The rise of Accountable Care Organizations (ACOs) specifically presents a unique opportunity to reinvent the relationship between the delivery system and community health, and to develop and implement sustainable business models that integrate the common agenda of medicine and public health. The triple aim of decreased costs, improved quality, and better population health further heighten the need for improved clinical leadership. To achieve cost and quality benchmarks set by the Centers for Medicare and Medicaid Services, ACOs will have to overcome traditional fragmented models of care for Medicare beneficiaries and build care systems that enable teamwork and coordination across the spectrum of care. A new kind of leadership is required for ACOs to achieve their true value; healthcare professionals need to be more agile and adaptive. Historically, medicine has strived to achieve better results through new technologies at the expense of using quality and safety as the drivers for change; clinicians need to be better engaged in the creation and management of ACOs. A great paradigm shift needs to occur as more emphasis is placed on public and community health. We know that the most expensive beneficiaries are those with chronic diseases.[i] There remains a paucity of cost-saving models of care that allow for high-quality patient centered care in the community based on the principles of shared-decision making amongst payors, providers and patients.
Medical training and practice environments have dramatically changed since Flexner’s vision. Hospital lengths of stay have shortened, reflecting a shift of diagnostic evaluation and therapeutic intervention to the ambulatory setting. Although most of the core diseases of Internal Medicine are now largely diagnosed and managed in the outpatient setting, residency training in Internal Medicine remains a series of largely inpatient transient experiences that promote a task-based orientation with over-emphasis on the biomedical aspects of care. There needs to be a movement that engages healthcare transformation into more humanistic models, as epitomized by the Patient-Centered Medical Home. The Patient-Centered Medical Home is based upon several principles: a team medical practice with collective responsibility for a patients’ care, directed by the patient’s physician; whole person orientation, including care for all stages of life, acute care, chronic care, preventives services, and end-of-life care; care coordinated and integrated across all elements of the complex healthcare system, with quality and safety assured by care planning, monitoring, use of evidence-based medicine and enhanced access to care and information. Patient-centered care envisions a coordinated team that functions with the long-term needs of the patient at its center, rather than, as often is the case, focusing on maximizing efficient use of inpatient resources.
Recently, former CMS Administrator Dr. Berwick articulated an approach to addressing the escalating costs in our healthcare system. He illustrated that if we could change from business as usual and eliminate waste represented by the seven wedges in our healthcare system we could achieve the triple aim of lower costs, improved quality, and better population health. These categories included the following: Failure of care delivery; Failure of care coordination; Overtreatment; Administrative complexity; Pricing failures; Fraud and abuse.  To take a different path than usual requires adaptive leadership among frontline clinicians to provide adaptive leadership that results in transformational change that Dr. Berwick illustrates is possible. We know it is possible…examples of Denver Health and NUKA in Alaska. There needs to be less of a focus on the technical interpretations and more of a focus on the adaptive interpretations. These are interpretations grounded in values, attitudes, beliefs, and culture.
How does one know that a challenge is technical versus adaptive? You can never be certain but you can make a fairly good educated guess. First, you know you are dealing with more than a technical issue when people’s hearts and minds need to change, and not just their preferences or routine behaviors. In adaptive challenge people have to learn to choose between what appear to be contradictory values. Cultures must distinguish between what is expendable and what must be preserved as they move forward. Second, you can distinguish by trial and learning. If you throw all potential fixes as we have done in healthcare and haven’t made significant strides on cost containment then the underlying adaptive challenge needs to be addressed. Another clue is the persistence of conflict. This suggests that people have not adjusted or will not tolerate the potential losses that might come with change. Furthermore, crisis is another example of adaptive issues left unaddressed. In times of crisis, as we are in our system the public looks to an authority figure to restore order. In each of the last ten years we have done this but haven’t significantly altered medical training, our outcomes among other countries in the world are still terrible even though we spend the most on healthcare, and patients are dying younger.
Health Care is responding to call and recognition for changes today. PCMH is one way forward as a response. This model puts clinicians at the forefront of leadership. To do this successfully, i.e. navigate and co-ordinate teams to deliver high-quality services, methods of leadership and what this means will need to be considered. There is clearly more work to do across sectors together to achieve the dream of a healthy society.
 Eliminating Waste JAMA. 2012; 307(14):1513-1516. doi:10.1001/jama.2012.362
 Kastor JA. Accountable care organizations at academic medical centers. N Engl J Med. 2011;364:e11.
 Association of Program Directors in Internal Medicine, Fitzgibbons JP, Bordley D, Betwkowtiz, L Miller BW, Henderson MC. Redesigning residency education in internal medicine: a position paper from the association of program directors in internal medicine. Ann Intern Med 2006; 144:920-6
[i] Anderson GF. Leadership in creating accountable care organizations. J Gen Intern Med. 2011 Nov;26(11):1368-70
Jay Bhatt is is part of the GovLoop Featured Blogger program, where we feature blog posts by government voices from all across the country (and world!). To see more Featured Blogger posts, click here.