Is it Time for a LEED-like Certification for Healthcare to Accelerate Shift to High-performing Health Ecosystem?

LEED certification from the U.S. Green Building Council has indisputably accelerated the development of the green building technology ecosystem. Over the last 20 years, green building practices as exemplified by LEED-certified buildings has evolved from a fringe movement to something that provided real estate developers a marketing advantage to table stakes for developers. Today, half of all commercial development has some kind of LEED certification. I believe a community developed, open source LEED-like certification for health and wellness can have a similar catalyzing effect for the new health ecosystem. A LEED-like certification will show that a particular healthcare or wellness service dramatically out-performs on the Quadruple Aim metrics versus the under-performing status quo.

An American solution to healthcare’s redistribution tax

We now have LEED-certified buildings (hospitals, high rises, multi-family housing, schools, etc.), LEED-certified professionals and LEED-certified products. There is no question that the green-building movement was catalyzed from the bottoms-up. It was only later that dozens of states, federal departments and municipalities further fueled the green-building movement by mandating LEED. Fortuitously, LEED shows how what’s good for the environment can be good for the bottom-line. In healthcare, there is a similar opportunity where the highest performing approaches also happen to be the least expensive and can fuel economic development in a much more sustainable manner than the caffeine hits that new hospital construction creates. The long-term story of new hospital construction is the redistribution “tax” by the health system on their local economy and the economic devastation of middle class directly resulting from the “tax” that is fueling a populist uprising.  

Update: A new definition of Transparency that borrows from Fair Trade is outlined here. 

Few would argue that the healthcare system far under-performs its potential given the smarts, passion and resources invested.  Further, it’s easy to argue that there is no greater immediate threat to America than our status quo healthcare system. Despite this, the great news is that every structural fix needed to realize healthcare’s full potential has already been invented, proven and modestly scaled — we just need to work to scale it broadly.  Traveling the country on my seven-year quest to find solutions to the predicament we’re in has fueled my optimism. For example, I chronicled the potential for Direct Primary Care (DPC) to radically overhaul healthcare and wrote the seminal paper on DPC. My optimism is furthered by the fact that so-called conservative ideas are coming from progressives and so-called liberal ideas are coming from conservatives. In other words, the solution isn’t a “right” or a “left” solutions — it’s an American solution. It’s worth noting that the U.S. is the worst performer in terms of bang-for-the-healthcare-buck but I’ve found that most countries aren’t far behind in facing the consequences of the under-performance. Thus, the Health Rosetta is equally applicable outside the U.S.

Great waste, great opportunity

In parallel to chronicling those organizations far out-performing their peers on the Quadruple Aim, I also began doing a root cause analysis of various dysfunctional aspects of healthcare (Lean startup and Toyota aficionados know this as the 5 Whys process). Every time I did that exercise, the root cause came back to the fact that we purchase health and wellness services incredibly poorly. Imagine any area of the economy where more than half of what is purchased adds no value.

In some areas, it’s even worse. For example, Virginia Mason and Starbucks did a study that found that 90% of the spinal procedures they were doing didn’t help at all. In a recent conversation with one of the foremost experts in the country on health benefits, Brian Klepper, he made the stunning point that 2% of the entire U.S. economy is wasted on musculoskeletal procedures (MSK) that add no value and aren’t evidence-based procedures (basic math is healthcare is nearly 20% of the U.S. economy, MSK is typically about 20% of spending and half of MSK procedures aren’t evidence-based).  

When healthcare purchasers get it right, the results are breathtaking. It has not only led to greatly improved results for employers, it has literally led to reductions in crime, doubling of high school graduation rates, and more. Sadly, too many people have given up hope that healthcare can be improved when that simply isn’t the case. Naturally, there are 3 trillion reasons to perpetuate that perception and perform innovation theater to make it look like something is being done about the problem. Meanwhile, forward-looking individuals have ignored so-called experts and decoded the healthcare system to achieve the Quadruple Aim.

Just as the Rosetta Stone decoded Egyptian hieroglyphics that were once indecipherable, innovators have decoded what many view as an indecipherable health ecosystem. Thus, we call the decoded blueprint for how to smartly purchase healthcare, the Health Rosetta. Organizations following Health Rosetta principles are spending 20-55% less per capita on health benefits with a package of health and wellness services that is better than what 99% of Americans have.

Having spent much of the last week in the middle of a family health crisis, I’m beyond thankful that my parents are in a Health Rosetta type practice. Previously, they had been in a practice/plan that is as good as it gets in the standard, under-performing healthcare system. My folks were in a well-regarded multi-specialty clinic in Seattle with a “rich” teacher retirement health benefit plan. However, “rich” doesn’t mean good. The stress my family was under would have been exponentially worse had we not shifted them into a Health Rosetta type model over a year ago. Even though the care they are now receiving is far, far, far better than before, it happens to be less expensive. In other words, it’s what every American deserves and we can afford this type of model if we don’t accept the status quo.

Overcoming the preservatives

No industry is more effective at preserving the status quo than the healthcare industry. The range of status quo preserving tactics are truly impressive if that was the measure of success. For example, turning conservatives and progressives into preservatives has been remarkably effective at entrenching the status quo. If the industry was as effective at achieving the Quadruple Aim as it was at protecting the status quo, we’d be achieving what one breakthrough integrated health plan has as their tagline — twice the healthcare at half the cost and ten times the delight. In light of the world class status quo protection, the only conceivable way to overcome those techniques is a grassroots movement. 

Examples in the past range from civil rights to addressing climate change to an overhaul of our food system. These all began at the grassroots and then steadily became what the mainstream adopted, eventually bringing along politicians who jumped to the front of the parade when they didn’t want to get left behind. Healthcare is no different. All of the forward-looking people I have spoken with believe the way to overcome entrenched interests is if there is a grassroots movement that is a partnership between clinicians and citizens — neither can do it on their own.

