is that their physician satisfaction is actually off the charts. They are able to get off the fee-for-service 7 minute appoint hamster wheel and take full ownership of the patient – get to know them better, have all the info before/at/after the moment of care for joint decision-making, take 30 mins in an exam if that is what it requires, are empowered to make the right decisions, etc. So much so that in our ACO 2.0 program we have formally added physician satisfaction as the Triple Aim plus One. Jim Hansen

  5. Dr. Harrison,

    Thank you for taking time to post a comment. The vision laid out originally by the IOM twelve years ago and incrementally updated here are purposely meant to transcend specific maturation stages along the way such as the age of accountable care that we likely find the industry in today.

    Your challenge of evidence is exactly why we created the Accountable Delivery System Instistute – to specifically share the 8+ years of quantified cost, quality and very high physician satisfaction findings that forward thinking physicians in Saint Louis have been delivering while practicing accountable care before it was ever called that. We have done so with dozens of health systems, medical groups and health plans over the past couple years.

    To your last point – Not all accountable care contracts and relationahips are created equal and like everything else in America there will be winners and losers – unfortunately many of today’s ACO contracts are not built on mutual provider-payer transformational behavior change and thus will likely fail to achieve meaningful results – see our blog posting here for more details: http://adsinstitute.org/2013/03/accountable-care-2-0-offers-promise-success-todays-accountable-care-1-0-maturity-level-approach/
    Jim Hansen

  6. It seems to me that the transformation about which you all write is rapidly becoming a devolution of health care, in which the process, meeting the ACO rules, and the EHR machines sap the most intellectual power leaving the patient care to the cookbook CDS built in to the ordering machinery in the EHR.

  7. Your vision of health care Utopia is fascinating. What is the evidence that outcomes will improve and costs will decrease in your accountable care Utopia?

    Most good doctors realize the sham of ACO that will only serve to shift more money from the care of patients to the cash registers of CEOs and consultants.

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