James Weinstein, MD, is set to retire from his role as president and CEO of Lebanon, N.H.-based Dartmouth-Hitchcock and Dartmouth-Hitchcock Health June 30, after six years at the helm of the only academic medical center in the state.
Speaking at the healthcare symposium Thursday at Northwestern University's Kellogg School of Management in Evanston, Ill., Dr. Weinstein's comments pertained to D-H but often spanned to cover the big picture of healthcare and its faulty system in America. He is a vocal advocate for change in healthcare delivery and payment, as well as macro-level improvements to improve access to care and reinforce healthy behaviors.
"I think the country is missing an opportunity," he said. "The current president talks about rebuilding infrastructure of America — it's an interesting thought. If we had to redesign healthcare today with a whiteboard, it wouldn't look anything like it looks now."
Dr. Weinstein, a spine surgeon and author of Unraveled: Prescriptions to Repair a Broken Health Care System, spoke about how the government, businesses, industry leaders and communities can rethink the current models of healthcare to better focus on equity versus "brick and mortar solutions that don't address the social and economic issues of our times." Here are nine of his strategic ideas for improvement, bricks and mortar aside:
1. Mandate the transparency of cost and outcomes. Dr. Weinstein likened the healthcare industry to a dysfunctional airline in which passengers are expected to board a plane that lacks instrument panels, flight attendants and a destination. Passengers simply board and see where they'll end up.
For many patients, this reflects the care experience — except instead of instrument panels or destination, they lack information about procedure prices, a surgeon's track record for patient outcomes or a distinct role in decision-making. "How many of you have physicians who can tell you outcomes for procedures they offered to you that they've performed for patients like you?" In a room of roughly 110 people, nobody raised their hand.
Dr. Weinstein said greater transparency will also catalyze greater efficiency and standardization from physicians. "These are smart people, they went through medical school. They will appreciate the data if they believe it, and building data systems they trust is the solution for that."
2. Focus on the top 5 percent of healthcare utilizers. Healthcare spending is noticeably imbalanced in the United States: Approximately 5 percent of the population accounts for nearly 50 percent of the spending in a given year. At the same time, half the population accounts for about 3 percent of healthcare spending.
This disparity has repercussions for national spending and debt. Last summer, HHS released projections that healthcare spending will grow at a faster rate than the national economy over the coming decade, and spending was slated to hit $3.35 trillion in 2016 alone. "Let's take care of those chronic conditions for the population that is aging and responsible for 50 percent of costs," said Dr. Weinstein. "Medicare is a national program — if you spend more money in Texas, that's less money to spend somewhere else."
3. Continue with value-based payments, but adjust for social determinants upstream. Dr. Weinstein does not think the industry is moving quickly enough from fee-for-service to value-based care models and payments. He said aspiration to become a healthcare system that rewards quality, not quantity of procedures, exists, "but it's kind of a low bar right now," said Dr. Weinstein. "It's still about money. It's always about money."
He argued for maintenance or proliferation of value-based payment, along with more programs that take socioeconomic factors into account when evaluating a healthcare provider's quality of care and the health of an individual. "Social issues account for most of the problems in this country, and we tend to avoid them," he said.
He mentioned 2008 data from Baltimore's health department that identified a 20-year gap in life expectancy for individuals living in the city's Hollins Market and Roland Park neighborhoods. More recently, in a national data analysis, researchers identified a spread of 20.1 years between U.S. counties with the longest and shortest typical life spans based on life expectancy at birth.
Dr. Weinstein's idea to account for social factors is in the early stages with the Accountable Health Communities Model, a program from the CMS Innovation Center that premiered this year. Its 32 participants will test whether systematically identifying and addressing Medicare and Medicaid patients' health-related social needs through screenings, referrals and community navigation services will influence healthcare costs and reduce healthcare utilization.
4. Revise or eliminate the Social Security max tax. Last summer, the Obama administration released findings that projected the Social Security program would reach insolvency by 2034, with tax collections then sufficient to pay only three-fourths of promised benefits through 2090.
Viewing this through a macro-level lens, leaving retirees to live and maintain their health with only a portion of benefit payments will have major repercussions on the U.S. economy, healthcare system and retirees' quality of life. Even more, healthcare costs are already slated to take up a growing portion of Social Security benefits. In 2016, the average woman could spend an estimated 70 percent of her retirement check on healthcare costs, according to a study by the Nationwide Retirement Institute. Although healthcare costs don't take quite as big a chunk of pie for the average man, he still uses nearly half of his benefits to cover medical expenses.
In 2016, the maximum taxable earnings for Social Security was $118,500; in 2017, the cap is $127,200. There is an economic debate about the merits of raising or eliminating this restriction. Max tax supporters say the upper limit was designed to assure no one contributed directly more than the value of the protection he or she received, whereas opponents to the max tax say eliminating it would generate more revenue for Social Security, shore up the federal social insurance program and level the playing field between high-earners who comply with a fixed tax limit despite growing income.
Dr. Weinstein sits in the second camp: "I can pay more." To prevent Social Security from insolvency and maintain full payments to seniors, Dr. Weinstein advocated for modification to the limitations on maximum taxable earnings that would enable high-earners to contribute more.
5. Require those who make more than $100,000 annually to contribute more toward health insurance. Salary-based premium models were rare until about 2010-11, when more companies and corporations began linking employees' premiums to their salaries under the ACA rule that required employers with at least 50 workers to offer affordable health insurance or pay penalties. Dr. Weinstein contends for the fairness of this dynamic, which is not widespread but more popular in the financial services industry.
6. Perform preventive or routine care visits remotely. Dr. Weinstein pointed to the 50 percent of the population that incurs roughly 3 percent of healthcare costs as a prime audience for remote preventive or wellness care. As for routine care or management of chronic conditions, his organization has employed a tech-driven strategy to meet patients where they are.
D-H launched ImagineCare, a 24/7 remote care management service patients can access through equipment mailed to their doorstep, texting and other virtual interactions with providers. The program is highly coordinated, intensely personalized and accounts for patients' physical, mental and emotional health. "ImagineCare is with you 24/7," said Dr. Weinstein. "We can monitor your blood pressure every day, five times a day, versus you coming in to the doctor three times a month."
7. Partner with industry and consumer groups for artificial intelligence, data analytics and predictive modeling. It takes a village in healthcare today, and hospitals alone will not make the most of technological advancements and breakthroughs. D-H partnered with Microsoft to create ImagineCare. Dr. Weinstein mentioned a host of other activities that require collaboration between healthcare providers and innovators.
For example, artificial intelligence has ignited new capabilities for personalized medicine, meaning patients can receive treatments based on their unique genetic defect or mutation. This is entirely impossible without technology, for comparing cancer cells to healthy cells and identifying that one genetic defect is like "finding that one red brick in Manhattan," said Dr. Weinstein. "No human can do that — you need technology tools."
8. Pharma repatriation should be tied to multibillion dollar endowments to support medications for those who can't afford them. President Donald Trump's plan to incentivize companies through tax breaks to return corporate profits they've stored overseas to the U.S. was a signature of his campaign. Dr. Weinstein said if this plan is enacted, pharmaceutical companies should establish endowments with the savings incurred from the tax breaks to help to fund drugs and medications for individuals who cannot afford them.
9. Consider social determinants of health when rebuilding America's infrastructure. Dr. Weinstein believes a modernized infrastructure that accounts for social determinants of health will "pay big dividends." These determinants include access to: public transportation, media and technology (including the internet), safe and barrier-free spaces for exercise, and healthy food options, among many others. "If we do rebuild the infrastructure of America, this is an opportunity," he said.