Susan Dentzer sees the concept of healthcare without walls not just as a goal for the industry, but also as a mandate.
“If we don’t plan for this transformation and make it happen, we know that the parts of the country and the people that need virtual care the most will get it the last,” says Dentzer, a leading healthcare policy expert and a Visiting Fellow at the Robert J. Margolis Center for Health Policy at Duke University.
Dentzer, the editor and lead author of the book “Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care,” will present a keynote session of the same title at HFMA’s 2019 Annual Conference. She spoke with HFMA about the major themes of her presentation and shared her thoughts on how and why care should become more virtual and person-and community-centered.
HFMA: What experiences or observations led you to develop your vision of healthcare without walls?
Susan Dentzer: Lots of aspects of healthcare are about the deliberate act of “laying on of hands.” If you get into a terrible traffic accident, you’ll of course want to go to a trauma center and be operated on by trauma surgeons if you need it. That’s essential “laying on of hands.”
But we also know a whole lot of healthcare is not about laying on of hands. It’s about exchanges of information: “How long have you had these symptoms? What does that thing on your leg look like? Here’s what I think it is. Here’s what drug I think you should be on.”
Those are all exchanges of information, which may or may not require the laying on of hands, and frequently don’t. So how do we exchange information in almost every other aspect of our lives now? Virtually.
We’re very comfortable with having moved to the virtual world in a lot of what we do, but then there’s healthcare, where the movement to the virtual world has been stalled for various reasons. It certainly hasn’t kept pace with the movement to virtual exchange of information in the rest of the world and in our lives.
HFMA: How do population health management and the social determinants of health factor into this vision?
Dentzer: We’ve known for decades that the primary determinants of one’s health status in life actually lie well outside the healthcare system.
We see what’s playing out now in the United States, which is that higher-income populations are living longer and lower-income populations are not. That isn’t primarily the fault of the healthcare system — incomes, poverty and education are much bigger drivers of this differential. However, healthcare does have the responsibility, I believe, to embrace the social determinants of health and incorporate them into an understanding of how to help people be as healthy as possible in everything that it does.
In the end, what we have in the U.S. mainly is a sick-care system. It’s an often-effective and almost always a very expensive one. We need to evolve into more of a health-promotion and health-inducing system because the health status of so many people in the country is already poor and deteriorating.
Again, that’s not healthcare’s fault, but if healthcare doesn’t own part of that responsibility, we’re doomed.
HFMA: Aside from implementing more virtual care, how else can the industry become more effective at de-emphasizing the acute-care setting when appropriate?
Dentzer: We’re seeing in real estate markets around the country that office use is shrinking because people are working more virtually or in co-working centers. What would happen if we started using less space in healthcare systems by shifting more care to the virtual mode? Could we reallocate space — using less space for waiting rooms and more space for something else that is more productive, in terms of creating “units of health”?
We had the famous Hill-Burton program after World War II, which resulted in the building of thousands of hospitals across the United States. I’ve argued that we need a 21st-century Hill-Burton.
This version wouldn’t be one that builds hospitals but rather one that refashions hospitals in many areas into something more like “health hubs.”
We know that hundreds of hospitals are struggling revenue-wise across the country. A lot of them are in rural areas. Because their volumes are so low, there are questions about the level of care they provide. If we have those questions and we have those doubts, and we still have healthcare needs in the community, why aren’t we thinking about a major investment program where we retool these places into something better suited to meet local health needs and more in step with technology and other aspects of modern life?
HFMA: How can such hospitals be reimagined?
Dentzer: We could create health hubs in the community. We could wire everybody up. We could have universal 5G broadband to have complete connectivity nationwide, from the most rural facility to the most sophisticated academic health center thousands of miles away.
Why aren’t we approaching the analysis this way: “This critical access hospital in this community has an average census of two, yet we still have major health needs that are going largely unaddressed. Why don’t we turn this hospital into a health hub?”
Maybe it has a couple of observation beds so that if people need to come in and be evaluated, they can be. There could be full telehealth capability that connects that health hub to a major academic medical center for consultations, if needed. There could be a transportation system devised to get people to larger hospitals if in fact they need to get there.
The staff of the hospital could be retrained to provide community paramedicine — this notion of turning [emergency medical service] systems from simply emergency responders into more proactive entities that go out into the community, stop off and see whether Mrs. Jones is taking her medication or whether she needs a refill, and figure out how to get it to her since she doesn’t have transportation.
It defies the imagination that we’re not thinking of very basic things that could be done to really improve and support health in communities, rather than spending the money the way we’re spending it, which is clearly not delivering enough better units of health. Otherwise, we wouldn’t have the miserable health statistics that we have.
HFMA: What has to happen from a high-level policy standpoint to make “Health Care Without Walls” come to fruition?
Dentzer: It starts with embracing a vision that we could have a better system that provides better access, deals with fundamental upstream health issues better than we’re doing, probably costs less and certainly takes advantage of technologies and a novel redeployment of the workforce to make it all happen.
Next, the payment models have to evolve to embrace this vision. Mainly, that means making an ongoing move to value-based payment and away from fee for service.
Many regulations at the federal and state level need to be updated. You could ask, in this day and age, does it really make sense to have state-by-state licensure of every type of healthcare professional when we’re talking about care increasingly being provided across state lines via telehealth?
Shouldn’t we start thinking about a national licensure system? Shouldn’t we also start thinking about more unanimity among the states in what scope of practice is going to be for different types of healthcare providers?
We also have to make major investments in the healthcare workforce of tomorrow. We’re not really providing the kind of training needed to serve in the roles that would be needed to support the system I’m describing — at least not in most schools of health-professional education. A lot of people in those arenas know it. They know our entire system of health-professions education needs to change.