In the wake of Amazon’s $3.8 billion offer to acquire One Medical, those working within the healthcare industry have adopted a new pastime: guessing the level of disruption the takeover will catalyze. The basic tenets of the opportunity are well-understood, namely that a) healthcare spending consumes more than its fair share of US GDP and consumer discretionary spending, marching steadily along each year at an unsustainable rate of growth b) if incentives are designed appropriately, effective primary care and prevention would be critical to bending the cost curve, and c) Amazon has repeatedly played disruptor in sectors it chooses to enter—so why not this one? 

Naysayers, however, will point to Amazon’s history of shutting down business models that do not prove themselves immediately accretive, as it did with its Haven partnership on healthcare financing with JPMorgan Chase and Berkshire Hathaway in 2021. When one considers that One Medical lost $250 million in its last fiscal year on revenues of only around $640 million, one must question whether Amazon will have the patience to see the business reach profitability at scale?

Other questions come to mind: Will this deal lead to other “big plays” in primary healthcare by emerging competitors (e.g., Walmart, et. al.)? What will the competitive response be among major health systems that have invested billions into building out their own primary care networks? While there are no certain prognostications, a lesson from the airline industry might provide a few clues as to how it might play out.

Regulatory Lessons Learned

Both healthcare and air travel are highly regulated industries—understandable, given the life-or-death consequences of error. Another commonality between the two is the correlation between shifts in the regulatory environment and changes in competitive dynamics. For the airline industry, the 1978 Airline Deregulation Act eliminated states’ ability to regulate the prices, routes, or service of air carriers. This deregulation proved transformational, flipping the competitive dynamic between established legacy carriers (United, Delta, Delta, etc.) and disruptive upstarts like Southwest Airlines.

While healthcare regulatory reform is likely to advance at a slower cadence than the shock caused by the Airline Deregulation Act, the business-school staple case study of Southwest Airlines provides a particularly good analogue (or perhaps cautionary tale) for primary care disruptors seeking to leverage and build upon recent state and federal regulatory shifts to gain advantage in areas such as telehealth payment parity, cross-state licensure compacts, price transparency, expanding PA/NP scope of practice, and others.

Deregulation did not create Southwest, but it can be said the airline’s arrival helped drive the policy change from which they then became the greatest beneficiary. Founded in 1967, the airline advocated aggressively for relaxing Texas state and then-Federal regulations while building a business model that has proven surprisingly difficult to replicate, even to this day. Efforts by legacy carriers (United, Delta, American, etc.) to create their own competitive budget airlines have failed repeatedly and miserably (take note, large health system retail clinics).

Amazon, fellow disruptors, as well as legacy health systems seeking to remain viable can all seek to understand why such a seemingly simple business model presents such a formidable challenge for competitors. Southwest’s ability to not only “ride the wave” of deregulation but also execute an operating model that effectively manages costs while driving differentiated consumer value has resulted in its consistent profitability and success (while other up-start budget airlines and legacy carrier imitations have mostly failed).

Models for Health Care Disruptors to Consider

Their winning model comes down to a number of key dimensions:

Designing differently from the outset to build an efficient cost structure:

• Simplicity in infrastructure: From the company’s founding until today, Southwest Airlines has flown only a single model of aircraft, the Boeing 737 (albeit different variants across the years). This streamlined design choice allows for versatility in staffing pilots, ground crews, maintenance, and other personnel. While this simplicity limits the routes the airline can fly, it pays huge operational dividends. Likewise, not every primary care clinic needs to be designed as a unique labyrinth, disorienting and overwhelming patients while driving up construction costs and the cost of maintaining aging infrastructure. Disruptive healthcare models might consider designing for accessibility, consistency, and throughput. This might require phasing out features that address patients’ #11-20 highest needs in order to exceed expectations and drive improved outcomes on their top 10 ones. Such streamlining around priority use cases might also mean jettisoning much of the brick & mortar infrastructure for basic primary and acute care, and adopting a home-first approach (e.g., telehealth paired with at-home visits as needed, as Amazon Care, Dispatch, and others currently provide), reserving in-person visits for more complicated needs. Finding the right balance with this minimal viable infrastructure model would be a critical success point for both patient experience and financial viability.
  
