We need to consolidate services. Today, the healthcare industry charges incredibly high rates for services inside of our hospitals. This happens because many hospitals are inefficient, and our fee-for-service reimbursement model allows it. I believe it’s time for the industry to consolidate our hospital assets and develop centers of excellence that are maximally efficient and utilized for the sickest of our patients, which will lower the per-unit cost of care. To achieve this consolidation, we need to develop the infrastructure to support care in lower-cost settings like the home.
The COVID-19 pandemic put a spotlight on the healthcare industry, showcasing the resilience of the U.S. healthcare system while revealing key areas in need of improvement.
In our interview series, “In Light of the Pandemic, Here Are the 5 Things We Need to Do to Improve the U.S. Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders for their insights on improving the current system and innovating for the future.
As a part of this series, I had the pleasure to interview Mark Prather MD, MBA. With the aim of reinventing our country’s approach to healthcare delivery, Dr. Prather co-founded DispatchHealth in 2013 — now a leading provider of comprehensive, home-based medical care. Serving as CEO, Dr. Prather drives the organization’s overall vision and the ongoing development of what is poised to be the world’s most integrated, convenient, high-touch system of care in the home.
Thank you so much for joining us for this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us about your backstory, and what brought you to this specific career path?
I am an emergency medicine physician by training and spent more than two decades at the bedside. Over time, I was drawn into the management side of my medical practice, where I learned the basics of running a small business. In 2007, the Institute for Healthcare Improvement introduced the “Triple Aim” initiative, which states that in order to improve our healthcare system, we need to find solutions to achieve the following three goals:
1) Reduction in the total cost of care
2) Improved clinical outcomes
3) Increased patient satisfaction
This concept spoke to me, and given my creative tendencies, I began ruminating on alternatives to the current care model that could achieve the elusive Triple Aim. Soon after, I put my initial ideas to work and became involved in a health-tech startup called iTriage. My job was to “put my brain in the computer,” and drive patients to the right care, in the right place, at the right time, through an app on the newly invented smartphone. From there, I had the opportunity to take the practice that I had been building over the years and roll it into a much larger clinical solution called U.S. Acute Care Solutions. That company is now the fourth-largest emergency-medicine physician group in the country. I stayed for a few years and ran operations for the western U.S., where I oversaw several thousand clinicians and staffed 64 hospitals. As a result, I learned a lot about managing and supplying high-acuity medical care at scale. Although I enjoyed my time at these companies, I still didn’t feel like my work was consistently furthering the concept of the Triple Aim. So, I began to think through alternative approaches that could lower the cost of care, and I stumbled upon the research of several pioneers who touted the improved efficacy and cost-efficiency of in-home care delivery. Although initially skeptical, over time I came to believe that at least one-third of the care typically provided in the hospital or a post-acute facility could be moved to the home. In doing so, we could achieve our Triple Aim goal and make a massive impact on the cost of healthcare in this country. At the same time, the shift to in-home care would significantly improve the lives of millions of patients who struggle with access to care or who find the current healthcare model challenging.
Can you share the most interesting story that happened to you since you began your career?
Well, remember that I’m an emergency room doctor and have two decades worth of fascinating human stories, but I will leave those for another time. Today, I will tell you a story about DispatchHealth’s movement of care into the home and three words you don’t often hear in a healthcare setting: “I love you.” When we began our Advanced Care service several years ago, offering an in-home alternative to the hospital, one of our first patients said, “I love you” to our intake team during the admission process. This team — our front line for patients who need care — decided to begin tracking what they called the “I love you” score. If a patient tells anyone on the care team that they love them, the team achieves a positive score.
