'Triple A' approach to building community health

  I chatted a while back with  a colleague, James Marcus (Marc) Pierson, M.D., a Cambridge Management Group (cmg625.com) senior adviser. Dr. Pierson — an internist, emergency physician and past vice president of clinical information and quality for PeaceHealth St. Joseph Medical Center, in Bellingham, Wash. — is a major health-care reformer. His leadership in helping to create an integrated and patient-centered health-care system for Whatcom County, Wash., has received national attention.

As a leader of the Pursuing Perfection program in the county, he helped develop the community-based, patient-centric Shared Care health-record system and participated at the board level in the Whatcom Alliance for Healthcare Advancement (WAHA). WAHA helped lead to the recently approved Washington State Health Care Innovation Plan, which has put the power of the state government behind the many ideas arising from Whatcom County’s whole-community and patient-informed perspectives.

He told us that “the county level is the smallest appropriate geographic base for creating a coordinated-care system.’’ Whatcom County was particularly attractive for such efforts because it has attracted a lot of civic-minded and collaboration-minded physicians who “didn’t move here for the money but, among other things, for the natural beauty.’’

Dr. Pierson said that creating an integrated-care model requires first observing how the chaotic traditional “system’’ was or was not working, then trying to understand it and then writing down observations and designing changes. It was crucial to understand the inter-actions of all of the parts of the health-care system, and, crucially, to use patients’ knowledge and opinions – those too-often-neglected elements of health-care reform – in changing the individuals and institutions that serve them.

He cited the “Triple A’’ approach: 1.) research and analyze the needs and desires of the patient population; 2.) understand (clinically and financially) the other parts of the system (doctors, nurses, hospitals, insurers, etc.; 3.) design together one integrated health-care community in which patients’ decisions play the most important part.

With that, he said, we can build a health-care system whose treatment and payment system addresses the ever-changing needs of the whole community. “The quality of the entire system suffers,’’ he said, “when the focus is more on the individual parts and loses sight of the whole community health system. Perfect parts do not make perfect or even good systems. It is the interactions between the parts that must be designed….’’ In any event, the improve-the-parts approach is unsustainable.

Further, Dr. Pierson said, we need to move away from the “extractive financing model’’ of American health care, in which much of the savings from improving a community’s health care leaves the community, making it unavailable for reinvestment. And he touted the idea of setting targets for spending on health within a whole community, citing the success of Jonkoping, Sweden, which set a target of 8.3 percent of the local economy for health care and has had very good outcomes.

He said that his experience in the mid-’80’s as an ER doctor trying to pull together in an ad hoc fashion a variety of specialists to treat a young man badly injured in a motorcycle accident helped get Dr. Pierson thinking about systems and coordination.

This line of focused community building would ultimately lead to his campaign for integrated, community-wide care. Along the way, he made it a point “not to ask anyone to do anything that was against their economic self-interest.’’ And he sought out the “most respected players’’ in the Whatcom health-care community to help him carry out this vision for the county. He's a very practical (and mostly behind-the-scenes) reformer, whose recommendations would be helpful anywhere in the country.

Given the widening income gap in the U.S., we wondered about whether only the rich would have the finest sort of individualized “concierge care’’. Somewhat to our surprise, Dr. Pierson was optimistic that the use of genomic information, personal medical devices and other advances would make “concierge care’’ available to everyone in the fullness of time, aided by the doctors, nurses, social workers and other health-care ‘’navigators’’ who will increasingly see a major part of their jobs as helping to guide patients to the information they need as well as through the system.

It’s all part of his vision to have all of us see “medicine as a part of health and well-being.’’ The whole community, he says, owns its health and well-being and we must design our futures in that context.

-- Robert Whitcomb