• A fit-for-purpose workforce: Southwest Airlines was designed with a flat organizational structure where roles tend to be comparatively broader than at legacy carriers. For instance, flight attendants double as cleaning crews and pilots fly more hours per year than they would with legacy carriers. Yet with fair pay practices and a strong culture, Southwest’s union workforce has experienced fewer labor disruptions than other carriers. The reason for this comes down to expectations. The company’s requirements of its people are high, but they are also stable, clear, and avoid the constant reorganizations commonly seen within the airline industry.  Primary care disruptors have a similar opportunity to design organizational models and clinical teams from the ground up, based on the patient experience and outcomes they wish to deliver rather than the status quo. One Medical’s Iora Health business unit has been a pioneer in this area with their Health Coaches that manage patient relationships and help connect the dots in coordinating their integrated care model. While Iora has a capitated model where incentives align to their unique model, even fee for service primary care models have the opportunity to compel regulators and policymakers to accommodate cost-effective and patient-centric models of care rather than repeatedly structuring themselves around the status quo regulatory framework.
  
• The right kind of tech: Stepping onto a Southwest plane does not generally seem like a high-tech experience.  There are no seatback infotainment systems, no lie-flat seats, just a very basic economy cabin.  But minimal flash does not mean the airline is technologically backwards.  Less visible features are critical to Southwest’s success, such as fleetwide wifi, a homegrown website used for nearly all flight bookings, and a sophisticated in-house-developed fuel hedging platform that has saved the company billions of dollars over the years. The airline carrier uses tech as a lever to support the customer experience rather than dazzle them.   In evaluating their tech stacks, primary care providers should be asking similar questions: how can technology enable greater connectivity and engagement with patients? How can it improve (rather than hinder) the effectiveness and job satisfaction of employees (particularly front-line clinicians)? How can it improve, or even fundamentally transform, incentive alignment and financial value capture (i.e., what is their “fuel hedging algorithm” related to contracting and reimbursement)?

Operate differently to deliver differentiated value:

• Design point to point instead of hub and spoke: When Southwest began flying, nearly every airline was configured in a “hub and spoke” model, with smaller airports feeding traffic to hubs that then ferried passengers along to domestic or international destinations.  Southwest decided to play a fundamentally different game, flying point-to-point routes between “second tier” airports that were cheaper to operate out of, saw less traffic (and therefore, fewer delays), and whose use generally created a less stressful travel experience.  The drawback with this model has always been that if travellers wish to continue on to long-haul international routes or certain high-traffic cities they often must transfer airlines. Yet it is a price millions of travellers are willing to pay for the convenience and value in the shorter hops. After all, Southwest’s original goal was to be able to compete with a consumer’s decision to take their car, not another airline. Primary care disruptors could take a similarly unique configuration path, not trying to grow into traditional health systems but instead competing with the drug stores, pharmacies, websites, and other day-to-day sources that patients go to most often when seeking health advice. In much the same design as legacy airlines, large health systems today have primary care clinics designed as hub and spoke feeders into their hospitals, ambulatory care centers, specialists, etc.  Primary care disruptors have the flexibility to independently channel referral volume to the best sources of specialty care rather than those to which they are aligned. They also can also locate their clinics without regard to proximity of hospitals or other aligned delivery system assets. Turning this perceived weakness into a strength at scale could enable such primary care networks to exert significant market power as referral gatekeepers (“air traffic controllers,” if you will).
  
• One class of service:  Because Southwest does not have First Class on its planes, it effectively does not have second class, either. While not luxurious, their egalitarian approach is highly equitable and works well on short haul routes by enabling “quick turns” of aircraft between flights. In much the same way, primary care disruptors that define a clear scope for what services they deliver (e.g., do not drift into delivering specialty care or ambulatory surgeries), but are able to deliver and resolve needs within their defined scope better than their peers, will be most well-positioned to deliver a singular and consistent patient experience at scale. They will also avoid “competing with themselves” when it comes to their role as a highly credible referral channel, as mentioned above.
  