Interestingly, today the team is running an “I love you” score of 70%. I have been fascinated by the engagement and positive impact in-home care provides, especially relative to my old world at the hospital. So many patients feel misunderstood and mistreated in the current model. The ability to treat a patient on their own terms is a gamechanger in regard to satisfaction rates and clinical outcomes.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
When we started DispatchHealth, we did so within the 911 system. As a medical director in an emergency room, I had the opportunity to partner with one of our affiliated agencies. I developed an innovative program within the 911 system that became the model for DispatchHealth moving forward. This starting point provided us with a consistent flow of patients and allowed us to hone our clinical model. When we decided to commercialize the pilot and become DispatchHealth, we had a rude awakening. The first day we opened, I remember sitting with the team in an office of approximately 100 square feet (about the size of an apartment bedroom) and staring at the phone. It did not ring. The “If we build it, they will come,” theory wasn’t working in this instance. We had no idea how to engage patients when we first started. I was used to opening an emergency department or hospital, sprinkling in some marketing, and watching the patients arrive. Well, that’s not how it works with a novel clinical offering.
Fast-forward six years, and a lot has changed. We learned which partners struggled with access to care for their patients and which patients needed an alternative solution to a brick-and-mortar healthcare setting. Every year since that time, we have roughly doubled the volume of our visits, and have developed strong partnerships that continue to produce benefits for our patients.
Can you please give us your favorite “life lesson” quote? Can you share how it was relevant to you in your life?
I’m a fan of philosophy, and a quote from the Roman Stoic philosopher Seneca has stayed with me since I heard it in college: “Luck is what happens when preparation meets opportunity.” As I moved through medical school and into my career as an emergency medicine physician, I knew that I wanted to experience more personally and professionally than I would if I remained a bedside clinician my entire life. Every time I felt myself becoming complacent, I would challenge myself to learn something new, and, inevitably, an opportunity would present itself that matched that new skillset. My internal drive as a lifelong learner, combined with a willingness to take risks, has served me well.
Are you working on any exciting new projects now? How do you think that will help people?
We are working on scaling our current solution to rural markets. Access to quality healthcare in the rural setting can be challenging. Our traditional care model was too asset-heavy to scale to the rural setting initially. Still, we have been experimenting for the past year with an asset-light model that leverages more virtual care, and the results have been compelling. A guiding principle of the company is equity and inclusion. We strive to make our model available to all types of patients in all geographies, and this extension of our services will go a long way towards achieving our goal.
How would you define an “excellent healthcare provider”?
Technically competent, intuitive, and a skilled motivator, drawn to medicine by an innate desire to help others.
Thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system, with some healthcare systems at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?
First, most of the care delivered in this country is within a fee-for-service framework based on the utilization of healthcare services — the more we use, the more providers get paid. During the pandemic, utilization dropped abruptly, which led to a significant reduction in reimbursement for fee-for-service providers. On the other hand, the handful of value-based providers did exceptionally well because they kept utilization in check, except for what was essential. Thus, COVID-19 highlighted the tenuous nature of healthcare utilization in this country and, to some degree, the potential for unnecessary utilization.
Additionally, the inability to rapidly mobilize adequate personal protective equipment resources was a travesty. It put providers and patients at significant risk. In the future, we need to consider supply chain as a component of national security and ensure that a steady supply of personal protective equipment is always in place.
Of course, the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID-19 vaccines are saving millions of lives. Can you share a few examples of ways that our healthcare system succeeded?
For me, three things come to mind:
- Rapid innovation
- The relaxation of some regulations
- An unwavering commitment to patient care
In terms of innovation, the speed at which vaccines became available was unprecedented. Typically, it takes scientists years, even decades, to develop formulas. Instead, COVID-19 vaccines were ready in less than a year. It’s impressive and comforting to know our pharmaceutical community can act this swiftly.
A less-celebrated win is the easing of some regulations, making medical care in the home more accessible. For example, the Centers for Medicare and Medicaid Services extended several waivers of existing rules to facilitate in-home care during the pandemic. These temporary waivers, built on decades of research, demonstrate that inpatient care at home is possible, safe, and preferred by patients. In addition, early studies by Johns Hopkins Medicine show that hospital-at-home patients experience better clinical outcomes with lower mortality rates and higher patient satisfaction. Not to mention, treating patients in their homes is more cost-effective. On average, total costs are typically 20 to 30 percent lower than a traditional setting.
