Integrative Health, The Medical Industry, and White Walkers: Regarding Berwick’s Reflections on 10 Years of the Triple Aim

Integrative Health, The Medical Industry, and White Walkers: Regarding Berwick’s Reflections on 10 Years of the Triple Aim

Spoiler alert. The title of a recent column marking the 10th anniversary of Triple Aim efforts to move medical payment and delivery from volume toward value makes no bones about the effort’s shortcomings. This report card from the Triple Aim’s top cheer-leader is meaningful to the high touch, human-intensive movement for integrative health and medicine for one important reason: the field’s potential uptake is pegged to advance of the values orientation. Success is more broadly meaningful because the values-based war against the forces in the industry that causally associate it with 250,000 medical deaths each year – effectively medicine’s white walkers in Game of Thrones terms – is the bullseye point of reference on what is at stake.

The column was published on February 14, 2019 by the Institute for Healthcare Improvement (IHI) as “The Triple Aim: Why We Still Have a Long Way to Go.” It was a Valentine to the industry from author, IHI co-founder Donald Berwick, MD, the effort’s top cheer leader. Berwick was tabbed by President Barack Obama as the Center for Medicare and Medicaid Services administrator where he was lead architect of governmental efforts to shift the medical industry toward value and away from its perverse obsession with production of services.

Berwick has proved himself friendly toward the integrative health movement. Ten years ago, at the Institute of Medicine meeting on Integrative Medicine and the Health of the Public, he suggested 10 Principles for Integrative Medicine. He has since credited multiple integrative health mentors for shifting his vision toward the ultimate value of health creation. Unfortunately, such encounters with integrative health and medicine did not seem to inform his grading of engagement with the Triple Aim.

Even without the integrative framework, Berwick delivers as disappointing if not dismal report card to the medical industry. Integrative health perspectives outside his lens take his judgement from bad to worse.

Berwick introduces the anniversary moment by honoring the IHI faculty members, John Whittington, MD and Thomas Nolan, who conceived the 3 aims: better care for individuals, better health for populations, and lower per capita costs. Berwick’s co-authorship on their first indexed commentary on the topic helped launch the model’s impact.

Berwick then turns his attention to the Triple Aim’s 3 goals. He off-handedly gives his industry colleagues good marks on “bettering patient care.” He calls this aim medicine’s “sweet spot” before focusing on what he considers the more “disruptive” forces in the Triple Aim’s other two goals.

I suspect that this light touch is Berwick’s spoonful of sugar to help the rest of his analysis go down. Because in crediting them for bettering patient care, he fails to mention – for instance – massive failures to shift resources from hospitals and specialists toward primary care and community-based practitioners. (Oddly, the minor but measurable advances in inclusion of integrative, mind-body and non-pharmacologic approaches are all budding signs of positive change – each disruptive in their own right – that a whole person-oriented sweet spot may slowly be coming into focus for regular medicine.)

Berwick’s diminution of the disruptive requirements to meet the patient care aim brings out a shortcoming in his analysis regarding the second aim of “population health.” In the early orientation toward the Triple Aim, many have come to know a pie chart that shockingly presents clinical care as just a 10% contributor to health.

Berwick both honors and is excited by the “population health” factors in the Whittington-Nolan work that make up most of the rest of the pie chart. He focuses on the “community determinants of health” – influences like housing, racism, employment, access to quality food, and education. He notes tentative actions in this arena, and a good deal of talk:

“There’s more rhetoric about that now. There are some good programs. Some countries have programs and approaches that we need to copy, but we are taking baby steps so far on the health of populations and giant progress is available if we want to go for it.”

Getting hospitals and major delivery organization with their present obedience to their bloated bottom lines and high-end specialists to prioritize investment in these causal factors would indeed be a grand disruption. I’d say the grade given by Berwick on moving the dial on “population health” is at best a C-.

Yet had Berwick’s respect for disruptive requirements in patient care run deeper, he would have found a missing link for connecting the clinical care to the determinants. Focusing only on “community determinants” is a bipolar framework. On one side is the conventional clinical care that is mainly the disease suppression and management rightfully deemed but a 10% contributor to health. Completing the bipolarity is his focus on community determinants.

This framing fails to honor the ways that volume-based medicine’s education, research and practice priorities suppress the uptake of integrative health’s clinical attention to behavioral determinants. The decade – indeed, the nearly 2 decades since To Err is Human made visible an estimated 98, 000 white walker medical deaths – has seen little infusion into clinical education of a whole person approach and the therapeutic tools that go with it in integrative, functional and naturopathic models: nutrition, diet, stress reduction, health coaching, self-care, lifestyle change, exercise, sleep, and environmental factors in health.

Research similarly remains focused on reductive, mechanistic solutions. And while education and clinical care have bowed toward interprofessionalism, the kind of shift one might hope would be compelled by learning one’s present practices have made one’s industry the nation’s 3rd most significant contributor to premature death has hardly been engaged.

Instead of uptake of the integrative model of clinical care that reaches into the 30% reflected in behavioral determinants, the medical industry’s investment in clinical care remains largely locked inside the 10% piece of the pie that the dominant school believes clinical care can contribute. Exceptions are the industry allowing integrative programs into academic medicine, complementary medicine into oncology care, and the elevation of non-pharmacologic, whole person treatment of chronic pain. All totaled, Berwick’s reference to a “sweet spot” seems a friendly grade. From an integrative perspective, the industry’s move to value deserves no more than a D.

On the third aim – reducing per capita costs – Berwick describes the industry’s persistent rationales for the failure to budge the dial. This, recall, is from a man who almost didn’t have, then lost, his CMS position because he believes that single payer is the best way to reduce the perverse incentives in the volume base industry. Such a national strategy is not mentioned in this column. Instead Berwick describes the destructive “habits” of the industry.

“Health care needs to [improve quality while cutting costs], but that’s not our mentality. It’s always, ‘We need more.’”

“… think of all the health care lobbyists that are on Capitol Hill arguing for more money. Think about the health care system that wants to build the next building and expand its work. To say we don’t need more is disruptive, to say the least.”

“… people would say, ‘Yeah, let’s stop wasting.’ And you know what? It really hasn’t happened. Maybe people don’t see it, maybe they’re worried: ‘Your waste is my job and you’re telling me this activity isn’t needed?’ It’s been hard to get organizations and individuals oriented around stopping non-value-added stuff.”

The habits of making boatloads of money off something do indeed die hard. In these last ten years – in part from the more hands-off approach of the Trump administration – governmental focus on value has declined as the industry has soared to $3-3-billion annually with no sign of limits in waste. Instead, an ugly new practice from the American Hospital Association of boasting its industrial prowess in job creation. What sane person can give the industry better than an F on the 3rd aim of lowering per capita costs.” Berwick concludes: “I can see places that are approximating pursuit of the Triple Aim, but no one’s really got it yet.”

This critique of Berwick’s portrait of the medical industry is not meant to diminish the potency of his role at his bully-pulpit at CMS and from the multiple pulpits IHI provides for challenging the industry come to value and health creation. He has urged new rules for radical redesign of health care. Yet this reflection on 10 years of the Triple Aim – that I have turned into a report card – is evidence the industry has hardly begun to budge much less make radical changes. Neither the pulpit from which Berwick has called for a new moral era for the industry nor the white walking enemy of 250,000 annual medical deaths seem to be proving to be enough.

It is hard to conclude anything other than what is needed is less pulpit and more of the bullying of governmental requirements to force the industry to take on the necessary battles, exit its entitlements, and begin thinking about the whole.

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