Seeing the future 45 years later at the Brookings Institution: CHF and Payment Reform

When I was at the Brookings Institution ( @BrookingsInst @BrookingsMed )with fellow Permanente physician, cardiologist Priti Sood, MD, for MEDTalk: Treating Congestive Heart Failure and the Role of Payment Reform | Brookings Institution, this quote immediately came to mind:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success….freedom of choice is important; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians. – Sidney Garfield, MD, Scientific American, 1970

It’s this one because I noticed how changes in our health system are inspiring physicians today to learn and grow as leaders.

I also thought of this image comparison, from yesterday (shown by Darshak Sanghavi, MD @DarshakSanghavi)

And one of Sidney Garfield’s diagrams, drawn more than 45 years ago:

“Rationally organized medicine” – Sidney Garfield, MD (click to enlarge)

In the diagram, the physician is sleeping, there’s a metaphysical spider web in their office because patients are now being cared for within a system of care, that includes prevention and sick care in the right amounts, on a foundation of pre-payment and integration. Hospitals and a sick care system still exist in this world, they are used and available when needed, and they are top notch, fit for purpose. Today, the spider webs are still metaphysical (no doctor is sleeping in their office today, far from it), and the system of care is today’s Kaiser Permanente.

The innovation at Duke University and University of Colorado can be found on the Health Affairs Blog here (see: Payment and Delivery Reform Case Study: Congestive Heart Failure – Health Affairs Blog) , the blog about Sidney Garfield’s innovation 45 years ago can be found here (Where we came from – Sidney Garfield, MD, 1970 | Ted Eytan, MD). Compare and contrast, the future is coming true :).

Dont’ forget about leadership

Larry Allen, MD, MHS, Cardiologist from University of Colorado, touched on this in his talk when he mentioned that the better way of providing care that was developed wasn’t instantly adopted by his physician colleagues – it required leadership and cultural humility on his part to protect change in the interest of patients. This is true regardless of the payment model. Aligned incentives are important (and great), they do not magically change behavior though, they facilitate good leadership. That’s the part of Sidney Garfield, MD’s diagram above that isn’t obvious to many who see it for the first time.

Patients included

As it says on their web site, the format yesterday was very “un-Brookings,” more modern, intimate and maybe exposed/vulnerable of all of the discussion leaders, including the patient, Lee Satterfield, who is really Lee Satterfield, the chief judge of D.C. Superior Court, also Lee Satterfield, cancer survivor and heart failure patient secondary to the use of chemotheraphy, stroke survivor.

If you click on the first link about Lee, you can see the last four years of his service, in photographs, to the people of our (awesome) District. It’s a very important reminder about our role to focus on people’s life goals and how health makes that possible. Sometimes that’s forgotten. In the ideal health system diagrammed by Garfield above, the physician earns their salary, the hospitals start to empty (or in reality get used when needed) when the patient is achieving their life goals.

I was so glad that in the final panel discussion – a short sojurn to the pre-modern Brookings Institution – that Mark McClellan, MD made a point to ask Judge Satterfield for his thoughts, because the patient voice often gets lost when they are the one “non-expert” on a panel:

I have to say what I say on here all the time for cermonial purposes, I see many analogies to health and health care in this statement šŸ™‚

You can watch the entire session here, and it’s embedded below. Thanks again for your time, Darshak, Brookings Institution, Judge Satterfield and our future health care leaders, including patients and their families.


Ted Eytan, MD