The Old Game and the New Game
As we’re getting a better and better handle on how the game is played, and what motivates the players, we can be more thoughtful about which games we choose to join.
And we can be more deliberate about who we play with; there are some groups of providers emerging who generally believe in the high-value care principles and may make good teammates for us in The New Game. They include most Direct Primary Care and Functional Medicine practices; most Patient Centered Medical Homes; the Council of Accountable Physician Practices; hospitals such as the Cleveland Clinic and the Mayo Clinic; employee health benefits thought leaders such as Dave Chase and John Torinus; and physician leaders such as Dr. Marty Makary, ZDoggMD, Dr. Eric Topol and members of the Right Care Alliance and Lown Institute.
Let’s take a look at some characteristics of the New Game that’s developing, and how it’s more favorable to us.
The Current Game: Patients are treated like pawns.
The New Game: Patients are treated like Kings or Queens.
The Current Game: Physical, mental/emotional, and spiritual wellness are all independent and are thought of and treated in isolation.
The New Game: A person is one complex, systemic, interconnected being. Physical, mental/emotional, and spiritual dimensions are all interconnected.
The Current Game: A reasonable diet and exercise = health.
The New Game: Well-being is a function of balancing diet, exercise, sleep management, stress management, and connectedness with our religion, family and friends.
The Current Game: There is a pharmacological solution to most problems.
The New Game: The right food is the best medicine there is. There is a lifestyle choice solution to most problems.
The Current Game: Health and sick care are provider centric.
The New Game: Health care is individual/Family/person centric. Sick care is patient centric.
The Current Game: Paternalistic relationship with healthcare providers, where they dictate and the patient complies.
The New Game: Collaborative relationship with healthcare providers, where our providers are carefully chosen because they’re trusted; then care and care planning is discussed collaboratively between provider and person.
The Current Game: The Informed Consent process and form is designed and used to financially and legally protect the provider, and obligates the patient to pay for any services not covered by insurance - often without allowing the patient to participate in the decision whether or not to consume the service.
The New Game: The Informed Consent process and form is designed and used to objectively educate the patient about ALL of their treatment options. Treatment options considered include doing nothing (giving the body the chance to heal itself), lifestyle or behavioral changes, minimally invasive treatments, and treatments not provided by that particular provider. Each option lists the likelihood of accomplishing that patient's treatment goals; the likelihood of doing harm; what evidence exists to validate anticipated help/harm; and the estimated costs. Options and referenced evidence consider that individual patient's personal attributes, such as personal and family medical history, other past and present medical conditions, sex, age, and - if the patient chooses - genetic profile.
The Current Game: Price disparity for the same services from different providers is mistakenly assumed to represent quality disparity; just like every other product or service we buy. Price and quality/outcomes/patient satisfaction information is very difficult to get.
The New Game: Price and quality are transparent, enabling consumers to make value based decisions.
The Current Game: Anticipated out of pocket costs to the individual for planned healthcare services are virtually unobtainable, and are uncontrollable.
The New Game: Anticipated costs can sometimes be obtained. Some costs can be controlled. Some information regarding reasonable and customary charges is available. Unreasonable bills for unanticipated costs can sometimes be identified and successfully challenged.
The Current Game: Charge Master based billing practices that are totally disconnected from value. Irrational, hyper-inflated prices from providers financially crush patients when they - often unknowingly or unwillingly - consume excluded benefits or receive services from out of network providers.
The New Game: Transparent, value-based, market validated pricing. Hospitals pressure all contract providers to be in network for all insurance plans the hospital has contracted with, and protect patients by being transparent about contracted, out of network providers when they cannot.
The Current Game: No goal setting, or goals based on lab results or other physiological measures. Example: ‘We’re going to work on getting your HgA1C down to 4.5.’
The New Game: Person-Centric goal setting for both wellness goals and for addressing conditions. Example: ‘I want to have energy at the end of my work day so I can play with my children, instead of collapsing on the couch.’
The Current Game: Patients resist medical advice and comply poorly or begrudgingly with care plans.