• Real transparency: In an industry marked by dozens of fare classes and opaque pricing algorithms, Southwest has always maintained a simple and transparent pricing approach.  The airline does vary pricing for flights, but effectively makes the lowest prices available on a first-come-first-served basis, and makes clear the linkage between available capacity and current price. This greatly limits questions around fairness or price gouging.  While such a discount strategy may not work in health care, primary care providers should consider what radical price transparency could look like for them—above and beyond pricing rules, such as proactively and prominently divulging and even advertising their undiscounted billing rates for key services, or adopting bundled or subscription models for most services as many direct primary care practices currently offer.  Given that primary care doesn’t tend to have massive differences in price the way hospitals do, this could be a fairly low-risk way for the primary care industry to lead change.

Alone, none of the key differentiators listed above will be sufficient to gain an enormous competitive advantage. Poorly executing a handful of them is even less likely to produce positive results. The secret sauce—at least for Southwest—is in bringing all of these seemingly simple and obvious design elements together at once. Time will tell whether Amazon or one of the other disruptors will be able to assemble and consistently execute on the type of differentiated experience in the health space that Southwest has been able to consistently deliver in the airline industry. But the comparison does demonstrate that a truly disruptive healthcare delivery model needn’t dramatically deviate from the status quo in order to be profoundly transformative to the industry as a whole.

The post Lessons for Primary Care Disruptors from Southwest Airlines appeared first on Camber Collective.

More time is needed to fully understand the impact of the current digital health boom but, as of today, we can only be certain that the past decade has yielded more impressive numbers for investors than it has for patients. This fact is particularly true when looking at access and outcomes for underserved and vulnerable populations. This is not a failure, but it is underperformance, and we should take it as motivational fuel to focus the next decade on realizing the full promise of these groundbreaking innovations.

Over the past two decades, we have been fortunate to work at the intersection between innovative digital health companies and large healthcare enterprises, which include large health systems, national and regional payers, pharma/biotech companies, and large health technology organizations. This intersection is where disruptive ideas and solutions created by entrepreneurs often collide with industry incrementalism guided by seasoned healthcare executives. This intersection is a place where ideas and opportunities collide to drive business growth, but also a place where misunderstanding and friction often takes root and creates antibodies to future partnerships. A recent survey of enterprise executives confirms this sentiment, where more than half of respondents pointed to cultural issues and organizational politics as the primary reason why prior enterprise innovation initiatives failed [1].

Great relationships are not generally born of casual encounters

While numerous enterprise-startup ‘matchmaking programs’ (e.g., incubators, accelerators, other “open innovation” models) exist in the market today, nearly all focus solely on the ‘tip of the spear’, namely identifying a match between partners and drafting up pilot partnership terms. Once a match is made, the matchmaker’s work is done, and the enterprise business unit and startup are sent off to figure out how to work together and achieve the goals they envision.  Unfortunately, the departure of this relationship facilitator occurs at precisely the most vulnerable stage of the partnership process. As startups and enterprises begin the real work of implementing a partnership, differences in goals, expectations, working styles and time horizons often decelerate progress until the partnership flickers and eventually dissolves over time, leaving a negative lasting impression on both sides.

We have had the opportunity to build customized enterprise-startup collaboration initiatives for some of the top healthcare organizations in the US, including large health plans, healthcare providers and publicly traded health IT companies. Pitchspace, in partnership with Camber Collective, was launched out of a recognition that most healthcare enterprises today can expand their growth prospects most effectively not by partnering more frequently, but by partnering more effectively. In supporting this shift, the goal is to not only improve the “win rate” of partnerships for enterprises and startups, but to improve the impact on patients through more effective and rapidly scaled innovations.

The Pitchspace Process – De-risked, Scalable, Replicable:

The most successful enterprise-startup partnerships incorporate a comprehensive and staged process from ideation through integration and scale-up – a hands-on approach to guide the solution through the enterprise environment, adaptation for unique obstacles that present themselves, and the continual management of expectations for both enterprise and startup partners. The Pitchspace process was created to help enterprises make replicable the most successful practices we have seen in de-risking, effectively managing, and scaling up enterprise-startup partnerships.

