Dr. William Kissick, famous for shaping the Medicare policies of the 1960s, became known later in his life for illustrating a healthcare dilemma he dubbed the iron triangle.
With the points of the triangle representing cost, access and quality, Kissick concluded that no healthcare system in the world can deliver excellence in all three. In his view, success in two areas inevitably came at the sacrifice of the third. This left healthcare leaders with a difficult choice: which two?
The dilemma of the iron triangle, first introduced in 1994, was an inescapable truth in American healthcare throughout the 20th century. Today, however, our nation possesses the tools and knowledge needed to overcome all three obstacles, simultaneously.
What’s missing is effective leadership.
This article—the third in a series that includes “Brain, Heart, Spine: The Anatomy Of Healthcare Leadership”—puts the anatomy of leadership in action. It explains how healthcare leaders can apply logic and imagination (the brain), passion and empathy (the heart), along with courage and persistence (the spine) toward the goal of achieving what was once impossible.
Flexing the brain
Assuming the head of a medical group or health system wanted to break the iron triangle—delivering simultaneous improvements in quality, access and costs—how might the leader think through the challenge?
I often begin with a thought experiment. As these experiments go, it helps to suspend the reality of certain obstacles. In this case, time and money. With these two realities temporarily halted, the leader then asks a question like: Would clinical outcomes improve if patients could see their physician(s) every day with each visit lasting as long as needed?
And assuming the answer is yes, the individual would then ask the all-important question: Why?
The reasons are plentiful. Daily visits would allow physicians to address gaps in patient care. Instead of cycling through 15-minute appointments, addressing only acute problems, doctors would take the time needed to prevent and treat the patient’s chronic diseases, which account for 90% of total healthcare costs and mortality. They’d adjust medications and modify treatments in real-time, too, thus preventing complications from chronic illness (like heart attacks, strokes, cancer, infection and so on). Furthermore, clinicians would pay more attention to patient wellness. They’d assist with lifestyle improvements. They’d help enroll individuals in programs focused on diet, exercise, smoking cessation, addiction recovery and stress reduction.
Having identified what doctors would do if time and money weren’t constraints, the leader’s next step is to figure out how these types of outcomes could be achieved in the real world.
Technology holds the key. America leads the world in technological development—with smartphones, deep-data analytics, secure streaming video, digital monitoring and artificial intelligence offering the potential to transform patient care. Yet, to date, none of these technologies has successfully moved the needle on healthcare costs, quality and access.
And so, with a potential solution at hand, the leader might then bring the idea to physicians and staff, inviting them to brainstorm ways to apply technology toward the goal of breaking the iron triangle. The list of tech-enabled opportunities may include:
- Work with IT experts to program an Alexa-like application for round-the-clock monitoring and home-based care.
- Have voice-enabled app prompt patients to take their medications (and confirm they’d done so); order Rx refills for home delivery.
- Provide patients with daily, voice-enabled updates on their health.
- Remind patients at home when they they’re due for preventive screenings.
- Use device to schedule preventive tests and services the doctor recommends; arrange for transportation, if needed.
- Sync a patient’s home-monitoring devices (glucometer or blood-pressure cuff) to the medical group’s EHR system.
- Develop an AI app to compare each day’s numbers against the expected range preset by the doctor—alerting both patients and physicians when something’s awry.
- Equip tech with lifestyle-improvement features: exercise programs, food tracking, a diet optimization based on specific medical conditions, etc.
All of these ideas are feasible and several of these technology features already exist—they just aren’t being used broadly by medical groups or healthcare systems to improve patient care. Leaders must guide the transition from opportunity to practice.
Appealing to the heart
In the anatomy of healthcare leadership, the brain’s function is to visualize opportunities and provide creative solutions. But the mind, alone, is insufficient for driving change.
To generate enthusiasm and compel people to act, leaders must also touch the hearts of those they wish to inspire.
If I were a leader in this scenario—having posed the thought experiment and stress-tested the ideas—I’d then want to humanize both the problem and the solution. Most likely, I would invite a friend of mine to tell the group about his father, who I’ll call Dan, and the many medical difficulties he experiences. Most clinicians have at least a dozen patients just like him.
Dan is in his early seventies, nearing retirement, and lives alone. His wife passed away a few years back, and Dan hasn’t been the same since. His three kids have all grown up and left the nest. They live several states away and worry constantly about their father’s physical and mental health. Dan has diabetes, high blood pressure and elevated blood lipids. He takes seven or eight medications and has a hard time remembering when to take which. After his last heart attack, Dan’s physical therapist told him it was important to take daily walks, but it has been a difficult habit to maintain. Most days, Dan skips out on exercise. And, in addition to struggling with his chronic illnesses, Dan feels increasingly isolated and lonely.
For the benefit of the physicians and staff in the room, I’d encourage my friend to talk about the challenges and consequences of his father’s current medical care. He would no doubt recall the times his dad ended up in the emergency room because he forgot to take his medications or couldn’t get in to see a doctor. I’m sure he’d express the frustration he and his sisters felt knowing those visits could have been avoided. I would encourage him to detail the last two hospital admissions Dan required so that the doctors could understand how easily they could have been avoided with more effective, continuous disease management.
After hearing Dan’s story, I’m optimistic the clinicians in the room would see the benefits of incorporating these technologies with patients and be willing to invest the time and energy needed to get these ideas off the ground.
Having a strong spine
Moving from episodic care (delivered in an office every three or four months) to a more continuous model of technologically supported disease management and lifestyle change may seem like a win for patients, clinicians and payors alike. But the transition from concept to reality always produces challenges and encounters resistance.
That’s why leaders need to have backbone.
For example, more home monitoring would lead to more frequent recognition of potentially serious problems—issues that may require patients to visit their doctor. Leaders will need to anticipate these occurrences, gain consensus on the expected turnaround for a response, and intervene quickly should clinicians fail to uphold this commitment.
Unless this happens, the breakdown in care will erode the patient’s trust in their doctors, and doctors within the group or health system will conclude that commitments don’t matter. And when that happens, the iron triangle stands firm.
These are the moments that test the strength of the leader’s spine.
When I was a CEO in Kaiser Permanente, the nation’s largest integrated health system, our medical group committed to becoming the best in the nation in chronic disease prevention and management. Using data analytics and our comprehensive EHR systems, physicians from every specialty agreed to address care gaps during every patient visit, even when they weren’t directly tied to the reason for the office visit.
Whenever a physician consistently ignored these types of medical problems, departmental leaders intervened swiftly. These difficult conversations weren’t always met with open arms. But the program was an unqualified success. By consistently seizing opportunities for disease prevention and better management of chronic diseases, the chances of our patients experiencing or dying from heart attack, stroke and various cancers fell by 30% or more. Quality soared and, thanks to helping patients avoid these medical problems, our cost of coverage dropped to 15% below the competition.
What’s next for the anatomy of leadership?
If effective healthcare leadership in the 21st-century is the ability to simultaneously improve quality, access and cost, then modern technology provides a clear path to victory.
But before charging forward, the leaders of tomorrow must effectively apply the anatomy of leadership to a few other problems, as well, including how doctors are paid, how they are organized and how they will work together as one.
The next article will focus on how to reward the doctors who prevent heart attacks, strokes and cancers—as well as those who treat them.