Often the key to solving a troublesome problem is approaching it from a different direction. As 19th-century mathematician Carl Gustav Jacob Jacobi wisely noted (and as popularized by renowned investor Charlie Munger), “Invert, always invert.”
Therefore, when we consider ways to transform our current health care system in the U.S. to deliver more reliable, equitable, cost-effective value, we should explore the factors that perpetuate a continued unreliable, wasteful system that propagates inequity.
Fee-for-service (FFS) challenges
Let me elucidate. The prevalent FFS payment model in the U.S. health system inadvertently fuels health inequities by incentivizing the volume of services over outcomes. It fails to account for and address underlying disparities in health care access and the impactful influence of culture and social determinants of health (SDoH) — both significant obstacles to well-being. Moreover, implicit and explicit biases, structural racism, and historical trauma contribute to our current inequitable care model. This intersectionality is why health inequities tend to manifest along lines of race, ethnicity, and socioeconomic status, persisting within historically marginalized communities.
Why are we ensuring a continued system marked by waste and inefficiency with meager results? Why have we doubled down on the current volume-focused strategy, one that has yet to demonstrate its efficacy in promoting population health or effectively serving disinvested communities?
The FFS model focuses on delivering medical services nearly exclusively without first understanding patients’ circumstances, capabilities, personalized needs and wishes – what we call “whole-person care.” It is a one-size-fits-all model that lacks the flexibility for personalization or additional measures to enhance patient outcomes and meet individuals where they are in their health and health care journey.
While this change to whole-person care brings several health and societal benefits, including an approximate gain of 10 days of life per screened individual, the FFS model poses challenges to ensuring these new recommendations are executed optimally.
For instance, a patient in her mid-40s living in a historically marginalized community might be unaware of the updated colorectal screening recommendation, and if she has previously struggled with accessing ambulatory care services she may be less likely to learn of this in a timely manner than other patients. Eventually, she might be informed by her primary care provider or insurer (if she has either) to have the screening done but she may not fully understand the benefits and the accompanied risks of screening depending on how the message was delivered (e.g., comprehension may be impaired in the event the communication was written in English if this is not her primary and preferred language).
She may be offered a referral to a gastroenterologist for a colonoscopy, despite not being informed of a number of other options for screening for those at average risk. Periodic reminders might follow to prompt her to set up an appointment for her colonoscopy if she still doesn’t get the screening done, but these messages never probe into any potential barriers that she may be facing. The FFS model, by nature, lacks proactive mechanisms infused with cultural humility to enhance her likelihood of completing this crucial screening, resulting in a suboptimal overall experience and outcomes.
In this reactive FFS model, we wait for the patient to hopefully undergo screening, offering minimal proactive engagement. This approach ensures anemic results for pivotal health promotion elements like screening and prevention in our society.
Invert, patients first
So, how does inverting this problem help us solve for a more equitable model of health?
Crucially, this mental exercise underscores the need to prioritize the patient, consistently keeping her needs and expressed goals at the forefront. The proactive strategy of tailoring care and emphasizing improved health outcomes and cost reduction is the optimal path forward. This approach initiates by understanding the person and their context, rather than fixating on the service to be rendered—be it a test, screening, or appointment. This principle encapsulates the essence of value-based care (VBC).
A VBC model would commence with a thoughtful patient interview—a meaningful discussion with the primary objective of delving into the patient’s history (medical and otherwise), overall circumstances, and personalized attitudes toward health and health care. In this collaborative effort involving a diverse team comprised of roles including but not limited to a medical provider, social worker, community health worker, outreach expert, and behavioral health specialist, a comprehensive understanding of the patient and their health care barriers is gained. The multidisciplinary team can then come together to determine the most effective way to support the patient while establishing shared goals.
Returning to the colon cancer screening scenario, the interview might unveil that our patient is effectively housebound as the sole informal caregiver for a senior family member, lacking reliable transportation for the colonoscopy but with a keen interest on getting this screening done after talking through some myths she had heard about this. Social services professionals within her VBC team could coordinate additional caregiving support and transportation, not only for the colonoscopy but also for routine clinical visits and respite from caregiving in the future. Alternatively, the patient might be offered the option to complete a stool-based study at home. The VBC model, designed to address individualized barriers, ensures a comprehensive approach focused on the patient’s overall, biopsychosocial well-being.
Upfront strategic investments
The VBC approach extends its focus to the critical objective of reducing overall health care costs, emphasizing that investing in a person-centered, proactive model yields long-term savings. While it may appear counterintuitive initially, strategic investments today can yield substantial cost benefits in the future.
Effectively implementing VBC necessitates upfront investments in people-led outreach, intelligently bolstered by technology and data science. This includes services like providing food, transportation, and other support to under-resourced communities, along with fostering coordination among various social services agencies and health care providers. Although this may seem more costly than passively waiting for a patient to access health care, the initial investment pays off with fewer emergency department visits, reduced and shorter hospital stays, heightened patient engagement, and the prevention or delayed progression of costly chronic conditions.
Ultimately, upfront strategic investments translate into improved patient health outcomes and lower health care costs by eliminating waste from the system.
As both public and private insurers transition to value-based payment models—rewarding outcomes that patients and families value over the volume of services—health care providers optimizing their VBC workflows stand to gain enhanced margins and increased revenue. This shift underscores the financial benefits tied to prioritizing patient outcomes within the VBC framework.
While VBC primarily concentrates on offering a more dependable solution to promote individual health, its ripple effect is inherently felt at the population health and community levels. This model holds tremendous potential for narrowing and eliminating health disparities by affording historically marginalized communities access to effective, culturally tailored care.
Closing the health equity gap would be momentous.
Michael Poku is a physician executive.