Breaking free from “Groundhog Day” syndrome

The Pitchspace process is intended to be simple and focused, zeroing in on the common points of failure and applying the most proven techniques to overcome the partnership hurdles that tend to present themselves repeatedly. In practice, this draws upon some of the best practices we have observed consistently in successful enterprise-startup partnerships. While each organization is different, and we gain additional knowledge with each new engagement, we have found these several principles to hold true consistently:

The US healthcare system has many “friction points” that result in higher costs, limited access and uneven quality. Among these, improving the quality and scalability of partnerships between startups and enterprises is highly solvable. More effective partnerships can be a win-win-win, driving meaningful market growth for enterprises, faster scale for startups and better outcomes for patients. Pitchspace is a model dedicated to building stronger partnerships that support bold innovations and growth ambitions that meaningfully improve the lives of patients.

[1] “The Biggest Obstacles to Innovation at Large Companies”, Harvard Business Review, 2018. https://hbr.org/2018/07/the-biggest-obstacles-to-innovation-in-large-companies

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by Ben Jenson, Matt Holman and Gavin Boileau

Our intention with this post is to imagine what a better future for rural health care could look like, including the key elements or building blocks most critical to making the transition. We also consider the sustainability of proposed future models and the potential impact on rural communities.

KEY BOUNDARY CONDITIONS

The pace of innovation in healthcare is constrained by a complex web of existing regulatory and incentive mechanisms that collectively reinforce the status quo. While these forces remain significant, we believe the disruptions created by the COVID-19 pandemic offer an unprecedented opportunity for systems-level change.

Many of the regulatory adjustments associated with COVID-19 are supportive to transforming rural healthcare, including CMS Section 1135 Waver and Section 3704 of the CARES act, which (in some cases temporarily) enable: (i) a meaningful removal of barriers to inter-state telehealth regulations, (ii) non-HIPAA compliant platforms, and (iii) “rural-to-rural” telemedicine by allowing rural sites to serve patients at other rural sites (including their own place of residence). The continuation of these practices, particularly the first and last, are instrumental towards enabling the telehealth component of the system we propose.

While current conditions provide some tailwinds, transforming rural health also requires trade-offs that current reimbursement models strongly disincentivize. In general, delivery of high-quality and cost-effective care will require a significant shift away from delivery of elective surgeries and specialty care on-site at rural facilities. These procedures tend to be major revenue drivers for rural facilities and systems, and thus will require that payers, particularly Medicare/Medicaid, increase reimbursement for primary care and behavioral health services or otherwise redesign incentives to compensate for this shift.

THE NEW MODEL

Modernizing our rural health care delivery system will require changes across three broad dimensions, in ways unique to individual community needs, in shifting away from the current paradigm of rural health as a full-service one-stop shop to one that is more fit for context and purpose given our current available technology and resource constraints:  

Shifting Site of Care Paradigms: Quality outcomes in healthcare tend to favor volume and comparative advantage, and for most complex specialty care the level of procedural volume and expertise is lower in rural communities than in regional or urban hubs.  This does not mean that rural residents should settle for poor care or outcomes, just as lacking a high-end department store does not mean they cannot have high-end merchandize delivered to their doors within a few days.  The rural retail experience has been thoroughly reordered over the past decade, and rural health can produce better outcomes at lower costs by applying a bit of modern technology to evolve the current supply chain and logistics of care delivery.  In an ideal future, the majority of rural healthcare resources would focus on delivering comprehensive primary care that addresses a range of physical, behavioral and chronic care needs (including ancillary preventive care such as vision and oral health). Low-volume specialty care services and procedures should largely be provided via regional or urban centers of excellence, via telehealth-based models for visits or consultations or via stabilization and transport for more urgent procedures. Depending upon regionally-specific specialty needs a smaller and more targeted set of specialty services could continue to be delivered within rural communities. Emergency services would continue to be provided but be further focused toward a stabilization, triage, and transport model which limits required local hospital bed capacity. All of these changes would require rural health systems and payers to adopt more sophisticated referral mechanisms and networks as well as fundamental changes to incentive mechanisms to achieve buy-in from providers and patients alike.

Re-Architecting Infrastructure: In practice, shifting specialty and procedural volume out of rural communities may look less like a downsizing and more like a repurposing of existing space and shared resources. Hospitals and their affiliated clinics are often the economic engines of the rural areas they serve and provide considerable high-quality and multi-purpose space. Repurposing space could allow rural health systems to serve as a flexible center of holistic, community health. Operating rooms, intensive care units and other spaces no longer needed could be retrofitted into a space for community groups, civic gatherings, and seminars tailored toward physical health as well as social determinants of health. Private or mission-driven enterprises, including nutritional counselors, private retail pharmacies, or charitable groups, could leverage excess space.

