Improving health care through better choices

Former U.S. Surgeon General and chief of health innovations at Canyon Ranch Richard Carmona MD, PMH, FACS addressed a full crowd at Marston Exploration Theater in the School of Earth and Space Exploration, drawing on his experience as the nation’s top doc, a university professor, nurse, police officer, and decorated Army Special Forces war veteran to diagnose what ails Americans and our health care system.

He applauded previous McKenna Lecture speakers who suggested a health care model based on patient-centered care that decreases cost, increases quality and access, increases efficiency, and uses technology as a tool — one with a state-of-the-art optimized supply chain is essential.

But it’s not enough, according to Dr. Carmona. “The questions we must ask are: What is our goal? What is our value proposition? Is our goal to provide the best care at the least cost to most people? Will that fix our progressively incentivized, sick health care system? I say no, it will not. We need more,” he said.

What’s plaguing health care?

“If we look at the entire supply chain for health care and look back but move forward to optimize each incremental variable in the health care supply chain, the preventable disease, and economic burden will continue to grow. And any threat we bear will optimize the care of a sicker, more costly population and health care system. That’s where we are today.”

While Dr. Carmona believes appointing management, eliminating fraud and waste, controlling pharmaceutical costs, manipulating formularies and payor plans, controlling physician and provider variability will all have incremental added value, ultimately, it’s tantamount to rearranging the deck chairs on the Titanic. “We are going down,” he said. “Simply adjusting the business increments of our health care system will not change this fact. Unless we address the approximate cause of what is plaguing us, the state of health care is not sustainable.”

And that, according to the former Surgeon General, is lifestyle choices. “It is the ultimate cause of the ever-increasing disease and economic burden,” he explained, highlighting tobacco, which kills nearly a half million Americans per year.

Putting politics in its place

Dr. Carmona also addressed the embarrassing plague of politics. “Those we have entrusted with our destiny, those we have elected ostensibly to act on our behalf selflessly, whom relentlessly in a hyper-partisan and sometimes malicious fashion blame each other, provide no value for us as citizens.”

He cited Obamacare, or the Patient Protection and Affordable Care Act, as an example of grave political inefficiency in finding a health care solution. “As a real democracy, we’d come together and say this is a good starting plan but we need to do about three or four other things and track it and get the metrics and change it as we move along. Instead, we buried it, and it became a political issue. We take complex issues and politicize them and get nothing of value.”

Improving value, quality, and efficiency

Furthermore, while America is proud of being the global economic engine of pharmaceutical and biotech innovation and our nation’s health-related intellectual property benefits the world, Dr. Carmona pointed out how ironic it is that our system is inefficient and the costliest.

“Our health metrics in some areas rival that of third-world countries, particularly disparities in childhood vaccinations and paternal childhood mortality rates,” he said. “The fact that we spend more than anybody contributes little to the real value that we get. We still have a challenging system that is perversely incentivized, that attempts to do the right thing. But then you start to look at metrics and see some countries that are economically decades behind us yet life expectancy and paternal childhood moralities rates are better.”

The difference is that priorities are different, according to Dr. Carmona. “We can’t forget about the basic stuff. And if you don’t take care of them before it becomes a problem, you will pay dearly later.”

The former and 17th Surgeon General also proposed adding a quadruple aim to the existing triple-aim model for optimizing health care performance (improve patient experience and care, improve population health, and decrease costs): Prevent health care professional burnout. “We are losing doctors, nurses, and health care professionals at a record level because the system is so convoluted and stressful, and they leave or quit,” he said.

Calling for health literacy and cultural competence

Despite the challenges, Dr. Carmona is proud of how far health care has come in the United States. As Surgeon General, he focused on prevention, preparedness, and examining costly health disparities and social constraints that burden health care and cost lives, particularly among the poor, Hispanics, African-Americans, and American Indians.

Two prescriptions, he suggests, are health literacy and cultural competence, to help repair a failing system. “We have the most heterogeneous nation in the world. The science we want to apply to help somebody stays the same, but the message has to change because we have so many languages, ethnicities, and histories. One message doesn’t fit all,” he said.

“What we are really trying to do is take the most complex science the world has ever known, and translate it in a culturally competent, healthful manner. Deliver it to an end-user, a fellow citizen we have the privilege to serve. And do one thing only: Affect them with behavioral change.”

Such measures will finetune the system, but you will still have a well-tuned system taking care of sick people with an increase in cost, said Dr. Carmona. “Chronic preventable diseases, which are significant and which are a major driver of the cost of health care, will confound our best thinkers who are trying to work on the supply chain, cost, quality — all those quadruple aim things.”

Leveraging technology to transform health care

He also stressed the need for the United States to leverage science and technology to other nations as a diplomatic health tool — a measure to help other nations be sustainable and ultimately end warfare. “Let’s have people see us as the real Americans that we are in the hopes of extinguishing ideas of fighting, wars, and terrorism,” he said.

On the home front, as disease and economic burden continue to increase, politicians cleverly avoid the most challenging issues, like eldercare, in the United States in an aging population where 10,000 people become baby boomers every day and have co-morbidities, including increased dementia and Alzheimer’s, Dr. Carmona added.

But with no infrastructure to take care of them, he warned the system is going to crash. “What I’m telling you is there’s a tsunami coming at us. These are thorny, tough issues but they are problems we need to address head-on because they are extraordinarily difficult but require some very significant thought.”

Yet, the platform of the future is not more bricks and mortar or building larger geographic footprints. “At some point, you can’t afford to do that. The real question is, ‘Is that benefitting the end user, the patient?’ If you ask patients, most will tell you it isn’t. They are struggling, they don’t understand the system,” he explained.

“It’s about leveraging your multidisciplinary platforms to create growth and more value. It’s about becoming a health home or aggregator of value-added services in your community and leveraging technology maximally,” said Dr. Carmona of creating health hubs and embracing things like wearable technology that will continue to distrust the status quo.

He cautioned that if those in the health care industry miss this fast transforming market they will be left behind. “We need to create a digital front door or somebody else will and that’s where the business will go. And we need to figure out how to reward our providers for keeping people healthy rather than rewarding them for when people get sick to make them better.”

Ultimately, Dr. Carmona said that the health care system has to drive affordability at increased costs or risk being seen as the problem rather than a solution. And he’s more firmly convinced than ever that the innovation and instruction propel our nation is fueled by our robust diversity that, paradoxically, still divides us at times.

“The future is here, and economic and catastrophic mandate is upon us, so we should heed Gandhi's words: ‘We should be the change we want to see in the world.’ And I hope our government will follow us.”