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April 11, 2017

Vital Directions and National Will

Author Affiliations
  • 1Editorial Affairs, Institute for Healthcare Improvement, Cambridge, Massachusetts
JAMA. 2017;317(14):1420-1421. doi:10.1001/jama.2017.2962

If the United States had undertaken road building or space exploration in the same way it is chasing health system reform, there would be neither an interstate highway system nor footprints on the moon. The successes depended on clear, bold, shared aims; strong investments in technical mastery; continuity of purpose over time; and continual learning at a large scale—not to mention considerable celebration. Health care reform has had none of these.

The reasons for the difference are many. The National Aeronautics and Space Administration (NASA) undoubtedly faced political headwinds, but they were not gale force, because NASA was not dealing with $3 trillion of the US economy, a panoply of stakeholders with financial interests in the status quo of health care, professional fragmentation, or a viciously complicated legacy payment system designed by no one at all. In addition, NASA’s tools—such as rockets and orbital mathematics—were fit for purpose, or could be made so. There was no prior moon shot to be displaced.

Also, NASA did not have to traverse a political landscape like that of health care reform, full of foxholes and trenches, with unprecedented factionalism overwhelming civil discourse and evidence-based inquiry.

Into this landscape, the report in this issue of JAMA titled “Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative”1 brings some welcome sense making. A stellar, bipartisan steering committee, drawing on advice from more than 150 of “the nation’s leading health and policy experts,”1 commissioned 19 discussion papers and offers a summary of 8 crosscutting policy priorities that those papers invoke. Their summary clearly reviews the magnitude of the problems in the current system, such as unreasonably high costs (now at $3.2 trillion per year), waste levels of 30% or more, persistent and unconscionable health disparities, vast failure to address social and behavioral causes of illness, and consequent, erosive burdens on the fiscal well-being of governments, the private sector, and working families. But it also notes with optimism “compelling opportunities and novel tools”1 for solving those problems, solutions that can thrive if conditions are set properly.

The authors denote 4 of their policy priorities as action priorities. These include (1) continuing and accelerating a shift of payment from volume to outcomes and value, especially to support stronger integration of health and social services; (2) empowering people with better health literacy, telehealth, data access, and attention to the health-related goals of individuals; (3) activating communities to strengthen public health and social care supports, especially for people with the greatest illness burdens; and (4) achieving much better integration of information systems with “end-to-end interoperability”1 and patient ownership of their own data.

The remaining 4 priorities the authors refer to as meeting essential infrastructure needs. These include (5) developing and deploying more meaningful and efficient measures of performance, especially ones linked to this report’s cousin, the 2015 National Academy of Medicine (NAM) report, Vital Signs: Core Metrics for Health and Health Care Progress2; (6) modernizing the skills of the health care workforce to succeed in a redesigned system; (7) improving investments and support for continuous learning from the processes of care, rather than overrelying on randomized clinical trials; and (8) expanding investments in relevant scientific research, including stronger public-private partnerships.

The strength of the Vital Directions report is not in its innovativeness; it contains no surprises. Every single recommendation has a public pedigree in prior NAM reports or well-known lines of scholarship. Its foremost contribution—and it is a major one—is its comprehensiveness. This report offers a template for change broad and inclusive enough for it to be a charter for coherent and effective system redesign.

If the nation had the will and courage to adopt the Vital Directions policy framework as a package, it would with high likelihood within a decade have far better health care quality, far higher health status, and much more sustainable health care costs than it can possibly ever achieve with health care in its current form.

The devil is not in the details here. Everything the authors recommend can, in principle, be done with remarkably few cycles of trial and learning. The devil is in the culture. It is all about will.

To comprehend the actual barriers, one need only imagine (or observe) what happens as each policy initiative comes to be debated. Take, for example, the first action priority: faster, bolder movement toward payment for outcomes. Under the provisions of the Affordable Care Act, the Centers for Medicare & Medicaid Services and its Center for Medicare & Medicaid Innovation are testing an entire fleet of alternative payment models. The potential learning is immense. Yet fee-for-service behaviors and top line–driven revenue growth strategies continue to dominate health care economies, and recent political pushback has been strong against expanding effective bundled payment models and value-based pharmaceutical purchasing.3,4 Public health initiatives and community-based programs for high-need individuals (the second action priority) require both new and expanded investments in the social safety net and transfers of funding from hospitals to community clinicians, but the trends have been inconsistent.5 As obvious as it seems that end-to-end integration of health data, with strong data standards, is essential to improve individual and community health (the fourth action priority), attempts to develop national standards have been agonizingly slow for more than a decade. The need to modernize skills (the second infrastructure priority) seems equally obvious, but the recent NAM report on revising Medicare’s general medical education funding guidelines and governance6 has gone nowhere.

Compared with putting people on the moon (an effort launched by a Democratic president) and building a national highway system (launched by a Republican president), rebuilding the nation’s health and health care system, as so thoughtfully described in the Vital Directions report, lacks not ideas but intent.

Vital Directions proposes a “vision of a health system that performs optimally in promoting, protecting, and restoring the health of individuals and populations and helps each person reach her or his full potential for health and well-being.”1

Does the United States intend to achieve that vision, or not? If so, stakeholder after stakeholder must help, voluntarily when possible but required by law and regulation when not. Leaders must recruit the courage to make the case and put their own political and organizational futures on the line. The public must develop a sense of solidarity about the aims and a sense of impatience with resisters. Those who stand to lose in the short run have so far been highly successful in slowing and often stopping the changes that will help the nation in the longer run. Only social solidarity on overarching aims can overcome that resistance.

The following are questions the nation and its leaders need to ask and answer as a precondition to make the Vital Directions priorities real.

  • Does this nation commit to basic health care as a human right, denied to no one?

  • Does this nation commit to improving continually the health of communities by addressing prevention and the social determinants of health?

  • Does this nation commit to reducing the costs of its health care by eliminating waste in all its forms, and not by harming either care or health?

  • Does this nation commit to navigating to these aims using science, evidence, and learning, not doctrine, as its guide?

The US discourse about health system reform at the moment is a debate about “whether” disguised as a debate about “how.” That will not do. This nation built the highways it decided to build. Its journey to the moon began with the decision to get there, and in no other way. It will prove the same for the health and care this nation seeks.

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Article Information

Corresponding Author: Donald M. Berwick, MD, Editorial Affairs, Institute for Healthcare Improvement, 20 University Rd, Seventh Floor, Cambridge, MA 02138 (donberwick@gmail.com).

Correction: This article was corrected online May 1, 2017, to fix a typographical error.

Published Online: March 21, 2017. doi:10.1001/jama.2017.2962

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Berwick reported being a member of the National Academy of Medicine and providing comments on the working papers for the National Academy of Medicine Vital Directions Steering Committee, but he did not participate in the final preparation of any of the articles.

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