Costs, con­sumerism

Modern Healthcare - - NEWS - By Rachel Z. Arndt

One year of health­care spend­ing can buy 15 iPhones. Or, it can buy over 3,000 gal­lons of milk.

Or, if you want to look at it in rel­a­tive terms, U.S. health­care spend­ing, which in 2015 hit nearly $10,000 for ev­ery per­son in the coun­try, was 29% higher than the next most ex­pen­sive coun­try, Lux­em­bourg.

No mat­ter how you size it up, what the U.S. spends each year on health­care is a lot of money. That’s why there’s near-universal agree­ment that, no mat­ter what hap­pens in Wash­ing­ton over the next few years, the pres­sure on health­care providers to trans­form the de­liv­ery sys­tem into one that achieves bet­ter out­comes at lower costs in a more pa­tient-and con­sumer-friendly way will only grow more in­tense.

As that pres­sure builds, a whole new “in­no­va­tion” in­dus­try within health­care has come into ex­is­tence. It in­cludes star­tups look­ing to help ex­ist­ing providers im­prove the ef­fi­ciency of their oper­a­tions; the qual­ity, safety and out­comes of their care; and their pa­tient or

Some are call­ing this pres­sure and the en­tre­pre­neur­ial re­sponse “the great dis­rup­tion.” Oth­ers, per­haps op­ti­misti­cally, are call­ing it a “trans­for­ma­tion.”

cus­tomer re­la­tions. Sys­tems also are cre­at­ing their own in­ter­nal meth­ods to achieve those goals.

What­ever it’s called, there is now a sys­tem-wide con­sen­sus that the es­ca­lat­ing pres­sure on providers to dra­mat­i­cally change how they or­ga­nize and de­liver care will con­tinue in the years ahead. Bot­tom line-ori­ented em­ploy­ers, cash­strapped fam­i­lies and tax-starved gov­ern­ments will in­sist on it.

Health­care costs in the U.S. for most of the past four decades have grown faster than the rest of the econ­omy, hit­ting $3.2 tril­lion in 2015, nearly a fifth of gross do­mes­tic prod­uct. Par­al­lel to this climb, the govern­ment has ratch­eted down re­im­burse­ments, and em­ploy­ers have put their em­ploy­ees on high­d­e­ductible health plans. In 2016, more than half of in­sured em­ploy­ees had de­ductibles higher than $1,000, up from just 10% in 2006.

In­sur­ers, too, are feel­ing the weight of ever-ris­ing costs and have be­gun the ar­du­ous switch to value-based re­im­burse­ment, which puts fur­ther pres­sure on ev­ery­one else to change how care is de­liv­ered. But even as they em­brace the reg­u­la­tions and value-based in­cen­tive plans like ac­count­able care or­ga­ni­za­tions, bun­dled pay­ments and shared sav­ings con­tained in the Af­ford­able Care Act, many ap­pear will­ing to adapty to a sys­tem where con­sumer-driven medicine—in which in­di­vid­u­als and fam­i­lies have more “skin in the game”—plays an equal if not more sig­nif­i­cant role.

That will only heighten the pres­sure on providers to put the push for lower cost, higher qual­ity and more pa­tient-fo­cused care at the cen­ter of their or­ga­ni­za­tional mis­sion and strategies. Their fi­nan­cial sur­vival will de­pend on suc­ceed­ing at new mod­els of de­liv­er­ing care.

For years, these changes have re­mained tan­ta­liz­ingly just over the hori­zon. Health­care sys­tems promised trans­for­ma­tion, yet they kept their day-to-day oper­a­tions firmly planted in fee-for-ser­vice medicine. But pay­ment mod­els are grad­u­ally shift­ing to en­cour­age qual­ity over quan­tity. Pa­tients are de­mand­ing friend­lier treat­ment and bet­ter out­comes for their sub­stan­tial per­sonal in­vest­ments in health­care.

The shift to value-based care won’t hap­pen all at once. And as ev­ery health­care sys­tem in the coun­try is learn­ing, change is dif­fi­cult. “Any change, in­clud­ing change for the bet­ter, is pain­ful and tu­mul­tuous and mis­er­able for the peo­ple liv­ing through it,” said Dr. Thomas Lee, chief med­i­cal of­fi­cer of Press Ganey, a pa­tient sat­is­fac­tion mea­sure­ment firm.

