Health-care reform & the lost art of healing

In 1996, the renown Dr. Bernard Lown—emeritus professor of cardiology at Harvard and founder of the Lown Cardiovascular Group, among other distinctions—published “The Lost Art of Healing.” The book may be more than 20 years-old, but its message is as timely as ever, and arguably more urgent today then in 1996. The New York Times put the spotlight on Dr. Lown’s message when it recently ran an Op-Ed by an intern at Brigham and Women’s hospital in Boston who encountered the venerable physician when Dr. Lown was in that hospital being treated for pneumonia.

In “The Lost Art of Healing,” Dr. Lown charged that “doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning” parts of the body. The doctor-patient relationship, the author lamented then, and still laments today, has become impersonal, mechanical, remote and cold. In “The Lost Art of Healing” he called for the revival of the “3,000-year tradition, which bonded doctor and patient in a special affinity of trust.”

As resident physician Rich Joseph wrote in his column, Dr. Lown has called for “a return to the fundamentals of doctoring—listening to know the patient behind the symptoms; carefully touching the patient during the physical exam to communicate caring; using words that affirm the patient’s vitality; and attending to the stresses and situations of his life circumstances.” 

At 96, Dr. Lown made it clear that he was not pleased with the state of affairs he had warned about all those years ago, and which today he describes as the “industrialization of the medical profession.”

The Times piece is worth quoting at length because it so pointedly and accurately describes the state of contemporary health-care in the US, both in its for-profit and publicly-funded forms. The case is worse for the latter, with traditional Medicaid being particularly prone to impersonal medical care and an emphasis on transactional treatment in the form of tests and perfunctory office visits; a formula that is prone to waste and fraud, and that provides very little if any opportunity for the establishment of a bond between patient and doctor.

Enter the Delivery System Reform Incentive Payment (DSRIP) Program, a pioneering approach to Medicaid ushered in by the New York State Department of Health that has just begun the fourth year of its five-year mandate. Its goal: the reduction by 25 percent of avoidable hospital use at the end of five years, which would amount to a savings of more than $12B for New York State taxpayers. 

These are impressive facts and figures; important as they are for the bottom line, they are secondary. At the heart of DSRIP is superior, holistic care for Medicaid patients who are treated as human persons, not as cost centers or bundles of various medical ailments—care precisely of the kind Dr. Lown insists has gone missing.

SOMOS Community Care is one of 25 so-called Performing Provider Systems (PPS) in New York State, which are funded by DSRIP. To qualify for maximum funding, each PPS is held to strict deadlines, delivering certain levels of care and meeting crucial milestones all, ultimately, leading to those dramatic reductions in hospitalizations. DSRIP is driven by the Value-Based Payment (VBP) or Pay-for-Performance formula. That means that physicians and other providers are not paid according to tests administered or office visits logged, but based on the longer-term health outcomes of their patients. If their patients stay healthy, their doctors earn more. It’s that simple.

VBP, however, is a tool, not an end in itself. Value-based care means that doctors are rewarded, are recognized, for paying closer attention to their patients. Better care, to cite Dr. Lown once again, depends on the development of that “affinity of trust” between doctor and patient. Such an authentic bond requires that doctors make a genuine effort to get to know their patients, which takes time, energy and resources.

Providing truly superior care means that doctors and their staff must go the extra mile not only to comprehensively assess a patient’s physical, as well as mental health; it also means getting to know the patient’s family, the family’s living conditions, and to develop an awareness of the environmental and social factors that affect the home life—the so-called social determinants of health, which Dr. Lown succinctly describes as the “stresses and situations of [the patient’s] life circumstances.” Only in this labor-intensive, patient, persistent and demanding fashion can doctors once again become genuine healers, patients’ confidants, who are trusted and admired leaders of their communities. 

SOMOS Community Care is unique among the 25 PPSs in New York State in that it provides services to the poorest residents of New York City through a network of independent physicians. The other PPSs are hospital-based, mostly massive corporate systems, for which the genuinely and indispensable personal touch is much harder to achieve. SOMOS supports its physicians with a team of Community Health Workers, which train the staff of physician’s practices in digital record-keeping—freeing up the doctor to give his or her full attention to the patient—and which make home visits as needed, making sure medical appointments and regiments are kept, and giving the doctors vital feedback on patients’ home circumstances.

SOMOS, in sum, is making for the contemporary reiteration of the family doctor of old, making him or her again a familiar and relied upon neighborhood figure. In many cases, our doctors live and work in the same communities as their patients, often sharing their ethnic background. Cultural sensitivity and competence, in fact, are a hallmark of the DSRIP VBP formula.

It must be stressed that our more than 2,000 doctors, most of them members of Independent Practice Associations, have gone out on a limb in signing up with DSRIP. The old Medicaid formula stood for a predictable, reliable level of income. The Pay-for-Performance model, by contrast, means that doctors have to work harder, and provide superior health-care, in order to qualify for higher compensation. As independent small business people, our doctors are really taking a chance and deserve a great deal of credit for thus boldly embracing their professional calling in a way that is by no means risk-free.

Value-based care is the new wave of health-care reform; it will deliver superior care, thanks, in part, to a strong emphasis on preventive care. This, in turn, translates into reduced health-care costs by keeping people healthier and out of hospitals, etc. It would make a lot of sense for policy-makers to begin paying closer attention to value-based care—and to consider funding the efforts of Independent Practice Associations. This would enable the independent doctor as entrepreneur to succeed under the VBP regime by providing truly personalized health care, whose quality hinges on that “affinity of trust” between doctor and patient. This would be a much-needed complement to the massive funding of inevitably more impersonal hospital-based systems that currently dominate the publicly-funded health-care arena.

As for SOMOS, we are laying the groundwork for life beyond the DSRIP mandate, which concludes on March 31, 2020. SOMOS Community Care will continue operations as a for-profit entity. Experience to-date has given us confidence in the VBP formula and we are prepared to, literally and figuratively, bank our future on it!