“Shift the business models”
“Re-align the incentives”
These phrases are not new.
Nor are the concepts they represent.
Yet we’re starting to see new experiments from the federal government, from states, and even small communities that demonstrate a new willingness to deeply engage in understanding and overcoming the barriers to true change in how we improve health.
Notice that I said “improve health.” I didn’t say “Improve health care.” This not just an insignificant semantic nuance. When we conflate care and health, we accept the fundamentally flawed assumption that in order for people to be healthy, we must in some way intervene and care for them. This assumption forms the basis of many traditions that pervade our broken system: in medical school and residency, I was taught that the individual with depression needs a medication, rather than improved coping skills. I was taught that the individual with diabetes needs a nutritionist rather than an exercise partner. I was taught that the the individual with hypertension or hyperlipidemia needed medications, regular lab work, and bi-annual follow-up visits, and I was taught that otherwise healthy adults needed an annual physical exam.
We now know that this medical education I received – as have tens of thousands of physicians, nurses, care coordinators, quality managers, hospital and health plan administrators and government officials – is in many cases based on a set of traditions rather than science. Marcia Angell’s compelling work on our (mis)management and misunderstanding of mental illness is a sobering review of how we’ve managed to create a generation of people who are dependent on the medications that we thought would help “cure” them. Zeke Emanuel has reminded us of the paucity of evidence for the “annual physical” and makes a strong case for eliminating it entirely. Finally the evidence for exercise as an essential component of prevention of (and management of) diabetes is well known, but when I recently asked a 3rd year family medicine resident what would be his choice as first-line intervention (I chose my words carefully) for a patient with newly diagnosed type 2 diabetes, his proud and instantaneous response was “metformin” rather than “exercise.”
These traditions, steeped in the very human need to be needed, find their common ancestor in the assumption that these people need us to get better. We sought careers in health care so that we can care for others. So that we can help them. We can rescue them. We can “make a difference.” Early in my career, as a young medical school faculty member, these are the words I would hear as I interviewed medical school applicants. Help. Care. Save. I never heard the words that will form the basis of our new model of health: Empower, Educate, Witness, Listen, Learn, Share.
The genesis of this new thinking comes from several communities – all working at the edge of public service. The edges, as I’ll discuss below, are where we see the birth of true innovation.
The term “Positive Deviance” has a long history – dating back to the nutrition research literature of the 1960’s, popularized in the 1990 book (pdf) by Zeitlin, Ghassemi and Mansour. The model is based on observations that “positive deviants are children who grow and develop adequately in low-income families living in impoverished environments, where a majority of children suffer from growth retardation and malnutrition.” What is different about the positive deviants? Can we learn from them, and amplify their success by sharing their success with others? Can we empower the community to find strength and success, rather than import and impose our own views? Of course. Over the last three decades, the Positive Deviance Initiative has used these principles to learn from communities, empower them, and facilitate better health and better lives for millions of people worldwide.
William Miller and Stephen Rollnick summarize the work of many psychologists, social workers and physicians through the 1980’s in their book Motivational Interviewing, published first in 1990. The basis of the work that framed MI is the same principle expressed in a joke that my dad (a psychiatrist) used to tell:
Q: “how many psychiatrists does it take to change a light bulb?”
A: “only one, but the light bulb has to want to change.”
MI reminds us that we can’t change people. People change themselves. Sometimes with our facilitation, sometimes despite our intervention. Always from within.
Both Motivational Interviewing and Positive Deviance place the important emphasis where it belongs: in the wants/needs/hopes and wishes of the individual. The smoker who chooses to keep smoking will always smoke, regardless of our judgement of them. Can we motivate rather than judge? Can we empower rather than diagnose? Can we really listen? (Alas, no. As this study reminds us – physicians interrupt patients after 12 seconds.)
In last week’s Sloan Management Review, Clayton Christensen observes that “… when the business world encounters an intractable management problem, it’s a sign that business executives and scholars are getting something wrong — that there isn’t yet a satisfactory theory for what’s causing the problem, and under what circumstances it can be overcome.”
So here’s my theory: traditions have shaped how health care delivery has evolved in the US and most Western cultures. Inherited from “expert-based medicine” of the 1950’s and 1960’s, the paternalistic medicalization of much of our societal challenges, and compounded by economic forces that have positively reinforced intervention over empowerment, education, and true engagement. The “patient centered medical home” of 2016 is no more patient centered than most primary care practices of the 1990’s, despite the dedicated work of many at NCQA and elsewhere to describe the attributes of a true “patient centered” experience. In order to break away from these traditions, we need to begin at the edges.