The value of value

The new­found fo­cus on pa­tients doesn’t come from mag­na­nim­ity alone—it comes from a push to­ward re­im­burse­ment mod­els that pay for value rather than ser­vices. “If you want to fo­cus on get­ting bet­ter out­comes at a lower cost, it can be help­ful to get paid that way,” said Dr. Mark McClel­lan, direc­tor of the Mar­go­lis Cen­ter for Health Pol­icy at Duke Univer­sity.

The ACA shoved Medi­care in that di­rec­tion. Pri­vate in­sur­ers and their em­ployer cus­tomers, pun­ished by ever-ris­ing costs, fol­lowed suit. They’re turn­ing to ACOs, bun­dled pay­ments and pa­tient-cen­tered med­i­cal homes to not only rein in costs, but also to im­prove the qual­ity of care.

The ACA au­tho­rized the CMS to in­sti­tute the Hospi­tal Value-Based Pur­chas­ing pro­gram to re­ward or pe­nal­ize providers when they don’t meet a set of qual­ity met­rics. The Hospi­tal Read­mis­sions Re­duc­tion pro­gram im­poses penal­ties on Medi­care providers whose pa­tient bounce­back rates are above a cer­tain thresh­old.

The CMS also in­sti­tuted the Medi­care Shared Sav­ings Pro­gram, an ini­tia­tive that en­cour­ages (though doesn’t man­date) providers to or­ga­nize in ac­count­able care

or­ga­ni­za­tions to in­crease the value of the care they pro­vide. In these ar­range­ments, a group of providers is held ac­count­able for the qual­ity of the care they pro­vide. The in­cen­tive, then, is for providers to work to­gether, co­or­di­nat­ing a pa­tient’s care across the con­tin­uum.

These kinds of mod­els, McClel­lan said, “en­able providers work­ing to­gether at the whole-per­son level to get re­im­bursed if they bring down the over­all cost.”

“If the in­cen­tive is for all these par­ties to work to­gether be­cause they have a shared in­cen­tive in terms of pa­tient out­comes,” said Joe Reilly, chief in­for­ma­tion of­fi­cer of the Cen­tral New York Care Col­lab­o­ra­tive, “they’ll be more in­ten­tional about mak­ing sure they’re all on the same page.”

Fo­cus­ing on out­comes

“It’s the ‘volume-to-value’ tran­si­tion com­ing to life,” Lee said of the fo­cus on the care con­tin­uum. Now re­cent pay­ment re­forms are hold­ing providers more re­spon­si­ble for out­comes and qual­ity and push­ing them to co­or­di­nate care to re­duce vari­a­tion and fill­ing the gaps when pa­tients move from one part of the sys­tem to an­other.

“In­te­grated care is bet­ter care, it’s more ef­fi­cient care, and it pre­serves re­sources for the en­tire sys­tem,” said for­mer HHS Sec­re­tary Mike Leav­itt.

Part of care co­or­di­na­tion is cost com­pre­hen­sion. Sys­tems like Danville, Pa.-based Geisinger Health Sys­tem that are both providers and pay­ers ben­e­fit from ac­cess to med­i­cal and phar­macy claims, which they can use to cal­cu­late the to­tal cost of care for pa­tients. “It’s re­ally im­por­tant that or­ga­ni­za­tions look at to­tal costs of care in ad­di­tion to out­comes,” said Janet Tom­cav­age, chief pop­u­la­tion health of­fi­cer of the 12-hospi­tal sys­tem.

When choos­ing med­i­ca­tions, it might seem at first blush that giv­ing pa­tients the most af­ford­able op­tion makes the most sense. But by study­ing claims data, Geisinger deter­mined it some­times pays to spend more up­front, as was the case with mul­ti­ple scle­ro­sis drugs. Data re­vealed that a more ex­pen­sive drug led to a lower over­all cost of care than a cheaper drug, which was as­so­ci­ated with more prob­lems and a higher ad­mis­sions rate.

By track­ing pa­tients across their en­tire time in the health­care sys­tem, not just their stay in the hospi­tal, Geisinger iden­ti­fied nurs­ing home care as an area in need of im­prove­ment. Af­ter ad­vanced prac­ti­tion­ers and case man­agers be­gan mon­i­tor­ing pa­tients’ progress in the homes in their net­work, the read­mis­sion rate for pa­tients sent to nurs­ing homes dropped to about 14% from 24%.