The “good news” is that clinicians are even more dissatisfied with the status quo as they live it every day. I’m further buoyed by the fact that even the status quo protectors are largely operating out of a fear of change and are good people. When they see there is a system they can be part of and have no qualms about what they are doing to their country, they readily switch sides.

You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete. - Buckminster Fuller  

One of the key reasons there has yet to be a great healthIT company ever come out of Silicon Valley is the mistaken belief that technology itself can cause disruption. If you don’t get at the root cause of how we pay and reward healthcare providers, we will continue to have high-prestige hospitals be out-performed by organizations with a superior culture and rational reward systems. Read Sarah Kliff’s powerful, Do No Harm article if you have any doubts about how damaging high-prestige hospitals can be. Sadly, it’s not only safer to walk into a plane that flies 30,000 feet above the earth than be admitted to a hospital, it’s statistically safer to jump out of a plane than be admitted to a hospital.  

On top of preventable deaths in hospitals, there are 4 million cases per year of serious, preventable medical harm in the U.S. healthcare system. That is four times the number of U.S. casualties in the entirety of World War II. The cases of preventable medical harm are the healthcare equivalent of “friendly fire” and that is a pox on the medical profession. As with friendly fire in a war context, it’s rarely due to bad “soldiers” — rather, it’s due to flawed approaches and reward systems as highlighted in Unaccountable by Johns Hopkins’ surgeon, Dr. Marty Makary. Culture always trumps strategy which is a key reason that a set of guiding principles is a key element of the Health Rosetta.

Ask your doctor if Health Rosetta is right for you

A LEED-like Health Rosetta certification would provide health and wellness purchasers a trusted resource to guide their purchasing. The certification must be an open, evolving and transparent approach that isn’t controlled by the suppliers of health and wellness services. It would be one of the pillars of how to shift the health ecosystem to a much higher performing model. The entire reason I’m working on healthcare equivalent of The Big Short/Super Size Me/An Inconvenient Truth is great films are effective at sparking grassroots movements. However, without a clear call-to-action, movements never get off the ground. The Health Rosetta is the call-to-action.  

It would not only serve as a blueprint for how to wisely purchase health and wellness services, it provides a set of guiding principles for how the suppliers of health and wellness services can succeed in the new health ecosystem. Leonard Kish and I curated the guiding principles from many of the leading thinkers in health and wellness. We’re inviting people to add to this open source resource by contributing essays to bring to life each guiding principle. When you visit the Health Rosetta site, you’ll see leading thinkers who’ve already contributed their essays that we’re starting to roll out.  

The Health Rosetta certification process will only have credibility if many contribute to its definition and view it as a challenging, but fair, industry resource. To those who would be critical, we invite them to suggest how the Health Rosetta should be improved. We’d be gravely disappointed if what is best today is best a year from today. If, however, critics simply attack it without offering evidence of something better, it’s clear their objective is to lock in the status quo.  

The following areas are being actively explored for certification:

• Specific health plan components such as value-based primary care, transparent medical markets, concierge-style employee customer service, transparent pharmacy benefits and an ERISA plan checklist with more on the way. A purchaser would be foolish to not incorporate these elements into their health plan.
• Benefits leaders whether they are benefits consultants or benefits leaders inside of an employer. Executives at employers would be foolish to not hire a benefits consultant/leader who wasn’t Health Rosetta certified. Read more in Benefits Brokers Are Dead. Long Live Benefits Advisors.
• Real estate communities: We know that the sick care system only drives 20% of health outcomes. Very large senior living real estate developers have approached me about having Health Rosetta certified communities. One of these initiatives is led by the former Chief Medical Officer of one of the highest performing, next-generation primary care organizations. Despite their fantastic results, he realized that he wanted to get to the root cause of health issues (e.g., social factors, health behaviors, etc.) and this required going beyond just a healthcare services business model to one that incorporates a blend of three business models — real estate, wellness and healthcare.
• Communities: Similar to real estate communities, much of what drives or impairs health happens at a community level. For example, walkability, access to quality food, education and more are big drivers of the health of a community. One of the key organizers of the mayors/counties climate declaration that ultimately led to the Paris Climate Accord is driving the definition of a loosely similar city/county-based movement. With healthcare, there is the additional imperative of most cities and counties are large employers in their own right and have healthcare-driven budget crises. As is being demonstrated in one community, the best way to slash healthcare costs is to improve benefits.

Millennials to the rescue?

Most movements start with younger generations whether it's something more trivial like social media or more substantial like civil rights. Boomer parents have left behind a big mess for their millennial children. Not only is the healthcare system designed as a perfect polar opposite of what the largest generation in history values, leaving things unchanged would make millennials indentured servants to the healthcare system for all intents and purposes. Of course, those of us who aren't millennials want the same thing. In fact, it's largely Generation X and younger Boomers who both have many years ahead in our careers and are in leadership positions to make the industry change.

In the end, all generations have a stake in ensuring that healthcare realizes its full potential. Young or old. Right or left. Private and public purchasers of health and wellness services are getting the shaft. The biggest lie in healthcare is that one can’t control the costs while maintaining or improving the quality of care received. Hundreds of thousands of families are saving $20,000 per year versus the status quo. Employers are saving 55% per capita on health benefits despite very challenging health challenges in their workforce.  

The Health Rosetta seeks to codify the smartest approaches to how to purchase healthcare. What do you think are the pitfalls to creating a certification for Health Rosetta? What’s your recommendation on how we can avoid those pitfalls? None of us are as smart as all of us. I believe this is the great challenge of our times and look forward to getting your ideas.