Changing Behavior and Reinstating Trust to Improve Healthcare Delivery

The American healthcare system is not the best in the world; it is failing, plagued by high costs and inconsistent quality, said Ezekiel Emanuel, MD, PhD, chair, Medical Ethics and Health Policy, University of Pennsylvania, at Quality Talks, held by the National Committee for Quality Assurance. The 1-day event was held October 22 in Washington, DC, and featured “TED”-style talks from thought-provoking speakers and leaders in the industry.

Emanuel kicked off the meeting with a look at the biggest challenges in US healthcare, such as changing individuals’ behavior and migrating care out of institutions. He also expressed optimism in America’s willingness to rise to the challenges.

“When we Americans put our minds to it, we can achieve greatness,” Emanuel said.

Behavior change is something that will be needed both on the part of physicians and other healthcare providers and on the part of patients. Providers have to change how they deliver care after years or decades of delivering it in one way, and part of that change is under way with value-based payment models. While there has been skepticism from providers regarding the success of value-based models, that skepticism is going away and will continue to be driven away with the implementation of things like the Medicare Access and CHIP Reauthorization Act and the Bundled Payments for Care Improvement initiative.

Emanuel called out physicians still using the old line that they have 1 foot in value-based payments and 1 foot in fee for service (FFS). “You can’t do that,” he said, adding that the groups that have actually made the change can attest to how long it takes. Research has shown it can take 4 to 5 years to transform from FFS to value-based care. “You have to start today for 2021, 2022,” he explained.

Patients also have their part to play. Somewhere between 40% to 60% of illnesses and premature mortality are a direct result of bad behaviors, like smoking, poor food consumption, and lack of exercise, Emanuel pointed out.

He also looked at the evolution of institutions of care and how people are being moved out of the hospital to get care in the home. Emanuel expects that over the next decade there will be a big movement out of the physician’s office, as well, and into the patient’s home. This is a continuation of recent trends that have driven down hospitalizations while outpatient visits have gone up.

“We’re getting rid of institutions as sites of care; we are moving to the outpatient setting, and, I think, we’re going to move from the institutional outpatient setting to the care at home,” Emanuel said.

Emanuel closed with the belief that America’s healthcare system can solve the problems facing it, and it will “become a real beacon of lower cost, better patient experience, and higher quality to the world as we proceed,” he said.

In addition to the challenges that Emanuel outlined in his talk, Toyin Ajayi, MD, MPhil, chief health officer and founder of Cityblock Health, focused on the importance of trust and how the lack of trust between patients and providers can lead to missed care and poor outcomes.

Ajayi stated that everyone involved in healthcare has to acknowledge that it is a system “steeped in a history” of enacting violence on marginalized and vulnerable people that continues today. She highlighted the Tuskegee Syphilis Study, in which black men with syphilis were studied, without their full consent, to see the progression of the disease despite there being a treatment available. She also discussed the Willowbrook Hepatitis Study by New York University in the 1950s in which children with mental health issues who were housed at a school were intentionally given the hepatitis virus in an attempt to track the development of the viral infection.

And today? Ajayi pointed to the current cost of insulin, which has tripled in a decade despite the fact that the drug was developed and discovered in the 1920s and the patent was sold for just $1. The result is that people who are vulnerable and underprivileged cannot afford life-saving medicine.

“Our patients aren’t blind,” she said. Patients who are part of a minority, have a disability, or are a member of the LGBTQ community know they run the risk of disrespect and a lack of care when they go to the doctor. As a result, low-income families have described having a significant mistrust of physicians, Ajayi noted.

“Let’s acknowledge those foundations and advocate for a better future,” Ajayi said. “Can we earn back the trust of those we seek to serve?”

Cityblock decided to build a trustworthy healthcare system starting with a workforce based in the community. The organization hired and trained people in the community who are there for their empathy, to listen, and to build trust. These individuals are then surrounded with a clinical workforce.

“Each [person] has a role to play, but none has primacy over the other,” Ajayi explained. Cityblock divests physicians of power and distributes the power across the team.

She added that measurement is important to be able to understand whether the work is building trust again. Cityblock is interested in measuring if members trust the organization and its workforce, if members will keep going back for care before they go to the emergency department, if they will take the time to explain what matters to them, and if they will trust Cityblock enough to listen to the recommendations its team members provide.

“We have to be able to measure [trust] and drive towards it,” Ajayi said.