The Wealth from Health Playbook

The Dramatic Path Forward in Healthcare Spawned by the Covid-19 Pandemic

Douglas J Ratner, MD, Walsh

• Publisher: Universal Publishers
• Year: 2021
• ISBN:
  9781627343329
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Two working physicians with a team of multigenerational, multidisciplinary and rising thought leaders created a system, Wealth from Health, to take an honest, unfiltered look at American healthcare. Rather than beginning from an institutional perspective,

Chapter One

The Wealth from Health Movement

The Wealth from Health (WfH) formula includes a wide span of comprehensive initiatives designed to establish a true road map to meeting the needs of patients with value, which is defined as melding quality and efficiency. The formula relies on proven templates of change, rather than theoretical ones. Healthcare professionals traditionally run from “theory” to “how” after being convinced of the “why.”

Wealth from Health is different because it is not theoretical. We have tested and revised all the initiatives in a large, multicultural and socioeconomically diverse urban population. We also have not relied primarily on nursing professionals (high compensation), community advocates (low skills), or phone follow-ups (low capture) to champion and implement the initiatives. WfH has sparked a movement, comprised of a unique “professional friend” model of college-educated salespeople who are skilled in developing trust and engagement. The patients come first.

Hospitals and physicians need to expand their offerings and see themselves, not just as providers of “sick care,” but as champions of maintaining health. And the care delivered must also change rapidly and radically, proactively promoting good health habits beginning in childhood. I must be unafraid to upset the status quo, make experimentation central to our actions, creatively connect things, observe our patients like an anthropologist would, and finally, harvest what we have learned. This is the Wealth from Health formula and movement toward positive change.

Health systems will generate membership by understanding their consumers and offering a deeper relationship that builds value over time. The current business model is good at diagnosing disease and ending with prescribing a course of therapy; however, it is dying a natural death due to failure to show consistent benefit to the patient or society. The new model, outlined in this book, with evidence of financial and health success, can most effectively help patients adhere to the recommended therapies and make the behavioral adjustments necessary to live free from the complications of their disease(s). WfH is a comprehensive plan that can serve as a strategic vision for your healthcare system for the next three to five years post-pandemic. The twelve key strategies are:

1. Wealth from Health Navigation Program. This initiative is an incentive-based, credit-system methodology. It rewards patient self-management and ties into community businesses for attractive discounts and giveaways. A current business model that is good at diagnosing the disease and prescribing a course of therapy must morph into the model that can most effectively help patients adhere to that therapy and make effective behavioral adjustments. Staying connected to sterling WfH navigators, who have assisted over 4,000 patients to date, with up to 100 unique self-management activities necessary to live free from the complications of their diseases and are perfect for video chats/visits. Credits earned are rewarded by gift cards.
2. Precision Medicine. This term refers to the fact that we finally have (and will continue to have) an ever better emerging database that represents a huge leap forward in understanding why people get sick and ways to prevent those illnesses. Why certain people succumbed to the coronavirus, while others did not, is a great example (correlations between age and certain serious preexisting conditions). Plus, by merging the socioeconomic and genomic information on each patient, we will finally uncover the issues that can accurately produce new therapies.

• CRISPR: (clustered regularly interspaced short palindromic repeats) is a gene editing technique.
• Gene Therapy: adding genetic material to cells to address abnormalities.
• Microbiome Sequencing: analyzing the genetic material of the bacteria, fungi, and viruses, etc. that live on and in one’s body.
• Whole Genome Sequencing: replace select gene analysis.