The New Game: People have an ownership stake in collaborative care plans, and are committed to compliance and follow through.
The Current Game: Ignore symptoms and conditions until they can’t be ignored any longer.
The New Game: Prevent conditions whenever possible; when not, detect and treat as early as symptoms present.
The Current Game: Screen broadly for asymptomatic problems, especially cancer. Use diagnostic tests freely, even when no symptoms or predictive risk indicators (such as family history) exist.
The New Game: After a collaborative discussion with your provider, screen selectively for only those conditions that the individual considers actionable. Consciously avoid circumstances predictably leading to ‘over diagnosis’.
The Current Game: Generalized medical best practices based on population research. ‘Treat the condition’.
The New Game: Precision, or personalized medical practices are informed by medical best practices, but are based on the uniqueness of the individual. ‘Treat the individual’.
The Current Game: Patients/individuals are on the outside edge of the medical decision making process; lack access to key data like alternatives, costs, efficacy, comparative effectiveness, and potential negative outcomes; and are generally fear driven.
The New Game: People/individuals are the center of the medical decision making process; have access (where it exists) to alternatives, comparative effectiveness and efficacy data, potential negative outcomes, and costs, and are equipped to be value based decision makers given their own unique beliefs and desires.
The Current Game: Follow up aggressively on every abnormal finding or anomaly.
The New Game: Follow up selectively on abnormal findings or anomalies. No human body is perfect, and no diagnostic test is perfect.
The Current Game: Diagnostic tests are often repeated (and costs incurred) due to lack of communication between providers.
The New Game: Diagnostic results are available for collaborative care planning between providers and are not unnecessarily repeated.
The Current Game: Some diagnostic test utilization is ‘Defensive’ or even financially motivated, instead of diagnostically motivated. Unnecessary over-utilization occasionally leads to false positives, resulting in unnecessary anxiety and cost.
The New Game: Defensive and financially motivated procedures are minimalized. The circumstances leading to over-diagnosis are avoided when possible.
The Current Game: More procedures = better care and outcomes.
The New Game: The right procedures at the right time = better care and outcomes. And usually lower cost.
The Current Game: All procedures and treatments are equally effective and beneficial for all patients they’re given to.
The New Game: Many procedures and treatments impact different individuals in different ways. Further, many can be predicted to be ineffective, or even harmful, and should be identified and avoided whenever possible.
The Current Game: If insurance pays for a test, medication, procedure, or treatment, then there is no reason not to get it.
The New Game: Regardless of low or no out of pocket expense, every procedure, treatment, diagnostic test or medication should be carefully considered for it’s predictable benefit or harm for that particular individual.
The Current Game: Access is defined by a doctor’s office hours and availability in their schedule. The only alternative is the ER. The patient’s physical presence is required for all care.
The New Game: Access is 24/7/365 via telemedicine and retail outlets for many situations. Virtual care via a smart phone is an option under many circumstances.
The Current Game: Specialty physicians isolate, diagnose, and treat, generally without collaboration from other treating physicians.
The New Game: Each individual is one interconnected, holistic system. All providers, and the patient, must collaborate for systemic care plans.
The Current Game: Health insurance is a mystery. Out of Pocket expenses can’t be predicted.
The New Game: Health Insurance is like any other product. History can help us predict OOP expenses.
The Current Game: Employer sponsored health insurance is my only option.
The New Game: There are alternatives to Employer sponsored health insurance, and they can be evaluated based on my/my family’s circumstances.
The Current Game: Bias to the status quo: don’t change anything unless all exceptional cases are addressed and everyone wins.
The New Game: Bias to change in favor of individuals and families; incrementally and steadily change the status quo when most improve, knowing there are difficult exceptional cases that may need to be addressed later, and some players lose.
Remember: We coach, support, educate, and empower. We illuminate options you may not have known you had. But we don't decide what's right for you in your unique circumstances; only you can do that. And we don't provide medical, financial, or legal advice; nor do we replace the valuable counsel of those who do.