Evolving the Rural Health Workforce: The proposed model of care would also require adjustments to the workforce of rural hospitals: namely an expansion of primary care and behavioral health providers as well as supporting resources to manage the enhanced logistics related to referrals, transport and case management necessary to provide an integrated patient experience. This should be buttressed by the expansion of education programs tailored toward rural health needs, including advance practice providers (e.g., NP/PA) that can play broad roles within the primary care-driven model. While specialty care delivered at individual rural hospitals will be downsized, COVID-19 presents a significant opportunity. In the past, rural health systems have struggled to hire specialists due to low patient volumes. However, recent telehealth regulation changes have allowed for rural-to-rural telehealth consults. This means that certain medical specialists can be located in rural areas and fill their time with regional service provision via a combination of telehealth consults and in-person care. Lastly, supplemental workforce adjustment is needed to adapt to a response, stabilization, triage, and transport model for acute situations. This could include additional EMTs and individuals able to staff the vehicles (e.g., helicopters, autos) needed for patient transport.

All system-wide changes come with tradeoffs. The adjustments we propose prioritize improving quality of care, increasing the sustainability of health care delivery in rural areas, and ensuring a breadth of access to care (understanding that much of this care will be delivered remotely). These steps reflect, at the highest level, a shift from profitability to sustainability of rural health care delivery. Without adjustments like these, we believe it is unlikely that the current model of rural health care delivery will be able to sustain itself.

While the model described will require major shifts to reimbursement, patient behavior, existing infrastructure, and likely policy to implement at scale, there are established cases where similar models currently exist and work very effectively.  One such model is Southcentral Foundation’s Nuka System of Care in Alaska, which focuses on the physical, mental, emotional, and spiritual wellness of its “customer owners”. (for more information, see this case study developed by their former CEO, Katherine Gottlieb). 

IMPACTS ON SUSTAINABILITY, QUALITY AND ACCESS

Rural health system sustainability is a complicated balance of cost and revenue considerations. On the cost side, patients will face competing out of pocket considerations, with the possibility of additional travel for acute cases, that may be offset fully or in part by reduced travel required given an increased use of telehealth care delivery. For health systems, the fixed costs related to providers, equipment and real estate oriented toward specialty care will be reduced, but costs related to transportation (e.g., ambulances & helicopters as well as their associated emergency personnel) will increase. The corresponding reimbursement mechanisms and regulatory framework will need to adjust to accommodate and sustainably compensate for these changes (e.g., reimbursement for primary care, referrals resulting in lower total cost of care, and coverage of emergency transport within an overall episode of care). It is likely that bundled payment or partial capitation models will be critical to adequately align incentives within this new model.

The challenge in making the case for improving quality in rural communities is that many patients do not perceive that they are receiving “low quality” care, and that the changes proposed here would in fact reduce the care available within their communities. In reality, what we are proposing would, if implemented well, result in far more comprehensive care and improved outcomes for most patients.  By focusing on primary care, acute care stabilization and triage, and specialty care referrals, rural health systems will be able to continue managing the vast majority of needs within the community while more rapidly connecting patients to care they need outside the community when they need it.

By focusing on lower-acuity care and leveraging telehealth to increase entry points into the health system, access can be expanded in the future model without any additional brick and mortar infrastructure being required. While this can be seen in some ways as a net neutral, the increased focus on supporting expanded (e.g., dental, behavioral health, etc.) service provision should provide a boost to primary care and public health resources in ways that makes preventive care more accessible and sustainable in the future.

CONSIDERING THE BIG PICTURE

Transforming rural healthcare will require many years and changes to incentives, regulations, infrastructure, and workforce. These changes themselves do not exist in a vacuum. This may require seemingly non-healthcare investments such as improvement of roads and airports, attracting new talent and retraining existing talent. It will require creativity in re-purposing current infrastructure and tough decisions in eliminating services and providers that community members are attached to.  It will require thinking very differently about hospital finances and likely absorbing some turbulence and losses during the transition. It will require both payers and providers to take more risks, literally and figuratively, in testing and transitioning toward new incentive models. It will also require new sources of government and private philanthropic funding to help fill the investment gap in expanding the pipeline of providers offering primary care and supporting services in rural areas and enabling critical technology and infrastructure investments.

