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Winning on Health and Economics for Real


For the past several years, I’ve allied with a team working to adapt the US healthcare system to serve both population health and regional economic health.  Here’s the current picture…

The US Centers for Medicare and Medicaid Services (CMS) recently issued draft rules for Accountable Care Organizations (ACOs).  As discussed here and here, ACOs seek to reframe care for payors, patients, practitioners, and regional populations.

Here’s how it works.  The ACO rules aim at improving Medicare operations.  However, to accomplish change in that very large piece of the US healthcare puzzle, the entire medical system must evolve across age groups, even though ACOs exist in the formal CMS framework only to serve better the Medicare population.

As a practical result, ACOs function like “Medicare for All” for systemic healthcare operations, but without a population-wide funding element.  It’s a separate matter that funding for the Medicare program itself currently is under attack.

There’s a clear way forward without attacking ourselves—use the ACO conversation to achieve population-wide growth in jobs and wages through sharply improved global competitiveness and economic expansion.  The approach is to supply what the ACO rules leave out of the picture.

We’ll need to take a step at a time.  Here’s the two-step…

First, the Goal

The goal for the way forward is for regions to create ACOs intentionally targeted to reduce the largest uncontrolled cost items for most private and public employers and regional economies – employee overhead cost, and unrealized regional increases in productivity, competitiveness, pay, and jobs.

And then, Getting There

Getting to more systemic regional healthcare linked with regional economic value says healthcare operations, and population access and support, will need to become more coherently connected.  What does this mean?

  • ACOs need to be sponsored by private and public employers, employee groups, and regional economic and workforce agencies, as well as by hospitals and Managed Care Organizations such as HMOs on a systemic regional basis; and
  • ACOs need to be oriented at the day-to-day working level around the regional population and the individual patient—not primarily around doctors, dentists, pharmacists, therapists, hospitals, or health payor subscription (insurance) firms.

Clearly and most certainly, there will be medical professionals, hospitals, and payors – but just like successful service and manufacturing firms and public agencies, they will face the implicit and explicit demands of the people at hand.  This means ACOs will need to face the patient and the population—both individually and regionally—much more deeply through a daily workflow orientation toward team-based care.  This will take a fresh regional flexibility, new to healthcare, but very familiar to the public-facing teams and the process-facing teams in firms, agencies, and supplier organizations.

You may wonder if I’m off my rocker.  Not in the least.  Let’s look at the picture.

The ACO rules leave out the direct connection between the vision of “accountable care” for all, and the vision of a globally much more competitive US economy based on becoming the world leader in regional system integration.  This matters because healthcare affects 17% of the US economy.  Competing nations spend only some 8 to 10% of their economies on healthcare and enjoy healthier populations.

It’s clear that US employers, employees, and regions have a global competitive stake in successful region-wide ACOs for efficient and effective operational implementation and positive population-wide health outcomes.

We know from working models that the link across regional health and regional economic value can be made with regional employers, employee groups, business associations, economic development agencies, stop-loss insurors, and public-private coalitions.  We can apply this experience within the ACO rules.

We know how to apply the operational and strategic lessons learned from employer and healthcare projects to achieve state, regional, and local health and business advantage.  The key step is for regional employers and economic and workforce organizations to connect with the economics and operation of population-wide, systemic regional care.  The connecting step unbundles into three core goals…

  • Team care system entry, coordination, medication management, and discharge;
  • Patient navigation and population-wide healthy behavior “nudge” assessments, credits, and first-level distance access for preventive, wellness, chronic, acute, and public health care; and
  • Transparent electronic health records access to medical records for all care.

Why take this connecting step?  Because regional systemic action, added to the ACO model, will do three sets of things…

  • Sustain lower overhead cost;
  • Increase population health, workforce productivity, global competitiveness; and
  • Grow jobs and take-home pay for more sustainable, resilient consumer demand.

Two quick stories make the point, highlight the process, and lead to lessons learned.  The two stories are Keene 2020 in New Hampshire, and Ontario’s Local Health Integration Networks (LHINs)—Ontario’s own ACO initiative.


The Keene 2020 story includes local business involvement in the medical center steering committee, but omits the personal nudge tools from Hannaford and the collaborative care practices from Asheville.  As a result, Keene succeeded in its hospital outreach to the community, but did not connect medical system change with ACO-enabled population-wide change, which is key to lifting a regional economy.


In contrast to Keene, the LHINs in Ontario are a success story for building the critical bridge linking regional health and regional economic value.  The LHINs lead to Ontario’s Mosaic of Stroke task and the Health Transformation Transition & Transformation Learning Project.  Ontario promotes “Quality Universal Low-Cost Health Care” as a regional economic asset.

And Lessons Learned Are on the Move

We’re bringing here the lessons learned from the Keene, Hannaford, Asheville, and Ontario stories.  These stories show that moving forward will require change.

The approach is to offer direct value across an entire region to small and medium employers and employee groups by offering direct value to employees, members, dependents, and their communities.  The ROI stems from two sources – direct cost advantages in systemic health care workflow, and region-wide productivity gains from healthier work teams and more alert training participants due to reduced absenteeism and (especially) less presenteeism.

Presenteeism is working while unwell, or while preoccupied by unwell dependents.  Work teams multiply member effort.  Teams also suffer team-wide on the downside if members are sick or off their game.  See here, here, and here for productivity gains from systemic employer healthcare initiatives beyond supply chain price bargaining.

The regional productivity aspect offers value to larger as well as smaller employers.  Smaller firms are the engines of invention and growth, and larger firms are the drivers for delivering large-scale prosperity and employment.

The results are hugely worth the effort.  Failure to act will reduce the ability of regional economies to succeed in US and global markets as offshore firms leverage the cost and health advantages that our healthcare process now surrenders.

The critical alignment from the US 2015 program is the ability to extend the Accountable Care Organization framework into a regionally systemic healthcare modernization and economic growth program.  This is an opportunity to leverage ACOs as regional assets for a serious kick-start to population health and economic value in the regions and states of the US.

3 Comments leave one →
  1. 2011/06/06 10:42 am

    Joseph, thanks for sharing your story about behavior modification in that most delicate of all scenarios — modifying an abutting neighbor’s behavior on his own nickel! But even closer to home was your story about the man and his boy picking up an idea about picking up on their walks that you offered as a demonstration, not as a lesson or lecture on clean streets — what a great idea that youngster took in as an action he could take. I’m thinking a sense of personal and public efficacy starts with hands-on examples, and builds from there. Nicely done, my dispassionate friend who is only seemingly so — your engagement with people and place rings clear and true.

  2. 2011/06/06 3:29 pm

    Aww…shucks…(blush). But please don’t spread around that I only seem dispassionate. I wouldn’t want to spoil my image with my tribe…


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