Albert Einstein is credited with a pithy definition that insanity is: “Doing the same thing over and over again and expecting different results.” By that definition, the U.S. health care system has been on an “insane” path for too long. Our fee-for-service payment model has rewarded volume of services over high-quality, coordinated care for decades. The results we get, year after year, are skyrocketing costs totaling $3.8 trillion in spending in 2019 with a growth trajectory to reaching $6.0 trillion by 2027. To put this in perspective, If the U.S. health care were its own country, it would be the 4th largest economy in the world.
We don’t get much for our spending either. We have the 55th highest infant mortality in the world (tied with Serbia), our life expectancy ranks 43rd in the world, and we are nearly 3 times more likely to die of coronary heart disease than someone in South Korea.
Perhaps finally taking heed of the famous Einstein quote, policy makers, payers, providers and patients are now looking to do things differently. These efforts are embodied in the concept of care transformation. Care transformation has become a favorite talking point and shared aspiration for a range of health care organizations. In fact, new Chief Clinical Transformation Officer roles are popping up at provider and payer organizations around the country, including organizations such as the Cleveland Clinic and Horizon Blue Cross Blue Shield of NJ.
But what exactly does care transformation actually mean?
I have the chance to see our health care system through multiple lenses, as a researcher, a physician, a father, a patient, and a business owner. In each of these roles, my view of care transformation is pretty straightforward: Care will be transformed when we offer consistent, evidence-based care that achieves the best possible outcomes at the lowest possible cost.
The clear conclusion from my health economics research, done around the world, is that health systems delivering consistent, evidence-based care deliver the highest value care to patients. Access to evidence-based care supported by the best available science is what drives the best outcomes when I see patients in the clinic. Consistently high-quality care is what I hope I receive when my children or I need medical attention. And avoiding low-value, high-cost services are key to keeping premiums low so I’m able to invest in my employees and product.
Care transformation through consistent, evidence-based care can only become a reality when we address what I consider to be a preventable national health crisis – unwarranted care variation. For too many years, we have been working under the same old incentives and training protocols that lead to a wide range of medical practices for the same conditions. This variation, we and others have shown clearly, can’t be explained by the severity of illness or patient preferences. This unwarranted variation is routinely observed between states, zip codes, and even between providers in the same facility.
For example, those visiting a bottom decile hospital more than double their chances of dying compared to a top decile hospital. The incidence of central venous catheter blood stream infection is nearly 20 times higher at a bottom decile hospital. Someone in Idaho Falls is three times more likely to undergo knee replacement surgery than a patient in the Bronx.
Variation like this negatively affects outcomes, experience and cost. We can all agree that where you live or which doctor you happen to see should never dictate the level or type of care received, yet the stories of care disparity are endless.
Our research and work in the U.S. indicate that most of this variation is avoidable. While evidence-based guidelines do not cover every potential clinical scenario, there is overwhelming evidence that high-quality guidelines across many common conditions are under-utilized by well-meaning, hardworking, busy clinicians struggling to keep up with the latest guidelines. Collectively, the decisions these providers make every day influence a staggering 80% of all health care spending.
There are a number of tools today that seek to address unwarranted variation, such as quality dashboards, EHR clinical decision support and changing incentive models. However, most of these tools have struggled to transform practice at scale through more consistent care. The missing piece, in my opinion, is true clinical collaboration with physicians in this care transformation journey.
Medicine is hard and any attempt to truly transform care, to do things differently, must actively engage providers on the front lines and arm them with the training and tools they need to make the best, most evidence-based decision they can for every patient they see. This is an essential part of getting the different results – high quality, high value – that unites these care transformation efforts.
Whether you have Clinical Transformation in your job title or not, reducing unwarranted variation will be critical to successful care transformation and to succeeding in the new value-based models, such as ACOs and capitated payments, that seek to reward organizations that do things differently to get different results.
If we can successfully bring consistency back to care and reduce unwarranted variance, we will all benefit through higher quality, better outcomes and lower costs.
 National Health Expenditure Projections 2018-2027, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf, Accessed February 2020.
 CIA World Fact Book, https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html, Accessed February 2020.
 World Health Organization, Age Adjusted Death Rate Estimates: 2017
 Rosenberg BL, Kellar JA, Labno A, et al. Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment. Plos One. 2016;11(12). doi:10.1371/journal.pone.0166762
 The data was obtained from The Dartmouth Atlas, which is funded by the Robert Wood Johnson Foundation and the Dartmouth Clinical and Translational Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).
 Crosson FJ. Change the microenvironment. Delivery system reform essential to control costs. Mod Healthc. 2009;39(17):20–21.
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