Rural health care delivery in the US is built on an old model, one that is propped up by federal funding structures and business practices that do not adequately address concerns of long-term sustainability nor the true health needs of their communities. The COVID-19 pandemic has revealed the imperative and created the conditions for broad systemic change in a way we have not seen in a generation. While we often think of healthcare innovations as emerging from urban health-tech hubs, perhaps the most exciting systemic changes to improve access and outcomes exist far to the periphery of traditional funding and focus within our rural communities.

The post Envisioning the Future of Rural Health appeared first on Camber Collective.

by Ben Jenson, Matt Holman and Gavin Boileau

Even before COVID-19 struck the United States in February 2020, the traditional hospital-centric rural health model was a failing business proposition that delivered sub-optimal patient outcomes. Well over one hundred rural hospitals have closed in the past decade with more closing in 2019 than ever beforeᵢ. For rural residents with diminishing options, higher rates of chronic conditions and hospitalizations for common ailments are a tangible leading indicator of the persistent and possibly growing lack of regular high-quality primary care utilization compared to urban areas. The threat of rural closures has increased dramatically as COVID-19 temporarily eliminated and continues to disrupt the flow of elective surgeries and other fee for service (FFS) volume that are critical to balancing the tenuous financial equation for most rural health systems. In the short-term, there is a clear imperative for ongoing state & federal flexibility and funding to reinforce the ability of existing rural institutions to continue to serve their patients during the pandemic. At the same time, we believe it is worth asking if the prevailing, failing model for rural health delivery is worth saving in the long term, or if we should use this moment as an inflection point for architecting a new paradigm.

In order to consider what needs to change in rural health it is helpful to consider how we got here. As with most aspects of the US health care system, our current rural care delivery infrastructure reflects the incentives in place as they emerged. These incentives date back to 1946 when the Hill-Burton Act began providing federal construction grants and loans for building hospitals, ultimately helping finance construction of over 6,800 facilities before being phased out in 1997. In addition, rural health has for decades operated under FFS reimbursement agreements with commercial insurers that were designed around urban area utilization patterns and based on high volume and efficiency that look very different in small communities. The Critical Access Hospital (CAH) program, enacted in 1997 and replacing Hill-Burton, further accelerated this trend by improving the incentives for hospital-based care of Medicare patients that tend to make up a large portion of rural hospital visits, as well as subsidizing capital improvements to rural hospitals. It is no accident that the “big blue H” typically stands as the largest employer, largest building, and community anchor point for small towns and cities across the country. By and large, federal and state incentives for nearly 75 years have focused on rural areas building health care “factories” in a scaled down mirror image of their urban counterparts. That model made sense in a time when rural areas needed to be self-reliant in managing a full range of medical needs. However, this model is inefficient and costly in an era where technology, telecommunications and transportation have evolved to a point where rural communities can and should leverage connectivity and comparative advantage to design a lighter and more unique footprint that better meets local needs.

While less than 20% of the US population is deemed to live in “rural” areas, the rural areas in which they live make up 97% of the country’s landmass. Rural populations skew older, less wealthy and less healthy than urban areas on a whole. Even so, rural communities are not monolithic, and the health care needs and issues facing America’s rural expanse are remarkably heterogeneous. Most major US cities have enough density that, while rates may vary, there is a minimum efficient scale of heart attacks, head injuries, cancer of most types, behavioral health conditions, etc., to justify the expansive generalist model of the US hospital. The health needs of rural communities can vary greatly, from a remote fishing community in Alaska to a retirement enclave in New Mexico to an industrial town in eastern Michigan. For each of these places there are common imperatives, such as emergency response, triage, stabilization and transport for acute care needs, as well as in delivering high-quality primary care and chronic care management. Where rural needs begin to diverge is across higher-level acute, specialty, and surgical care. As a result, the future rural health operating model likely has a core that is similar across communities, but very different from today, and a tertiary layer that is far more specialized to specific local conditions and needs.