Low­er­ing read­mis­sions is just one part of the in­creased fo­cus on qual­ity and safety. Bet­ter med­i­ca­tion rec­on­cil­i­a­tion cuts down on ad­verse drug events. Teams of providers work to­gether to treat high-risk pa­tients. Pa­tient nav­i­ga­tors guide pa­tients through the sys­tem, co­or­di­nat­ing care with spe­cial­ists and other providers.

Bos­ton-based Part­ners Health­Care Sys­tem’s In­te­grated Care Man­age­ment Pro­gram, for in­stance, pairs nurse care man­agers with high-risk pa­tients to help co­or­di­nate care, which leads to both bet­ter pa­tient out­comes and cost sav­ings: The pro­gram saved $2.65 in health­care costs for ev­ery dol­lar it spent.

This fo­cus on costs isn’t just about the bot­tom line. It’s about pa­tients get­ting higher-qual­ity care. “Now we’re start­ing to think about it from a pa­tient per­spec­tive, which forces you to think about care de­liv­ery from a ser­vice line,” said Rob Demichiei, chief fi­nan­cial of­fi­cer of UPMC, which op­er­ates more than 25 ma­jor fa­cil­i­ties and 600 physi­cian of­fices and out­pa­tient clin­ics in Western Penn­syl­va­nia.

Rather than look­ing at in­di­vid­ual units ver­ti­cally, UPMC has be­gun com­par­ing sim­i­lar ser­vice lines and med­i­cal spe­cialty prac­tices across all its fa­cil­i­ties in an ef­fort to iden­tify best prac­tices and re­duce both costs and clin­i­cal com­pli­ca­tions. “By un­der­stand­ing vari­a­tion,” he said, “we can see which ar­eas have higher cost than oth­ers and hold them ac­count­able.”

“Now we’re start­ing to think about it from a pa­tient per­spec­tive, which forces you to think about care de­liv­ery from a ser­vice line.”

Rob Demichiei, chief fi­nan­cial of­fi­cer at UPMC, Pitts­burgh

From “pa­tient” to “con­sumer”

To meet the over­all im­per­a­tive to de­liver higher-qual­ity, lower-cost care, providers are step­ping up their fo­cus on the pa­tients they serve. Medi­care has cre­ated in­cen­tives to pro­mote this be­hav­ior, too, bas­ing a hefty share of its hospi­tal value-based pur­chas­ing re­wards and penal­ties on pa­tient re­sponses to a post-dis­charge sur­vey.

Hospi­tal of­fi­cials are quickly learn­ing that pa­tient­cen­tric care is good for out­comes, too. In the val­ue­based re­im­burse­ment world that is slowly evolv­ing, that will be good for the bot­tom line. “Peo­ple in health­care are good peo­ple to be­gin with, but this is busi­ness strat­egy, too,” Lee said.

Greater pa­tient sat­is­fac­tion also builds brand loy­alty for health­care sys­tems to hold onto pa­tients. “Con­sumers don’t want the same old same old,” said Matthew Cham­bers, CIO of Bay­lor Scott & White Health, whose app in­te­grates with Ap­ple’s Healthkit. “They want to be de­lighted in the jour­ney just like they would be with Ama­zon.”

Health­care sys­tems must there­fore dif­fer­en­ti­ate them- selves to win over pa­tients. “Medicine is a vastly dif­fer­ent in­dus­try from re­tail, but we can learn from it and other in­dus­tries to pro­vide a more en­gag­ing and con­ve­nient ex­pe­ri­ence,” he said.

“There’s a con­ver­gence of hos­pi­tal­ity and health­care,” said Sarah Thomas, man­ag­ing direc­tor of the Deloitte Cen­ter for Health So­lu­tions. Get­ting that con­ver­gence right pays off, she said. “The hospi­tals with higher pa­tient ex­pe­ri­ence scores are higher fi­nan­cial per­form­ers.”

The rise of high-de­ductible health plans is driv­ing pa­tients to act more like con­sumers. “Pa­tients pay­ing more them­selves out of pocket for their care might be in­vested in shop­ping for the hospi­tals with the best out­comes for the lower costs,” Thomas said.

“With con­sumers bear­ing an ever greater share of health­care costs, they are much more en­gaged and are de­mand­ing more in­for­ma­tion about qual­ity and costs and a bet­ter con­sumer ex­pe­ri­ence,” said Ed McCal­lis­ter, CIO at UPMC.

