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Integrated Care Lessons from Across the Pond (11:06)

“As a Londoner who has now started to call America home, I live a version of the reality of ‘all health care is local,’” says Nick Seddon, Senior Vice President and Head of Corporate Product for Optum, and former Special Adviser for Health and Life Sciences at 10 Downing Street. “I’m beginning to learn a little bit more about what that means.”

Seddon grew up receiving care from the British National Health Service — accessible, for everyone, and free at point of use. “It certainly wasn’t perfect, but I learned a lot from that,” he says.

“When I moved to America, I realized just how complex and bewildering and difficult this health care system is to navigate. After a recent trip to an urgent care center — my son had head-planted into a concrete block — my wife and I received a pretty eye-watering bill and we both looked at each other with complete astonishment.”

How is it possible to have a system where you buy something, a month later you’re charged for it, and it’s 10 times what you expected or imagined it would cost? “You wouldn’t go back if that was an online retailer,” says Seddon.

When looking at the U.S. health care system as an outsider, certain things don’t make sense: lack of price transparency; patchiness of quality and outcomes information; and navigation difficulty. “It’s bad for consumers,” he says. “Any system is bad for consumers when it’s difficult to make a decision because you don’t know how good something is or how much it’s going to cost.”

Yet there are many similarities between the British and American health care systems, and common challenges. These include increased demand, demographic shift, disease burden shift, political change, cost challenges, and unexplained and unacceptable variations in quality. “And, of course, both the British and American systems are practically keeping the world’s fax manufacturers in business,” Seddon jokes.

“Perhaps the most pernicious foe is the fragmentation of both systems,” he says. “In a fragmented system, data doesn’t flow smoothly. Money doesn’t flow smoothly, either. Pathways are broken, communication is difficult, patients fall between the gaps.”

“The good news, despite all of that doom and gloom, is that we have a lot to learn from each other,” says Seddon. “Our systems, despite being structured very differently, give us some cause for hope at least when we’re looking at the beacons.”

He mentions an article that he and Tom Lee wrote in 2013, “Envy: A Strategy for Reform,” which makes the same point. “The basic idea is that if we spent a bit more time looking at what is good about each other’s systems rather than what we hate about each other’s systems, that would be a good thing.”

One of the big themes Seddon and Lee identify is the importance of integrated care. To some degree, the U.K.’s universal health insurance model forces, at both a local and national level, a series of difficult decisions and trade-offs to be made to improve care at a system level as well as for the patient groups in a geography.

“That said, the U.K. system is much less integrated than everybody in Britain likes to think it is,” says Seddon. While much of the American system is fragmented, those organizations that “have faced up to this, that have acknowledged this reality, have become some of the best integrators and organizers in the world.”

“What they have is really important: a shared sense of accountability and responsibility for the patient, wherever the patient sits in the system,” he explains. These health organizations are aligning incentives and culture to drive improvement, and they are gaining market share by delivering excellent service and quality outcomes that in turn generate loyalty.

“More and more, the direction of travel has become one toward integration,” Seddon says. “British and American policymakers and operators are particularly focused on this as an organizing principle.” In the U.S., we’ve seen the ongoing improvement of established health care names, along with new models that “hold out a great deal of hope for the future” — accountable care organizations (ACOs) and other risk-bearing entities. In the U.K., we’ve seen broad array of new models of care and “a whole series of other three-letter acronyms,” primary and acute care systems aiming to vertically integrate, multispecialty community practices aiming to horizontally integrate out of hospital, and integrated (accountable) care systems.

“I want to be clear that in all of this movement, just throwing things together doesn’t make for integration,” Seddon cautions. He recalls a conversation with former Kaiser Permanente leader David Lawrence, who said, “When we think about integration, you cannot ‘pimp the ride.’ You have to reengineer the chassis.”

“You need a clear understanding of what you’re trying to achieve, a shared objective, a path forward to achieve it, new ways of organizing, new ways of designing supply chain and managing complex operations and analytic systems,” Seddon says. “It requires a series of delivery systems, scale, and broad relationships that enable you to do something different at scale and pace.”

That’s one of the reasons Seddon moved to the United States and joined Optum. They have pharmacy, health delivery, population health management, and data analytics businesses, and they’re trying to fix not only “the vertical story,” but also how they build across each of those segments, from the digital front door through clinical programs and the physical front door for various types of health care.

“Team-based, data-driven, evidence-led, tech-enabled,” says Seddon. “The aim that we have, just like the aim that everybody has, is to get 2+2=10. It’s not easy.”

He describes one model that’s trying to synchronize care across the pharmacy, behavioral, and medical benefit, engaging patients at multiple touchpoints and engaging multiple stakeholders, with the goal of identifying opportunities to improve care in ways that haven’t previously been identified.

In this model, John and Mary, for example, both have multiple chronic conditions, including diabetes, and represent somewhere in the zone of 50% of the population and 90% of the cost. Where they differ is in their needs. John isn’t much engaged in his health care, but he’s worried about cost, whereas Mary is engaged, but she doesn’t know what to do.

“Every time a consumer interacts with a pharmacy, that’s an opportunity to touch them, to connect them to a vital set of health services,” Seddon explains. When John or Mary go in for a refill, one of Optum’s machine learning engines proposes targeted opportunities for their needs — a cheaper diabetes drug for John and enrollment in a diabetes program for Mary.

“If we approach this with the right level of humility, everything that we’re doing is kind of day one. We have such a long way to go,” says Seddon. “To impact the total cost of care, we need to address not just clinical, administrative, and operational inefficiencies in the delivery systems, but we need to go after the real drivers of health.”

Only 11% of an individual’s health is determined by the medical care they receive; the rest is genetics, biology, physical and social circumstances, and individual behavior and choices. “I want to make sure that we’re not narrow in the way that we’re thinking about how we bring things together for the whole patient,” Seddon says. “I know that’s a great buzzword, “’whole-person care,’ but it must be the guiding principle.”

“Siloed data becomes shared data so that the advanced analytics enable us to have a playbook that we’re all playing off together, so that then an individual can be tracked through the system with a 360-degree view of Nick Seddon or Tom Lee or Laura Forese, so that today’s pain points become tomorrow’s gains.”

From the NEJM Catalyst event Disrupting the Health Care Landscape: New Roles for Familiar Players, held at NewYork-Presbyterian, October 25, 2018.

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