The biggest challenge to human health over the next 25 years will come from climate change. It will also cause and amplify the impact of future pandemics. Both climate change and pandemics will disrupt the economic, physical and social infrastructures of countries around the world. The events of the past 18 months are a window into our future. Preemptive and adaptive policies and strategies will be needed to avoid even worse consequences than we have experienced to date.
The U.S. healthcare system could play a seminal role in addressing these twin threats. To do so, healthcare leaders must reinvent what constitutes the healthcare infrastructure; accelerate the implementation of population health budgets that encourage prevention and continuously improving care; and adopt new business models.
President Biden has broadened the historical notion of infrastructure beyond the tangible “hard” assets of roads, bridges and buildings to the more intangible “soft” assets of human capital development needed for a more equitable and robust economic recovery and advancement of citizen engagement. This is reflected in proposed expanded investment in home- and community-based care; preschool education; child tax credits; parental leave policies; and incentives to reduce greenhouse gas emissions by reducing reliance on fossil fuels through wind, solar and related “clean” energy sources. The healthcare system is responding in kind by expanding its notion of infrastructure beyond the bricks-and-mortar inpatient care settings to stronger primary care, home care, and cross-sector engagement with organizations addressing food insecurity, education, housing, transportation and community development.
Such an emerging infrastructure of healthcare delivery will require healthcare leaders to more rapidly adopt and implement risk-adjusted population health budgets that eliminate fee-for-service payment. Adjustments will also need to be made for differences in people’s living conditions that adversely affect their health. While challenging to implement, risk-adjusted population health budgets provide the incentives to keep people well, to innovate in redesigning and continuously improving care, while providing a predictable revenue flow from year to year.
The new healthcare infrastructure supported by risk-adjusted population health budgets will also require leaders to adopt new business models. A parallel exists between climate change and historical healthcare delivery. Both produce human-induced waste into their environments. For climate change, it is carbon dioxide and other greenhouse gas emissions. For healthcare, it is the estimated 30% of waste in spending created by duplicate tests, medical errors, rework and provision of low-value care.
In the case of climate change, “capping and trading” sets price limits on companies’ pollution allowing them to buy and sell their allowances. Organizations that cut their pollutants faster can sell their allowances to those that pollute more or “bank” them for future use. In similar fashion, a tax or limit could be placed on the waste that healthcare organizations produce and a market created to address the underlying social determinants of health: food insecurity, housing, education, transportation and community development.
A leadership action plan for the new infrastructure, payment and business models will look like this:
- Invest in the community. Invest in primary care and prevention.
- Provide care in lower-cost settings using technology-enabled lower-cost providers fully using their competencies allowed by updated licensing laws.
- Eliminate any steps in care that do not produce value for patients.
- Continuously improve care using data-informed and evidence-based proven systems of operational excellence.
Key to achieving all of the above will be greater investment in community-linked primary care. Countries that produce better health outcomes at much less cost than the U.S. spend two to three times as much of their healthcare expenditures on primary care than the approximate 5% in the U.S. The greater investment in primary care needs to be accompanied by a better climate-prepared and pandemic-prepared workforce, building on the lessons from COVID-19.
Implementing the new infrastructure, payment approaches and business models will also require new behaviors from our healthcare leaders. Understandably, these will be uncomfortable for many. But failure to take such actions now will only repeat the calamity of this pandemic and invite an even more disastrous future.