To mea­sure how well they’re per­form­ing at de­liv­er­ing that con­sumer ex­pe­ri­ence, health­care sys­tems are us­ing a net pro­moter score, a met­ric com­mon in the re­tail in­dus­try (Ap­ple uses it). It gauges how loyal a cus­tomer is to a provider by ask­ing a sin­gle ques­tion: How likely are you to rec­om­mend our com­pany, prod­uct or ser­vice to a friend or col­league?

To raise the score, health­care sys­tems should look be­yond medicine it­self, said Dr. Bob Kocher, a part­ner at Ven­rock who fo­cuses on health­care IT. “You can make your tech­nol­ogy more el­e­gant; you can make your park­ing bet­ter; you can have gowns that don’t fly open in the back,” he said.

One way to im­prove ex­pe­ri­ence, and to save money do­ing it, is to take a cue from the con­sumer world and go

“Pa­tients pay­ing more them­selves out of pocket for their care might be in­vested in shop­ping for the hospi­tals with the best out­comes for the lower costs.’

Sarah Thomas, man­ag­ing direc­tor of the Deloitte Cen­ter for Health So­lu­tions

“We spent less money, we gave her a far bet­ter out­come, and the pa­tient, of course, would tell you that it was very high-qual­ity care. We just did a clin­i­cal trial of one, and the end re­sult was she was cured and had no side ef­fects.”

Dr. John Halamka, CIO at Beth Is­rael Dea­coness in Bos­ton (with his wife, Kathy)

dig­i­tal. “We’re look­ing at con­vert­ing a sig­nif­i­cant amount of our in­ter­ac­tions with pa­tients to be­ing done over tele­health,” said Dr. Peter Fleis­chut, chief in­no­va­tion of­fi­cer at New York-Pres­by­te­rian Hospi­tal.

Apps to open com­mu­ni­ca­tion are an­other way health­care is learn­ing from other in­dus­tries. “In health­care, we have not ex­actly pro­vided the most pleas­ing con­sumer ex­pe­ri­ence,” said Dr. John Halamka, CIO at Beth Is­rael Dea­coness Med­i­cal Cen­ter in Bos­ton. But that’s chang­ing. At Beth Is­rael Dea­coness, pa­tients in the ICU and their fam­i­lies use the MyICU app to get up­dates and care plans. “The pa­tient is be­com­ing more and more the con­sumer,” Halamka said.

Still, dig­i­tal health has its lim­i­ta­tions. Doc­tors must be trained specif­i­cally for tele­health vis­its, for ex­am­ple. Some­times ac­cess is a prob­lem, as it is for some pa­tients in ru­ral ar­eas who have dial-up in­ter­net. And some­times pa­tients don’t want to use tele­health in the first place. “Some peo­ple are wor­ried about pri­vacy,” Thomas said. “They’re wor­ried about strangers look­ing into their homes.”

Cost is also a lim­it­ing fac­tor. A re­cent study pub­lished in Health Af­fairs found that tele­health didn’t save money. Though tele­health vis­its were usu­ally cheaper than in-per­son vis­its, they were used so fre­quently that they can­celed out the sav­ings, and costs ac­tu­ally rose.

The prom­ise of big data

Data un­der­lie nearly ev­ery change in health­care, from an­a­lyz­ing the care con­tin­uum to ne­go­ti­at­ing value-based con­tracts. They also un­der­lie care it­self, as providers mea­sure and use ev­i­dence to de­ter­mine how and where to direct care.

This can hap­pen at the level of a sin­gle pa­tient, or it can hap­pen at the level of an en­tire pop­u­la­tion. Pre­ci­sion medicine and pop­u­la­tion health, though dif­fer­ent in scope, share the aim of per­son­al­iza­tion, which not only saves money, as re­sources are more ac­cu­rately di­rected, but also saves lives.

That was the case for Kathy Halamka. When she was di­ag­nosed with stage 3 breast can­cer at the end of 2011, she and her hus­band—who hap­pens to be Beth Is­rael Dea­coness’ John Halamka—turned to data to come up with a treat­ment plan, which in­cluded a re­duced chemo­ther­apy reg­i­men. Us­ing the Shared Health Re­search In­for­ma­tion Net­work search tool, her providers went through 6.1 mil­lion records to look at sim­i­lar pa­tients’ out­comes from var­i­ous treat­ments and choose the one that would best serve her. Nine months af­ter Halamka’s di­ag­no­sis, she was can­cer-free.