Finally, the level at which healthcare providers jumped into action was nothing short of inspiring. Despite the fear that came with all of the unknowns, the DispatchHealth providers I work with showed no hesitation walking into the homes of those who were fearful they would become infected, as well as those who tested positive for COVID-19 positive and needed help. I know this was true among the entire healthcare ecosphere nationwide; many of our partner health systems sent nurses to hospitals that were overwhelmed. Here in Colorado, we partner with Centura Health; they had dozens of nurses that jumped on airplanes to support states that were desperate for help. That level of dedication is heartening and makes me proud of my profession.
Here is the primary question of our discussion. As a healthcare leader, can you share 5 changes that need to be made to improve the overall U.S. healthcare system? Please share a story or example for each.
- Our country’s healthcare system would benefit significantly from a value-based reimbursement model, instead of the more popular fee-for-service model. Unfortunately, while the industry is moving toward a model that revolves around preventative medicine and better outcomes, we remain stifled by the traditional way of incentivizing providers based solely on the number of services performed.
- Secondly, while there will always be unexpected illnesses, traumas, and genetic predisposition to disease, our healthcare system would benefit from a greater focus on long-term wellness strategies. This ties nicely into my first point; reimbursing providers based on outcomes should motivate caregivers to keep their patient populations healthy.
- Next, the breadth of care we can deliver in the home is something most people do not understand. Today, we can safely bring high-acuity care right to a patient’s home. Even better, a significant body of medical literature demonstrates that in-home healthcare reduces cost, decreases unnecessary hospital utilization, and improves outcomes. For example, the data around home hospitalization shows a 20 percent reduction in mortality, compared to patients admitted to the hospital setting. One of our advisors, Dr. Bruce Leff, likes to say that home hospitalization is a more influential modern-medicine accomplishment than a blockbuster drug like statins.
- Additionally, we need to be more mindful of social programs proven to reduce healthcare utilization and promote wellness. More than one-half of our health outcomes are related to social and environmental factors, as opposed to medical interventions. Until very recently, however, we haven’t paid a lot of attention to those factors. If our goal is wellness — which I think it should be — and we start incentivizing care delivered in a value-based model, we will find a way to pay for these social services. As care moves into the home, we’ll be able to engage patients on a more personal basis, monitoring, identifying and addressing potentially harmful social determinants of health in their environment.
- Lastly, we need to consolidate services. Today, the healthcare industry charges incredibly high rates for services inside of our hospitals. This happens because many hospitals are inefficient, and our fee-for-service reimbursement model allows it. I believe it’s time for the industry to consolidate our hospital assets and develop centers of excellence that are maximally efficient and utilized for the sickest of our patients, which will lower the per-unit cost of care. To achieve this consolidation, we need to develop the infrastructure to support care in lower-cost settings like the home.
Let’s take a deeper dive on this topic. How do you think we can address the problem of physician shortages?
I recently came across data from the Association of American Medical Colleges projecting a physician shortage of up to 122,000 by 2032 — that is a real problem! Of course, the obvious solution is to make it less costly to receive a medical degree and less cost-prohibitive to get malpractice insurance. Still, a few other things that get talked about less frequently could help more immediately.
One strategy is to encourage clinicians to practice at the top of their licenses. In medicine, we typically under-utilize our different provider types. By enabling all clinicians to practice at the top of their licenses, we utilize the most expensive provider, the physician, for the most complex cases.
We also need to train more clinicians like physician associates and nurse practitioners, who can treat various illnesses and prescribe medication. These providers can handle the front lines very effectively, and getting the required education and certification is less time-consuming and significantly more cost-effective. Let’s elevate awareness and encourage enrollment in advanced-practice provider programs.
The other strategy is virtual care from anywhere, and inspiring things are happening in this space. For example, at DispatchHeath, medical technicians visit patients in their homes with some really excellent tools, and facilitate a doctor joining virtually. Innovative technology allows us to see inside someone’s ears and throat and listen to their lungs and heart, all remotely. The ability to effectively treat patients from any setting empowers physicians to see more patients, more cost-effectively while still preserving their work-life balance.
How do you think we can address the issue of physician diversity?
Research shows that health outcomes improve when the race and ethnicity of the patient are the same as their physician. Considering this and knowing that Black and Hispanic physicians make up only 11 percent of the workforce, diversity in medicine is important. So how do we address it? First, we need to show young people of diverse backgrounds the numerous benefits of becoming a physician, then we need to change the medical school acceptance algorithms, and finally, reform the overall cost of receiving a medical education.