So, what should the rural health care system of the future look like? Among the many models our Medicare financing model has incentivized, the path forward likely looks less like the traditional Critical Access Hospital and more like the more nimble Rural Health Center (RHC) and Federally Qualified Health Center (FQHC), models that were created to support primary care rather than acute episodic needs. If you were to re-architect these centers to be patient centered care delivery hubs, absent existing regulations and incentives, they would likely take on a broader mandate as medical home for primary care and overseeing acute care triage and specialty referrals (including hosting tele-specialty visits). Ideally they would address a wide range of health and social needs would incorporate case management to ensure an integrative approach across patient needs. They would leverage technology to bridge the miles between patients’ homes and their care teams. If done well, they could close the current health outcomes gap and provide flex capacity for serving a community as it grows.

COVID-19 and the related economic and social upheaval are creating generational tailwinds for health care transformation. In addition to the practical imperative for rural health care delivery to change by merit of financial crisis, many regulatory barriers have temporarily come down in ways that reflect the needs and demand for delivering care differently in rural areas. This includes provisions within the CARES Act and a CMS 1135 Waiver that temporarily removed interstate telehealth restrictions, expanded the range of platforms that can be used to deliver telehealth, and enable rural clinics to be deemed “distant sites” for originating telehealth visits to patients as well as for provider-to-provider consultations. The FCC, for its part, has added nearly $200 million to its rural health care program which focuses on increasing broadband and telecommunications capabilities in support of patient care. Some of these temporary changes will revert, but momentum is clearly with the trend toward greater flexibility by CMS and commercial insurers.

The starting point in transforming rural health must be grounded in a clear-eyed consideration of trade-offs. Is the priority to deliver all care in the community? Or is it to deliver the highest-quality care? Or to achieve lowest cost? In our current model we have chosen community-based delivery at the expense of quality and cost. In our second post on this topic, we’ll further tease out these tradeoffs, and put forward a specific vision for what a rural healthcare delivery system of the future could look like. We welcome your perspectives and feedback as we continue this important conversation.

This is a two-part series. Part 1 provides an overview of the challenge and opportunity. Part 2 articulates a specific vision for the future of rural health.

The post Rural Health Needs a Reboot appeared first on Camber Collective.

Amid a national dialog on systemic racism and police use of force and the continuing need to manage COVID-19 through efforts that include contact tracing, the creation of public health case management forces could be a compelling and cost- effective way to address both challenges.

COVID-19, Black Lives Matter, and Defund the Police. In recent weeks, a confluence of crises has led to a national conversation on racial equity after COVID-focused news cycles that had previously dominated our collective mind share for most of 2020. Making progress on systemic racism requires new policies and practices, no doubt, but in the near-term it also requires a more immediate and direct response to offset and mitigate systemic failures that will take years to solve. Case management provides a great model to begin this work, and the current need for COVID-19 contact tracing provides a unique launching point. Add to this the current dialog on police funding, which provides potential municipal discretionary funding sources to expand and elevate the contact tracer’s role, and these ingredients could come together to transform US social services and even healthcare delivery in a powerful and lasting way.

At the heart of the outcry to “Defund the Police” is the very real need to re-evaluate the role and responsibilities of police officers, including tactics and use of force. While defund the police is currently polarizing, in time, it is likely there will be consensus that the role of policing in the US has evolved to include many responsibilities that officers are simply not well trained or suited to address. Are they best suited to intervene on calls about homeless loitering? Mental health checks? Substance use? The list goes on – if we take a detailed look at the case load of police officers we quickly realize a lot of what they do, day to day, can and should be done by qualified case workers, public health workers, or social workers, who understand the issues better and are more likely to show up with relevant community context, specialized training and expertise, resources and solutions. 

Now consider our ongoing battle with COVID-19, which requires investment in an estimated 100,000 temporary public health contact investigators at an estimated cost of $3.6B in the US[i][ii]. While, significant, this investment barely exceeds what the NYPD spends annually on pensions and bolsters a public health workforce in the US that has declined by 50,000 workers since 2008[iii][iv]. In many ways, the temporary role of COVID-19 contact tracers aligns well with the responsibilities currently placed on police officers that many cities are re-evaluating. Contact tracers are trained to go door to door in our communities, document cases, talk to individuals about their needs and living conditions, provide information, and identify necessary behavior changes or clinical needs. This new workforce is temporary, but it has the potential to serve a broader and more permanent need. 

