HJNO Sep/Oct 2023

HEALTHCARE JOURNAL OF NEW ORLEANS I  SEP / OCT 2023 15 barriers, obstacles, and challenges is a con- stantly revolving loop of learning. Creatively addressing and overcoming those barriers by applying the right level of domain knowledge to the problem to be solved becomes essential to success. A SMART (specific, measurable, at- tainable, relevant, and time-bound) goal frame- work is essential where attainment of the goals follows a strategic planning process where spe- cific goals are documented, progress toward the goal is both measurable and measured, is realistically attainable, and time-bound. And like any good strategy, it takes a multidisci- plinary team working together to achieve the shared action plan codeveloped and copro- duced with each patient. The entire microsys- tem then relies on rapid iterations of learning and improvement, with performance manage- ment governed by the outcomes achieved. In other words, the entire framework of the lean startup method applies. It starts with a vision of delivering a product that earns the stewardship of a group of loyal customers by helping them to accomplish what matters most to them. Doing so requires constantly evolv- ing the delivery model — or clinical microsys- tem — to help understand their pain points and challenges with a goal of eliminating or overcoming them. It requires a strategy of as- sembling the right collection of resources and adopting a business model that aligns financial objectives with clinical outcomes. And it clearly requires a build-measure-learn and improve framework that relies entirely on economics that enables value to be created and captured differently. Based on my own experience in hav- ing developed two different clinical microsys- tems in two different geographic areas, I firmly believe that 15 to 20% reductions in weight using these approaches will become the bare minimum of expected performance, just like 90%-plus rates of hypertension and diabetes control will become the bare minimum as well. And it isn’t even by designing the microsystem specifically as a medical weight loss clinic. In- stead, it is by designing it as a comprehensive, whole-person-centered primary care model that focuses relentlessly on helping people achieve the health-related goals that matter most to them. Weight loss, when it occurs, is typically just an inevitable result. The hard part is not in achieving the results, it is in reconfigur- ing the business model to align value creation for patients with financial value capture for the system. As Oak Street Health has shown, it is easy to do in a Medicare Advantage popula- tion where a risk-adjusted, population-based payment is the revenue source. It is also easy to do in a self-insured population where the em- ployer pays for the value of outcomes rendered rather than the volume of services delivered. I am optimistically hopeful that in time it will become the normative standard for all health- care delivery, and we will finally succeed in ending the scourge of this obesity epidemic. n REFERENCES 1 Bohn, R.E. “Measuring and Managing Techno- logical Knowledge.” MIT Sloan Management Re- view 36, no. 1 (1994); 61-73 Specifying their goals is also important for appealing to the one proven method for fos- tering sustainable behavioral change, which is their own intrinsic motivation. Fear-based mo- tivation is not effective. The goals are different for each patient, but almost every patient I’ve ever encountered within this type of micro- system wants to be on fewer medications as a goal. And believe me, I can attest that helping patients lose 20% of their body weight reduces their medication burden, and not just insulin either. Getting patients off proton pump in- hibitors (medications used to treat heartburn that are potentially toxic to the kidneys) has become commonplace in an effectively de- signed microsystem. Addressing each goal also entails understanding where the patient stands regarding the stages of change: pre- contemplation, contemplation, preparation, action, and maintenance. If they are in pre- contemplation or contemplation, motivational interviewing techniques need to be deployed to understand why they are there and what be- liefs are barriers that are standing in the way of them advancing to preparation or action. Variables like self-efficacy also become essen- tial, because if a patient has low self-efficacy, then involving a dietitian at that point is an in- efficient use of resources. But getting a good behavioral therapist involved at that point is in- valuable. Once they’ve made substantial prog- ress toward improving self-efficacy, then we can involve other members of the care team such as the dietitian. Along the way, discovering the “... the problemwith surgery or any fad diet is that it doesn’t fundamentally address the root causes of disordered eating patterns. ... It also doesn’t address the fact that many people with obesity suffer from impaired self-efficacy or adverse childhood trauma and have not yet embarked on a mental health improvement journey that provides them insight into their current patterns of unhealthy behaviors.”