Pre-med students who interact with physicians at the undergraduate level are more inclined to pursue a career in medicine. Shadowing experiences also look good on a medical school application. However, for underrepresented minority students that may have limited contacts in the medical field, finding out about these opportunities can be difficult, and the cost and time investment required is often prohibitive. If we could elevate access to internship programs and add some financial incentives to help pay the bills, this would give minority students a more equitable chance to pursue a career as a physician.
When it comes to medical school itself, a recent study focusing specifically on minority students in medicine revealed that the application itself was the most challenging aspect of applying — the process and expenses can be overwhelming, costing up to 15 thousand dollars. Those who make it through the application process still face the oppressive cost of attendance; the average medical student without scholarships can expect to graduate with 250,000 dollars or more in debt, which can double or triple once you figure in loan interest. These exorbitant costs disproportionately impact students from underrepresented backgrounds.
Census projections suggest by 2050, minority groups will account for about one-half of the U.S. population. Considering that many pervasive health disparities are rooted in a lack of diversity in medicine, you can start to see why getting this right is so important. The founding dean of Morehouse School of Medicine, Dr. Louis W. Sullivan, has said, “When minority students give up their dream of becoming a doctor, they are depriving future patients who would benefit and depriving the nation of the contributions they could make.”
How do you think we can address the issue of physician burnout?
American business writer Daniel Pink described the concepts of autonomy, mastery, and purpose in his book, Drive. These three factors are highly motivating for professionals. However, incentivizing a widget-maker is vastly different than incentivizing a professional. Unfortunately, our approach to the physician workforce has become less aligned with the concepts of autonomy, mastery, and purpose. As a result, we see an increase in burnout.
In addition, much of our current fee-for-service healthcare system is designed to drive maximum utilization at the highest unit cost through each physician. If you ask, most physicians will say they didn’t go to school to be so counterproductive, and it’s a sure-fire way to cause burnout. In alternative value-based payment models where increased wellness and reduced overall utilization drive incentives, we see a very different level of provider satisfaction. Clinicians can spend more time with their patients and, in many cases, receive better compensation than their fee-for-service counterparts.
What concrete steps would have to be taken to actually manifest these changes? What can individuals, corporations, communities, and leaders do to help?
Raising awareness of and understanding in the complexities of healthcare is the best way to drive an overall improvement of the U.S. healthcare system. If individuals, corporations, communities, and leaders alike gained a better understanding of the barriers to a better healthcare system, we would see movement.
Customarily, Americans are not good healthcare consumers. When healthcare was a bit more affordable, insurance companies paid most of our medical bills, which blinded many to the costs and waste associated with receiving care. In other service industries, consumers ask questions and shop around — we should be just as involved with our medical care dollars.
Many corporations already engage associates with wellness programs, offering incentives for things like not smoking and gym memberships. We need to do more of that! If human resource representatives worked to educate associates on the ins and outs of their healthcare insurance policies and shared strategies for the most efficient use of their healthcare dollar, that would help too.
We also need our community and government leaders to be more mindful of social programs that will reduce healthcare utilization and promote wellness. It’s worth repeating that more than one-half of our health outcomes are directly impacted by social and environmental factors. By moving healthcare into the home, we get to identify impediments to good patient outcomes in the “context” of the patient’s natural environment.
Bottom line: if we become better patient-consumers and change our overall mindset towards wellness, we will see improvement in the U.S. healthcare system.
You’re a very influential person. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be?
While this may sound a bit self-serving, one of the fastest ways to fix our underperforming healthcare system is to move as much care as we can to the home. Americans spend 4 trillion dollars on our healthcare system today, and 1.3 trillion dollars of that spend is on “facility-based” care. We can move at least one-third of that into the home — where social determinants of health are more readily identified and addressed — and cut the cost of care significantly while improving outcomes and reducing the need for overall utilization.
Shifting to in-home care is one of the fastest ways to optimize care delivery while driving down excess cost in healthcare.
How can our readers further follow your work online?
Thank you so much for these insights! This was very inspirational, and we wish you continued success in your great work.