A colleague asked me today how I would shape a DSRIP program if I were to design one from scratch. My response is a confluence of the theories of Motivational Interviewing, Positive Deviance, and Clayton Christensen’s theory of disruptive innovation. Christensen argues that a new-market disruption is an innovation that enables a larger population of people who previously lacked the money or skill to begin buying and using a product (or service). DSRIP Background: DSRIP programs exist in New York, New Jersey, Massachusetts, Texas, Kansas and California, and are a product of a CMS innovation program that:
- Gives states autonomy to spend medicaid money in new ways – toward a set of “triple aim” goals.
- Must be budget neutral for CMS
- Should facilitate transformative changes in the care delivery system
Here’s what I told her:
DSRIP 2.0 programs should focus on a small set of very tangible goals that align with the triple aim:
- Cost of care for a medicaid population should be reduced by at least 25%
- Quality of care should improve (yes – this is hard to measure)
- The experience of individuals should improve (also hard to measure)
- Eliminate process measures, and any central attempt to dictate how the DSRIP participants achieve the goals. Yes – there can (and must) be accountability, but the accountability will exist in the form of reporting on progress toward achievement of the “triple aim” goals, rather than achievement of a set of prescribed milestones that must be traversed.
My colleague wasn’t happy. My explanation was too simple! “Shouldn’t we hold them accountable for solutions we know are effective in improving the health of these vulnerable populations?” I replied that this is exactly what the early Peace Corps volunteers did wrong when they imported ideas from Washington DC to communities in Asia: they assumed that they knew what was right. “No. DSRIP participants should be exposed to programs that have been successful, but they should have the freedom to achieve the goals in any manner they choose.”
A model for DSRIP 2.0
Positive Deviance teaches us that what works in one community may work in one community and only one community. The needs of a community are best understood and met by the members of that community. Folks who enter and seek to improve the lives of those in such a community will need to be ethnographers first, and “fixers” second. This calls for teams of DSRIP leaders who are trained in anthropology, design thinking, population health, and social work. Doctors and nurses? But they are in the back seat.
Who is doing this today? Companies like ChenMed in Miami have Tai Chi classes, free transportation, and proactive care managers.
Motivational Interviewing teaches us that individuals make decisions because of internal incentives, not because authority figures tell them what to do. This informs a DSRIP approach that is focused in listening rather than speaking, on amplifying individuals’ own interests in healthier living, and offering ideas that will facilitate change during teachable moments rather than mandating new behaviors, or imposing penalties for behaviors that are unhealthy. A DSRIP program might therefore hire teams of health educators from within a community: a trusted, yet trained group of people who can listen, empower, and facilitate change.
Who is doing this today? Community health workers in Massachusetts (pdf) have helped to reduce costs, improve health, and improve health experience for thousands of residents.
Disruptive innovation teaches us that the non-consumers of services (in this case – it is health – and not health care services that are not being consumed) is the best entry point for new market entrants and new product creation. We’re not going to create new hospitals in the next five years, nor will we change how they operate, how the incentivize their employees, or how they market their services. So hospitals are the wrong places to invest DSRIP dollars. Rather, DSRIP money will be best spent on community initiatives (see above) and innovative “point solutions” that help can communities reach the triple aim, by addressing the health needs of individuals proactively.
Who is doing this today? Vital Score (I’m an advisor and investor), identifies individuals at peak moments of receptivity and matches them to services that will improve their health. Cohero Health created a metered dose inhaler that enables a care coordinator to track and monitor inhaler use in real time, and detects not just whether the inhaler was used, but whether proper technique was used.
As William Gibson may have said, the future is already here — it’s just not very evenly distributed. While we often think of the fitbit-wearing, Volvo-driving soccer parents as opportunities for innovation in health, my hypothesis is that true change in the delivery of more health (rather than more care) will arrive in the form of DSRIP and other innovation programs. The opportunities to build successful programs, successful companies, and healthy communities are (finally) plentiful – if we know where to look. Inertia, combined with traditional payment models in traditional care delivery organizations will work against any of the innovations that will truly serve these communities, and this is why the greatest improvements in health will occur as a byproduct of work that precedes “health care.” This won’t be easy. But we can do it. As Yoda said: “do or do not. There is no try.”