Imagine if we expanded upon this investment in contact tracers to make their role permanent as a new ”public health force“ of case managers trained in basic medical/clinical knowledge as well as mediation, conflict resolution, and de-escalation. These workers would be tasked with documenting issues, providing resources, solving problems with empathy and making connections to specialists or other social services in the community. Police officers would still need to play a role in security in some instances for this work, but likely a supporting role and only when needed. This is not an entirely new idea. Camden, NJ disbanded its police department in 2012 and replaced it with a force expected to show up to calls “more like the Peace Corps than the Special Forces”. Eugene, OR and San Francisco are also in the process of re-imagining ways to supplement their police forces with officers trained in public health and social services skillsets. In 2019 the Oregon program called CAHOOTS responded to 20% of 911 calls by sending out a medic and crisis worker team to respond to behavioral health incidents; of the 24,000 calls received only 150 times were the policed called for backup. The program costs $2.1M annually, compared to the budgets of the Eugene-Springfield Police Departments $90M. On average, from 2014-2017 the program has saved the community $8.5M annually, by picking up calls otherwise would have required law enforcement, EMS response, or ER visits[v]. Around the world, countries including Sweden, Scotland, Switzerland, and Finland have all established social and public health workforces to replace and augment traditional policing responsibilities[vi]. Meanwhile, robust COVID-19 contact tracing programs and teams have been highly effective in managing and containing spread in S. Korea, Germany, Taiwan and Australia[vii].

Contact tracers-turned-community case workers could be a big part of identifying and addressing both infectious disease as well as current social inequities in the US while identifying opportunities to create sound policies and practices to drive longer-term systemic change. A shift this dramatic would not come without a cost. Expanding the remit and scope of contact tracers beyond COVID-19 would likely require redirecting discretionary funds away from police departments and possibly other state and municipal services, but reflects a rebalancing of focus versus “de-funding”. Creating such a workforce would require case workers to develop a basic understanding on a wide variety of health and social issues in the specific communities they serve – everything from food insecurity, homelessness, substance use, domestic disputes, petty crimes, cultural and race considerations and more. These case workers need to know what issues they are likely encountering during the house call and how to offer an immediate solution or resources. It also requires training to know when to use their direct line to police back-up for security, or an ambulance to help save a life, or some extra muscle from the fire department. If done well, they could become a critical fourth leg of our first responders – a public health force of case workers that connect the dots and navigate citizen needs for a wide range of social services in appropriate measures where today we have in many cases become out of balance in our incident responses. This will require case worker “detectives” who live in the communities they serve, who understand the people and local nuances, and who know how to start solving the problem.

 We are currently in a “once in a lifetime” crisis that is forcing our country to rethink everything from policy and business to politics and values. We are also in some ways fortunate to be stuck in a “new normal” purgatory for 1-2+ years as we await COVID-19 vaccines, which requires prolonged behavior modifications and investments that would be unheard of during normal times. This is the time for local and state government leaders to seize the moment and take bold actions in addressing racial inequities and our broken social safety net. Investments in innovative public health case management models can address two needs at once and are a great place to start.

[i] “”A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US”, Johns Hopkins University, April 2020, https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200410-national-plan-to-contact-tracing.pdf

[ii] “A National, Tiered Approach to Scaling up Contact Tracing”, Association of State and Territorial Health Officials, April 2020, https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing/

[iii] Citizens Budget Commission, https://cbcny.org/research/seven-facts-about-nypd-budget

[iv] ”A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US”, Johns Hopkins University, April 2020, https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200410-national-plan-to-contact-tracing.pdf

[v] “’CAHOOTS’: How Social Workers and Police Share Responsibilities in Eugene, Oregon”, NPR, June 10, 2020

[vi] https://www.washingtonpost.com/world/europe/police-protests-countries-reforms/2020/06/13/596eab16-abf2-11ea-a43b-be9f6494a87d_story.html

[vii] https://theconversation.com/contact-tracing-is-working-around-the-world-heres-what-the-uk-needs-to-do-to-succeed-too-140293

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