3. High-Value Care Center (HVCC). To have any hope in competing on price, hospitals and health systems must address the root causes for their runaway price structure. Issues of overuse, misuse, and underuse along with diagnostic errors must be met head-on. A huge percentage of medical issues can be managed remotely with efficiency and help eliminate the $1 trillion of systemic waste mentioned earlier. Predictive analytics and knowledge management are the key and core features of these centers. A game changer.
4. Primary Care Transformation. Video/smartphone consultations will stand alongside office visits with office visits recommended only when necessary. The emerging standard for accessibility will provide seamless care that extends beyond physical access to care sites. COVID-19 has hammered this fact home. Virtual visits must take a seat at the table, starting with the fields of behavioral health and postacute care (the period after hospitalization) where reinvention is so critical.
5. Reengineered Projects. Innovation for the sake of your customers’ health through offering affordable, reliable, and accessible products that meet discrete customer needs, such as the Race to Zero—a symptom-reduction program to make patients comfortable during the last two years of life—and the Environmental Housecall for asthmatics to root out indoor pollutants, a major factor in the illness itself. Additionally, the Getting Stronger Program, the Help the Helper Program Financial stewardship, Behavioral Health Program, and other initiatives provide efficient and effective care and are the result of initiatives tested and proven in a large urban center.
6. Diagnostic and Management Excellence Center. This initiative utilizes newly created software and simulations to assist clinicians in developing a solid differential diagnosis and make “diagnostic reasoning” a vital core function in their daily routines. Also, acknowledging “management reasoning” as a separate learned skill set. Just by looking at this pandemic, one can readily see a hodgepodge of management reasoning decisions that, in many cases, defy reason and coincide with “medical intervention by exception” practices.
7. Pharmaceuticals Affordability Initiative. The cost of pharmaceuticals is also unsustainable for a significant segment of the population, the elderly, take many medications at one time and are on a fixed income. Faced with buying food and paying rent, guess which necessity is ignored? When, not if, antivirals and vaccines for COVID-19 are studied and tested appropriately, costs will need to be addressed to ensure compliance and accessibility.
8. Healthcare Leadership and Innovation Initiative. We must train our healthcare students and residents, leaders of tomorrow, now to become “change agents.” If not now, when? we ask.
9. Value Analysis Committee. Establishing a business case based on cost-effectiveness must supersede political and hierarchical considerations when purchasing expensive equipment or electing to use expensive therapies. The use of ventilators—instead of the latest robotic surgery options, for example—is an eye opener in this pandemic. This includes self-service applications and self-service diagnostics.
10. Cancer Survivorship, HIV Survivorship, and Sickle Cell Survivorship. For the millions of Americans in which cancer has been relegated to the status of a chronic disease, as HIV and sickle cell disease have, navigating these individuals through the rest of their lives will require trained professionals who look to coordinate care for these unique patients.
11. Community Health Trust. Communities must establish their population priorities according to the social determinants of health and then match the communities’ resources in order to level the playing field. A perfect formula that leaves no one behind as we speak of transportation, access to fruits and vegetables, legal advice, and so forth. Thoughtful collaboration by corporate, philanthropic, education and government as well as social networking is the key.
12. Financial Care Stewardship. Considering our patients’ finances must no longer be ignored. Structuring a method by which a physician can advise and share expense information prior to ordering procedures, medications, etc., while seeking effective alternatives, must be established. If fee for service (FFS) remains, make it cost-effective and transparent as in telehealth promulgation.

The Wealth from Health Paradox

“What is the Wealth from Health paradox?” you might ask. The dictionary defines the word “wealth” as “an abundance of valuable possessions or money.” In fact, most definitions refer to material entities. However, we firmly believe that good health makes one truly wealthy, because without it, life is exceedingly difficult, if not lamentable. Furthermore, we cannot measure up as a society unless we come to the realization that every life matters; being poor or uneducated does not make one less important in this world. Stating the obvious: we are all God’s children.

After a solid month of social distancing, New York City officials noted that Hispanics averaged 22 deaths from COVID-19 per 100,000, Blacks 20 per 100,000, Whites 10 per 100,000 and Asians only 8 per 100,000. The obvious evidence of health inequality this pandemic has revealed remains a perfect storm. The gap will, undoubtedly, widen as the unemployment rates rise and individuals will have less access to health insurance. If healthcare is in high demand and the supply is short, personal wealth (or lack thereof) will play an increasingly ugly role in obtaining it.

In a perfect world, we would hope that all individuals involved in the healthcare delivery system—insurers, hospital CEOs, pharmaceutical companies, etc.—provide value and have the patients’ best interests at heart. However, my four decades in healthcare informs me otherwise. Many of them have economic goals from the start, which you might say are not irrelevant to good outcomes. However, as the waste in the gargantuan American healthcare system is fast approaching $1 trillion per annum in a $3.6 trillion per year industry,14 the time for change is now. Objective data conclusively proves that more healthcare does not always translate into better healthcare, regardless of some who claim otherwise.

The insurance companies have always wanted to insure healthier people because they save on payouts and the majority of the premiums stay in their coffers. The fact that the people they want to insure are healthier is a business move, short and to the point. The insurers steadfastly refused to cover preexisting conditions until Obamacare shoved it down their throats and gave them an ultimatum in 2014.

On the other hand, the CEOs of hospitals need sick patients because that is their business model; their jobs have depended on filling beds … as long as patients do not wear out their welcome. That is, diagnosis-related groups (DRGs are the present system of reimbursement) pay better if you grace their doors but don’t stay long. Simply put, profits are limited by beds that don’t turnover fast enough. Perverse? You betcha.

Physicians, however, know that due to the dangerous microorganisms existing in hospitals, less time means less exposure, hopefully. I can assure you that this fact is not on the radar of most CEOs though. One ambitiously driven CEO explained why he refused to consider backing the WfH disease-management initiatives: “They will keep fannies out of my beds.” Outrageous? Yes, but I am certain he is not an outlier in this misplaced belief.