The ap­proach Kathy Halamka’s doc­tors took is pre­ci­sion medicine, but the un­der­ly­ing idea is the same as what guides pop­u­la­tion health man­age­ment: Use data from spe­cific pop­u­la­tions of pa­tients to im­prove out­comes.

For Oak Street Health, a Chicago-based sys­tem of 20 pri­mary-care cen­ters, that spe­cific pop­u­la­tion is Medi­care pa­tients, most of whom are low-in­come. To shape care plans, pa­tients are seg­mented by clin­i­cal and so­cial data: The 5% of pa­tients clas­si­fied as “crit­i­cal,” for in­stance, are seen ev­ery three weeks. No mat­ter the tier, each pa­tient has a care team that usu­ally in­cludes a physi­cian, who

han­dles just 500 pa­tients, a nurse prac­ti­tioner, reg­is­tered nurses, med­i­cal as­sis­tants, a care man­ager (who’s a so­cial worker) and a med­i­cal scribe.

Mike Pykosz, CEO of Oak Street, thinks the model is suc­cess­ful in part be­cause it was built from the ground up. “We’re strong be­liev­ers in tech­nol­ogy,” Pykosz said. “But we think it has to be tech­nol­ogy en­abling a model, not a model en­abling tech­nol­ogy.” So though Oak Street uses plenty of data, it uses those num­bers to sup­port the pa­tient-cen­tric model it al­ready has in place.

It also helps that Oak Street is fully at risk for all of its man­aged pa­tients. “We can in­vest re­sources in all of those things that al­low you to man­age chronic ill­ness more ef­fec­tively and treat peo­ple in a bet­ter venue,” Pykosz said. “By do­ing that, you can ac­tu­ally lower the over­all cost a lot.”

Pop­u­la­tion health man­age­ment can be more dif­fi­cult for providers who still use fee-for-ser­vice mod­els. “Most of the pay­ments and reg­u­la­tions we have are de­signed not for these trans­formed care mod­els and are not about re­ward­ing sup­port­ing the best out­comes at the low­est costs,” Duke’s McClel­lan said. “If you want to fo­cus on bet­ter out­comes at a lower cost, it can be help­ful to get paid that way—more on a per­son level or at least an episode level. Then you can spend money on things that don’t typ­i­cally get re­im­bursed un­der fee for ser­vice.”

The case for ef­fi­ciency

Low­er­ing costs de­mands not only trans­form­ing pa­tient care but trans­form­ing the ad­min­is­tra­tive tasks that en­able care. As value-based care takes hold, health­care sys­tems are feel­ing ever more pres­sure to in­crease ef­fi­ciency.

“Health­care keeps adding more work­ers, which is a big driver of cost growth,” Ven­rock’s Kocher said. The in­dus­try adds an av­er­age 30,000 jobs per month. As sys­tems feel pres­sure to cut costs, they’re also go­ing to feel pres­sure to slow down hir­ing. They’ll have to turn to tech­nol­ogy, rather than peo­ple, for cer­tain tasks, much as air­lines and fi­nan­cial ser­vices have done, he said.

Some tasks might be turned over to pa­tients. Beth Is­rael

Dea­coness, for in­stance, is test­ing vir­tual as­sis­tant­fa­cil­i­tated self-sched­ul­ing. Staff who would oth­er­wise be sched­ul­ing might tend to other tasks, like care man­age­ment.

UPMC is be­gin­ning to use bio­met­ric scan­ners for pa­tient ap­point­ment reg­is­tra­tion. “This gives our reg­is­tra­tion staff more time to spend with pa­tients on higher value ac­tiv­i­ties,” CIO McCal­lis­ter said.

At Beth Is­rael Dea­coness, nurses and physi­cians rely on ma­chine learn­ing to help them quickly get struc­tured in­for­ma­tion, such as a pa­tient’s chief com­plaint. A nurse en­ters a brief triage sum­mary into a pa­tient’s elec­tronic health record, and an al­go­rithm pro­cesses that text, us­ing nat­u­ral lan­guage pro­cess­ing and data from hun­dreds of thou­sands of pa­tients. The sys­tem gives the nurse the top five pre­dicted chief com­plaints, which the nurse can edit. The re­sult is a struc­tured and stan­dard­ized de­scrip­tion of the chief com­plaint that’s used to trig­ger clin­i­cal path­ways.

As use­ful as tech­nol­ogy is, it’s im­por­tant for hu­mans to stay part of the equa­tion. “We have to be so care­ful to not as­sume the ma­chines are think­ing,” Halamka said.

