Opinion: Value-based care starts at the bedside
As an immigrant child from a war-torn nation, medicine was not the path I would have chosen to contribute to social justice. During medical school, I realized that the science of medicine could change the course of pathologies that are inherited at least partly due to socioeconomic factors—and as a physician, I could right a wrong.
When I began my clinical rotations in New York City, I quickly realized how different the study of medicine was from its practice. At one of the busiest hospitals in the country, without an electronic health record, I learned that continuity of care is a hard-fought struggle. Overpopulated and understaffed, we were a conveyor belt for patients who were getting the equivalent of Band-Aids for acute manifestations of deeper and more complex medical issues. .
This led me to seek out a smaller city with a slower pace, where I could think more critically about the pathophysiology of my patients to fix what was wrong. In residency, I experienced the transition from “medicine” to “healthcare.” But I couldn’t just take care of my patient, I had to take care of their medical record and prioritize it, in fear of missing something. Meanwhile, the patient was trying to tell me everything I needed to know, but that didn’t matter because it wasn’t documented, time-stamped or discoverable. Furthermore, “medical necessity” often meant patients couldn’t receive care in the hospital that could be delivered in an outpatient setting, although there was no mechanism to ensure this would happen after discharge.
At the end of training, I still didn’t feel effective as a doctor. It was because hospitals were meant for episodic care. To have the continuity of care that I craved to better manage patients, I took my first job as an outpatient practitioner in an underserved community. I soon learned that although I had more time with my patients, I didn’t have the resources to provide the care they needed. I didn’t know how to help the patient who couldn’t afford their life-saving blood thinner at over $500 a month or the patient who didn’t have transportation to get to their appointments.
After six years of satisfying my intellectual curiosity but never truly fulfilling my need to help patients, I realized that I was suffering from physician “burnout.” But I couldn’t shake the feeling that this wasn’t burnout, as that implies that I wanted to pull back and do less, but I wanted to do more—so much more. What I was suffering from was the moral injury of knowing what my patients needed but not having the training to fit this into the construct of the business, the resources needed to accomplish it, nor the incentives aligned to support it. So I ultimately found my way to what felt like the beginning of a solution to this phenomenon: value-based care, which I like to think of as patient-based care.
Today, the U.S. spends over $4 trillion on healthcare with more than 900,000 healthcare companies, over 6,000 hospitals, 500 accountable care organizations and about 1,000 health plans, yet falls short in terms of outcomes compared with other developed nations. I am part of this ecosystem yet I constantly am left wondering: How involved are our providers? And I don’t mean providers like myself, who left the game, albeit in an attempt to design a better playing field for others, but the ones who defend the front lines while waiting for a better system driven by a purpose much greater than their own self-interest. This has compelled me to go back to the bedside as I continue this journey to be the change I hope to see in the world.
Recently I saw my first patient after two years and I felt like I picked up where I left off. This patient was the same person I had met during my first hospital encounter in the busy inner-city medical center. The difference was, I was changed. While I didn’t know how to solve for all her needs right away, I knew where to find the solutions. And better yet, I knew that solutions exist.
As providers pivot their focus from the science of medicine to the gaps in care delivery, it will take a village of business and academic leaders, technology solutions, payers and policymakers to be successful. While value-based care solutions are far from perfect, they are the first step to recognizing that change is needed. As we embark on this journey to design the healthcare system of the future, I urge my physician colleagues to break through past feelings of discouragement and hopelessness to propel this movement forward and lead the village, because ultimately, this change begins at the bedside.