HJNO May/Jun 2024

CHANGING THE CARE: CHRONIC KIDNEY DISEASE 30 MAY / JUN 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   realized by her not having a single emergency room visit or admission over the past couple of years along with her delayed progression of both CKD and CVD. The hypothesis is that clinical excellence is less expensive than frag- mented, transaction-based, volume-driven care, and that it is within our capability of mak- ing this type of care the normative standard for all patients. However, to turn today’s dream into tomorrow’s reality, we will need a “bridge to tomorrow,” where the dream will only be re- alized by getting the architectural design struc- turally sound at the clinical microsystem level. The 5 P’s of the Clinical Microsystem In a prior article, I described the five Ts of changing how care will ultimately be delivered — team, talent, technology, time, and trust, of which trust is the most important. The deliv- ery of clinical excellence in the above patient example is emblematic of deliberately archi- tecting a care delivery model that can achieve these results while also curating the “art of the possible.” Before we introduce the “5Ps,” we need to shift our mindset away from blame for why this type of care is not yet possible and in- stead toward understanding the root cause of the structural problems as to why it is not yet possible. Different stakeholders will all quickly point the blame at each other. Traditional health systems will quickly point blame at the payers, while payers will just as quickly lay the blame on providers and health systems. Some will try to blame government intervention and the Affordable Care Act (AKA ObamaCare) while others will simply point blame at every- one but themselves. The truth is that we all have our share of blame here, but I prefer not to even think of it as “blame” but rather as what are the problems that need to be solved. Let’s start at a micro level, both literally and figura- tively. The smallest — and indeed microscopic — functional unit of the kidney is the nephron, and the glomerulus is a key functional unit of the nephron. Breaches in the structural integ- rity of the glomerulus that result in albuminuria are metaphorical “cracks in the bridge” in the transport of fluid and solutes from bloodstream to urine. The smallest replicable unit of care delivery is the clinical microsystem, which is comprised of the patients, providers, pro- cesses, patterns, and purpose of that micro- system — known as the “5Ps.” This framework was developed by an esteemed group of re- searchers at the Dartmouth Institute for Health Policy and Clinical Practice. In the case of the 5Ps, purpose is probably the most important. With the role of patients and providers being self-evident, let’s expand on the last three Ps. Processes refer to the workflows, protocols, and procedures followed within the micro- system to deliver care. Patterns represent the data and information collected within the mi- crosystem, including patient outcomes, utiliza- tion metrics, and other performance indicators. And purpose reflects the overarching mission, goals, and values of the microsystem. Aligning activities and decisions with an organization’s purpose fosters a sense of shared vision, re- sponsibility, and commitment across patients and providers, ultimately driving improve- ments in patient care and outcomes. And for the 5Ps to be deliberately architected in a way that delivers differentiated care and outcomes, we need a sixth P, the right type of payment. The 6th P: The Bridge to Tomorrow’s Reality While a sixth P — payment or payers — is not included as part of the clinical microsystem, it can be argued that it is indeed the most impor- tant player in the clinical macrosystem. After all, what gets paid for is what gets delivered. It seems that what is being delivered is frag- mented and at times chaotic care that is failing to achieve consistently reliable results of differ- entiated clinical excellence. And in the words of Warren Buffet, “Price is what you pay, value is what you get.” This quote begs the question, are we getting enough value in return for the price that we are paying for healthcare? Ac- cording to the Commonwealth Fund, while the U.S. clearly ranks first in the amount of money we spend on healthcare, Americans in most states are expected to live shorter lives than people in other countries, and deaths from avoidable causes are higher in the U.S. than in many other countries around the world. 1 I once had a meeting with the new CEO of a major commercial health plan to discuss my vision — dare I say dream — of the future of healthcare delivery. The new CEO listened pa- tiently and smiled, and subsequently described how the payer is really the architect of the macrosystem of healthcare delivery. He went on to describe how their policies, processes, and people would ultimately determine how healthcare is delivered. In that CEO’s first ever presentation to the health system where I was working at the time, his opening slide featured an image of a bridge spanning a large river. The image was meant to depict a “bridge to tomorrow” and convey a vision of a future of better healthcare for all. That presentation was almost a decade ago, and while that CEO would be considered successful by convention- al measures of financial success, the health of the state where they operate and where they are the largest commercial insurer still ranks near the bottom of rankings for health in the U.S. I would posit that the structural integrity of that bridge is as flawed as the glomerulus of a patient who has experienced a lifetime of poorly controlled diabetes and hypertension, one who is progressing to more advanced stages of CKD. This bridge to tomorrow is so structurally impaired that it wouldn’t take a collision with a large cargo ship to render its eventual collapse, but rather simply a large vol- ume of metaphorical traffic in the form of the growing burden of uncontrolled chronic con- ditions and their downstream complications. Any CEO, including those who lead health plans, are obviously very smart and accom- plished individuals. While all CEO’s bear a fidu- ciary responsibility to the organization that em- ploys them, they are also held accountable to a governing board that oversees their decisions, along with their attendant consequences. The unfortunate reality is that the “no margin, no mission” philosophy of traditional health sys- tems applies equally to health plans and the boards that govern them. And if health plans simply raise their premiums each year to main- tain their margin in response to the out-of-con- trol costs of healthcare — and the dysfunctional system delivering that care — the structural problems of care delivery will simply continue to mount. Until they get down to developing and implementing solutions that target the root cause of these structural problems and successfully enable the architecture of a care delivery model comprised of clinical microsys- tems that reliably deliver clinical excellence, we face a failing and flawed system in danger of