Keep­ing the right hu­mans around is im­por­tant, too. “Ev­ery time some­one leaves, it could cost you one and a half times their an­nual salary to re­place them,” Lee said. So health­care sys­tems are keep­ing em­ploy­ees en­gaged through lead­er­ship and sup­port pro­grams, like Brigham and Women’s Cen­ter for Pro­fes­sion­al­ism and Peer Sup­port.

Care pro­cesses, too, can be­come less waste­ful. Doc­tors at Sut­ter Health, for in­stance, cut back on blood draws by learn­ing about their col­leagues’ or­der­ing prac­tices and by chang­ing a but­ton in its Epic Sys­tems Corp. EHR that in­structed how of­ten to take blood for labs. Pre­vi­ously, doc­tors were choos­ing to have the labs done daily, even when pa­tients were do­ing well. Af­ter Sut­ter re­moved the but­ton to have the tests or­dered daily, re­peat labs de­creased from 21% to 13%.

The fu­ture

Most sys­tems de­vel­op­ing lower-cost, pa­tient-cen­tered mod­els quickly re­al­ize they have to move into realms that have tra­di­tion­ally been out­side of health­care but are key to help­ing some of the most ex­pen­sive pa­tients in their sys­tem. The so-called so­cial de­ter­mi­nants of health—food, hous­ing, em­ploy­ment, so­cial re­la­tion­ships and ed­u­ca­tion—can de­feat the best care plans.

Re­searchers es­ti­mate that in­di­vid­ual be­hav­ior—of­ten driven by these so­cial de­ter­mi­nants—ac­counts for 40% of the risk of pre­ma­ture death. Health­care ac­counts for only 10%. “You of­ten have to ad­dress these un­der­ly­ing is­sues if you want to get at the ones that are more direct cost drivers,” said Roy Rosin, chief in­no­va­tion of­fi­cer at Penn Medicine.

That can mean en­gag­ing with pa­tients in un­con­ven­tional ways that are also part of the trans­for­ma­tion now un­der­way. One ex­am­ple from Oak Street Health: A man who’d be­come a reg­u­lar in the com­mu­nity room of one of its clin­ics failed to show up. The lo­cal staff no­ticed. He didn’t come in the next day, ei­ther.

Some­one from the clinic called. His foot hurt, he ex­plained, and he couldn’t walk the half mile to the cen­ter. Oak Street Health sent a van to bring him in—it of­fers the ser­vice to many of its pa­tients—to treat a foot in­fec­tion. “We were able to catch it, and it be­came a non­is­sue,” Pykosz said.

Other sys­tems are also try­ing to get out ahead of health is­sues. Geisinger started a food pantry for pa­tients with di­a­betes. Penn Medicine has a com­mu­nity health pro­gram called Im­pact, through which health work­ers help pa­tients reach their goals, some­times even work­ing out with them at lo­cal gyms.

Such a care model re­quires leav­ing the hospi­tal and in­ter­act­ing with pa­tients more of­ten. But it’s time well­spent. “For the most vul­ner­a­ble pa­tients, that high-touch model,” Rosin said, “is ac­tu­ally high-value care.”

The trans­for­ma­tions tak­ing place in many cor­ners of the health­care sys­tem are far from universal. But un­less the im­per­a­tive to de­liv­ery higher-qual­ity care at lower costs goes away—which is highly im­prob­a­ble—then ev­ery hospi­tal and physi­cian in their sys­tems and prac­tices will soon face both the prom­ise and peril of in­no­va­tive changes com­ing to their ex­ist­ing way of do­ing things.

“It’s im­por­tant for or­ga­ni­za­tions to not think there’s only one thing they need to do,” Duke’s McClel­lan said. “It re­ally is a set of steps to take to­gether. That’s what we’ve seen in or­ga­ni­za­tions that have been suc­cess­ful in trans­form­ing care.”

“Or­ga­niz­ing around pa­tients, com­pet­ing on cre­at­ing and im­prov­ing value for pa­tients, and do­ing what it takes to ef­fi­ciently meet the needs of pa­tients—that’s the core theme,” Lee said. “That makes me feel op­ti­mistic.”

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Each pa­tient at Oak Street has a care team that usu­ally in­cludes a physi­cian, who han­dles just 500 pa­tients, a nurse prac­ti­tioner, reg­is­tered nurses, med­i­cal as­sis­tants, a care man­ager (who’s a so­cial worker) and a med­i­cal scribe.

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