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Health 2.0: Decoupling Geography from Health Care (12:40)

Speaking to an audience in Shanghai, China, Amy Compton-Phillips, Executive Vice President and Chief Clinical Officer for Providence St. Joseph Health, imparts some knowledge of American health care and her experiences working within it to improve quality and access to care.

Providence St. Joseph Health, a large health care system in the western United States, consists of 51 hospitals and 800 clinics from Alaska down to southern California and as far as Texas and Montana. “If you think about that delivery area, it’s large. It’s spread out, and there are some big cities in there like Seattle and LA. But there are also a lot of rural areas,” she begins.

Compton-Phillips, who is also NEJM Catalyst’s Care Redesign Theme Leader, describes how a patient in Montana, a largely rural state of about 150,000 square miles in size and with a population spread across that distance of only about 1 million, had to drive 2 hours to the nearest city for a diagnosis. It turned out he had a liver tumor, and there was no access to care, no oncologic surgeon there who could take care of him. The nearest one was another 5 hours away — a 7-hour drive. The patient did not have a car or the funds to pay someone to bring him there, there was no public transportation, and being on probation meant he couldn’t cross state lines to find care elsewhere.

“It was completely impossible for him to get the care he needed in the system that we have today, despite the fact that our mission for our organization is to create health for a better world. Somehow, we have this incredible mismatch between where patients are and where care is offered,” says Compton-Phillips.

She notes similarities in China regarding access to care. “We have great resources, but the resources aren’t always where the need is. How do we solve for that?”

Health care has been solving big, complex problems for the past 100 years. Polio, for example — a huge concern a couple generations ago — is now nearly eradicated. Compton-Phillips’ brother had acute leukemia when he was younger, and today the cancer is highly curable. “We’ve been solving big problems in health care for a while, but the problem is we keep finding new ones,” she says. “Now it’s this mismatch.”

Fortunately, there is a recipe for solving those problems. When Compton-Phillips worked for Kaiser Permanente, one of her projects was to try to figure out why, when trying to solve big problems, sometimes it works well and other times a solution you thought was great doesn’t spread.

Kaiser brought together a group of leaders who had led big changes such as ensuring heart disease was no longer the number-one killer of Kaiser Permanente members. That was a complex, adaptive change — no one simple thing to solve it, but rather a system of things. Then Kaiser asked these leaders how they led large changes to learn how to replicate the process and create a recipe for driving large-scale change.

“The recipe that we found has five elements,” Compton-Phillips explains. “Like many things, it’s a few simple rules, those elegant few simple rules that allow big change to happen.”

  1. Start with a vision. “They led with why, not what they were going to do, with what problem they were going to solve, and why they were going to do that.”
  2. Build trusted teams, networks “able to deliver the social capital to drive change.”
  3. Rely on data and the scientific method.
  4. Focus on capacity: what you need, project management, electronic tools to allow for change, etc.
  5. Make sure there is alignment “so that you aren’t trying to tell people to do one thing and pay them to do something else.”

Shortly after developing the model, Compton-Phillips was recruited to Providence, and she took the model with her. “One of the first things we did was to ask, ‘What problem do we need to solve here?’”

It’s common knowledge that health care in the U.S. is too expensive. “We have priced getting great care out of the ability of many of our communities to afford it,” says Compton-Phillips. As a not-for-profit health system that competes in an environment of many players, Providence needed to compete on value and provide access to care that’s both low cost and high quality. The health system’s number one payer is the government, which covers 66% of their patients, according to Compton-Phillips. “We lose money on every one of those patients,” she explains. So they came up with the goal, or vision, to make nation-leading care available at Medicare rates.

“That’s what we talk about all the time now at Providence,” Compton-Phillips says.

Providence’s network infrastructure is built along clinical institutes, which are like service lines: the heart institute, for example, has cardiologists, heart surgeons, rehab surgeons, and heart failure specialists who all work together. Experts from across the geography of the Providence health system came together to discuss how to improve care, lower cost, and compete and grow.

After a conversation about what is possible, Compton-Phillips’ team asked these experts for the top three things they wanted to accomplish this year and promised to help them accomplish those things with data, project management, and administrative support. The catch? Commitment. “We’ll help you do those three things, but you have to do it everywhere across our system,” Compton-Phillips recalls.

Each institute asked for specific kinds of data, which leaders worked to provide in an intuitive and understandable fashion. They also provided support to create projects, embedded tools in the system’s electronic medical record, and wrapped in tools to help patients navigate through the system. Additionally, the hospital received whatever machines were needed and added support in the operating room. There was also a quality incentive: institutes would receive a bonus if they hit certain quality thresholds and patient satisfaction thresholds. If they lowered cost, extra resources were added back into that practice.

“By doing all of that, we have been able to turn the tide despite the fact of costs going up for labor, for drugs, and for supplies,” says Compton-Phillips. “We’ve been able to take costs out of the top 10 diagnoses that we started this with so far, and the good news is we’ve been able to do that in every state and every one of the geographic regions that we participate in — this wasn’t an isolated thing.”

“By thinking about the entire system of care, we’ve been able to improve it broadly. We really like our version of vision, trust, data capacity, and alignment to help us create these large changes.”

The next vision Providence is working on is how to do this without boundaries, how to not only expand access to care, but to create cutting-edge, digitally enabled care that’s available anywhere — and make sure that rural patient with a liver tumor can see the right surgeon.

“We’re working to decouple care from geography so that we can break that constraint,” says Compton-Phillips. “To do this, we have to have a different business model than today. We can’t just be a hospital system.” Instead, Providence is working on building business verticals, such as for the physician enterprise, ambulatory care, and home and community services.

Providence is working on retrieving data to create a sustainable business model for this digital health care; with headquarters in Seattle, Amazon.com and Microsoft are down the street, meaning there are a lot of data scientists in the area. Providence is leveraging these data scientists to embed AI, machine learning, and data science, and in terms of capacity is investing in tools that decouple care from geography, including a variety of apps.

The health system’s telemedicine network includes, for example, a Telestroke program in 100 hospitals. With telemedicine, Providence has been able to work around the conundrums that come with regulatory differences in different states. In addition to access to care, they’ve also developed online health professions education at the University of Providence, providing long-distance learning and simulation and matching up resources to where they’re needed so that students can stay in their rural communities rather having to move to a city.

“We’re working hard to create a system in what we call Health 2.0, going from a system that today is centered based around a hospital system and instead creating a Health 2.0 framework where we’re centering care around what patients need, supported by a competitive landscape of these health care verticals and delivered through tools that enable us to decouple geography from care,” says Compton-Phillips. “In the U.S. there’s a saying that ‘geography is destiny,’ and that’s not the way we think it should be.”

“We’re on a journey. It’s a long journey, but it’s going to be faster than we think,” says Compton-Phillips. She quotes Bill Gates: “We always overestimate the change that will occur in the next 2 years and underestimate the change that will occur in the next 10. Don’t let yourself be lulled into inaction.”

“My belief,” Compton-Phillips concludes, “is that if we continue to focus on a revolutionary vision that allows us to imagine a different future; if we focus on building the trusted networks that actually allow us to deliver change; if we rely on data, especially the sources of data we have available today that are completely different and so far beyond we’ve ever had anything before; that if we think about having the capacity — and it doesn’t take a ton, it just takes drips and drops of little bits — extra capacity in the right strategic locations; and if we make sure that there’s win/win models for everybody, that we really can deliver on our promise of health for a better world.”

From the NEJM Catalyst event China’s Changing Health Care: Global Lessons at Scale, held at Jiahui Health in Shanghai, April 25, 2019.

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