Others will reason, “No money, no mission.” I would submit and have done so to their faces: “Since when does doing the right thing for our patients take a back seat? Doesn’t that sound like a cop-out?” In fact, innovative CEOs are always trying to recognize new streams of income to stay afloat while serving their patients. They are necessary businesses, after all. However, only some are undertaking capitated risk, in which a system’s revenue is not tied to intensity of care but rather to efficient, effective care. The majority of CEOs do not because their efforts to make people truly healthier lag woefully behind their profit center: treating the sick. It is simply too difficult to do so profitably.

Some CEOs will throw some real money to fund an onsite farmer’s market, while others will come up with “wellness” efforts that pay lip service to the concept, but do not reach the individuals who need these programs the most. Incidentally, although this may sound overly cynical, and you may be prematurely concluding that this author represents just another disenchanted physician, you needn’t worry. After this eye-opening chapter, you will spend the remaining time on tested and proven, positive, game changing efforts that can help fix this broken system.

I am aware of a hospital in Illinois that offered their services at a markedly discounted rate, only to be overrun by consumers who had previously eschewed healthcare due to the exorbitant prices. The hospital had simply not done the necessary work (over time) to prepare for a new paradigm of care. I submit, however, that if the Walmarts, the Amazons, and so forth can figure it out, why can’t we do so with a new breed of enterprising CEOs?

As far as the pharmaceutical industry is concerned, their profit motives are out there for all to see: drugs that cost $100,000 per year and, in many cases, much more. Is there any wonder why healthcare costs are the leading cause of personal bankruptcy in the United States?15

Federally Qualified Health Centers and the Underinsured

My career in medicine spans four decades and, following long stints as a Chairman of Medicine in two healthcare institutions, I have seen and participated in many healthcare activities that have been inspirational, heartbreaking, instructive, and, lastly, illustrative. Throughout most of that time, I have maintained a close relationship with my patients and, in fact, am spending my semiretirement taking care of patients at a Federally Qualified Health Center (FQHC) in Asbury Park, New Jersey.

For those unfamiliar with FQHCs, there are about 9,000 of these ambulatory sites in the United States that care for all comers regardless of ability to pay: uninsured individuals and those on Medicaid, an insurance most of my professional colleagues refuse to accept due to its meager reimbursement, are the majority of patients. These centers rely on grant dollars, insurance, and sliding scales (income-based fees) for payments. This is our country’s best attempt to deal with health inequity, but time and time again, when I’ve found myself confronted with a complicated patient whose medical management superseded my ability to be “all things to all people,” I reached out to a subspecialist for guidance and failed to receive it. I sought their expertise in invasive procedures, such as cardiac catheterization, gastrointestinal endoscopy or colonoscopy, and pulmonary bronchoscopy … to name a few of the skills beyond my expertise as an internist. Over the decades I might add, either through my teaching of over 500 residents, or from sheer necessity, I have learned to be rather self-reliant. Consequently, I only reach out, in my opinion, when absolutely necessary. R...

Table of contents

• Cover Page
• Half Title
• Full Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Introduction
• Chapter One - The Wealth from Health Movement
• Chapter Two - Fixing Present-Day Healthcare
• Chapter Three - Living Up to Donald Berwick’s Vision of the “Triple Aim” (Quality, Cost, and Care)
• Chapter Four - Laying the Groundwork
• Chapter Five - Innovation in Healthcare Delivery Systems
• Chapter Six - The New Dimension Called “Social Determinants of Health” Delivery Systems
• Chapter Seven - Is High-Value Care the Holy Grail?
• Chapter Eight - Precision Medicine, a Cautionary Note
• Chapter Nine - Personalized Healthcare
• Chapter Ten - Remote Monitoring and the Transformation of the Practice of Medicine
• Chapter Eleven - Financial Stewardship
• Chapter Twelve - Clinical Variation
• Chapter Thirteen - Diagnostic Errors
• Chapter Fourteen - Cancer, Behavioral Health, Palliative Care, Postacute Care, and Other Reengineered Projects
• Chapter Fifteen - Our Prodigal Sons and Daughters
• Chapter Sixteen - Killer Apps and the Value-Analysis Committee
• Chapter Seventeen - The Wealth from Health Key Strategies
• Epilogue - Good-bye to Fee for Service: A Must
• Appendix One - How It All Began
• Appendix Two - Jersey City Medical Center-RWJ Barnabas Health System’s Quality Improvement Projects Initiative—an Abbreviated List of Medical Student Projects
• Appendix Three - Selected Achievements by the Wealth from Health Team
• About the Authors