As lawmakers on Capitol Hill wrangle over the fate of the Affordable Care Act and its would-be replacement, the American Health Care Act, the National Academy of Medicine said its four main priorities for fixing the country's healthcare industry include continuing the shift from fee-for-service to value based payment models; empowering people to be fully engaged in their healthcare decisions; tapping communities for local health solutions; and implementing integrated services and seamless digital interfaces.
"The strength of the Vital Directions report is not in its innovativeness; it contains no surprises," said Berwick. "This report offers a template for change broad and inclusive enough for it to be a charter for coherent and effective system redesign."
The first step in that redesign, the shift from volume to value, is already underway, and the academy contends that its continuation is vital in terms of reducing waste and improving value.
Berwick agreed that this shift is needed, but wrote that fee-for-service behaviors "and top line-driven revenue growth strategies continue to dominate healthcare economies, and recent political pushback has been strong against expanding effective bundled payment models and value-based pharmaceutical purchasing."
The report also cites evidence that underinvestment in social services relative to healthcare services may be contributing to the country's poor health performance. To reduce inequality and increase cost savings, the report recommends integrating clinical care services and non-medical services, such as housing, food, transportation and income assistance.
That solution leads into another of the report's action plans, activating communities. A person's health is very much a product of the available social supports within their community, their physical environment and their behavior. The U.S. continues to invest far less in community-based social services, which the report said is vital to combating health threats such as chronic disease and substance abuse. The report recommends investing in local leadership and infrastructure capacity for public health initiatives, and calls for collaboration from leaders in different sectors, such as business, education, housing and transportation. For this approach to be successful, close coordination is needed between medical and social services.
When it comes to empowering and engaging people, the report claims that patients are often insufficiently involved in their own care decisions, sometimes resulting in care that doesn't take their specific life situations into account. Health regimens and treatments should work within that context, and policymakers should focus on increasing the amount of information that's available, the authors wrote. Telehealth was identified as an important component of that, as it helps patients in underserved or remote areas and essentially gives them greater ownership of their health information.
Revamping digital interfaces, the fourth action plan, is particularly vital, the authors said, because the extent to which systems can share and make use of data remains severely limited. That causes breaks in care continuity, which not only predisposes the patient to harm but increases stress for the clinician. Creating principals for end-to-end interoperability, strengthening the overall data infrastructure, building public trust around privacy and security, and smoothing over inconsistent state and local policies on data use and sharing are possible solutions.
Berwick wrote that if the country adopted these policy frameworks, healthcare quality and costs would likely improve dramatically within a decade.
"The devil is not in the details here," wrote Berwick. "Everything the authors recommend can, in principle, be done with remarkably few cycles of trial and learning. The devil is in the culture. It is all about will."
"Leaders must recruit the courage to make the case and put their own political and organizational futures on the line," wrote Berwick.