Leidos’ Chief Medical Officer, Donald Kosiak, MD, recently sat down to discuss his views on new trends and technologies in Healthcare and wellness, how they affect the performance and readiness of Service Members, and their potential impact on military families.
What is the Biggest Change in Healthcare that Military Members are Likely to see in the Coming Years?
I’d like to start by saying that we have world-class Healthcare. Most Healthcare systems and provider/patient interactions in this country are built around the fee-for-service model, which means the system is rewarded for treating people when they are ill—the more people treated, the more the system is rewarded. The result is that the system actually benefits the most when people consume Healthcare for illness-related reasons. When Military Members receive care outside the walls of a Department of Defense facility, they likely receive that care in a fee-for-service model.
If we can continue to change incentives to align more with wellness and prevention than illness, meaning the system gets paid the most when it keeps people healthier and prevents the need for treatment, then behaviors and workflows begin to change. That is value-based care. Everyone in the system starts to look at things differently. The Military Health System already has an advantage in thinking and acting this way, and this is the lens we all need to look through when it comes to Healthcare in general. The shift to this value-based care model has begun in the commercial space, but it is not well adapted yet. I think the challenges of COVID-19 have really shined a light on the need for change. In the midst of the largest medical crisis in more than a century, hospitals and clinics in the United States posted some of their largest financial losses ever, furloughing and laying off thousands of workers. The reason became fairly obvious—consumption of Healthcare decreased dramatically in the early days of the COVID-19 pandemic, and without significant patient volume, Healthcare entities suffered financially.
With value-based care, the financial risk is generally shifted to the provider of care. Some advanced examples are a per-member/per-month model, capitated fee model, or bundled fee for services rendered. These models encourage the Healthcare team to think in terms of the patient’s longitudinal journey, rather than primarily thinking about what the patient needs at the moment. The Healthcare team builds a clinical pathway for the patient and family for the coming months and years, seeking to prevent problems, catch signs of illness early when they may be easier to treat, manage chronic illness tightly to minimize acute episodes, and spur end-of-life discussions and wishes when those are needed. The health system and the patient both benefit from this approach—the health system succeeds medically and financially, and the patient enjoys a healthier future.
To implement this value-based care approach, we need to rely more on primary care management, standardization of wellness, and clinical data to help predict what the patient’s problems and needs might be in the future. We need visibility not only into what makes sense now, which is the first step toward lifetime health, but also what steps 2, 5, and 12 will be down the road. Step 12 might not seem to make sense right now, but planning for it might prevent and solve a lot of problems. We need to think about the entire journey and understand where the patient is in the lifecycle of wellness. Will this model prevent all disease? The answer is no, but a focus on prevention, early intervention, and well-orchestrated care coordination when acute issues develop can go a long way toward improving the health and wellness of patients and their families.
What about Behavioral Health?
Thanks to periodic checkups, routine testing, and advances in electronic health records, we do a pretty good job of gaining insight into the overall physical health of Military Members and their families. However, readiness goes beyond physical health. There is a mental and emotional side to being an effective Warfighter, Peacekeeper, and family member, and it can be just as important to readiness as Service Members’ physical fitness, training, and the equipment they take onto the battlefield.
Nevertheless, stigma lingers around seeking help with behavioral health. Many Service Members are still hesitant to access services because they perceive it to be a sign of weakness. Others can’t seem to recognize that a problem exists in the first place. There are different ways to address these challenges.
We can certainly make behavioral services more available and access to them more flexible, while at the same time ensuring there is anonymity when accessing these services. As you expand access, you hope to improve wellness. Increasing access could include expanding into community locations outside the traditional Healthcare locations; such locations often have extended hours of operation and provide services outside the traditional workday, including 24/7/365 support that is essential to round-the-clock military operations. Still, some Service Members just do not want to knock on that therapist’s door. For those who prefer technology and mobility, we can provide the same access to behavioral health services via telehealth from the convenience of their homes. Additionally, we can continue to grant access to wellness applications that focus on behavioral health, mindfulness, and wellness.
Lastly, some Service Members may just need a caring professional to reach out occasionally with a soft touch in person or over the phone, such as by calling and saying, “Hey, just checking in to see how you are. The last time we talked you said you were experiencing some stress because of car troubles. How’s that going?” This outreach can be done by a non-medical behavioral health specialist. These sorts of interactions, which take place in a comfortable, private way without fear of negative consequences, can make real headway in identifying at-risk personnel.
Can More be Done for the Military Family?
Service Members can be trained to be highly effective assets on the battlefield, but if their home life is difficult or diminished in some way, it is certain to affect their performance. That’s why it is so important that our programs pay close attention to Service Members’ partners, children, and extended families. We need to do everything possible to give Service Members confidence that their families are being cared for and their needs are being met. This helps lessen the tug that Service Members feel during deployments and reduces the distraction of worrying that they should be home to help the family with unaddressed wellness problems.
Part of building Service Member confidence is improving the portability of care for the military family. If family members have special health needs, how do they continue to access the right specialists and care providers when they move every few years? There is already enough stress related to moving, including a different home, different schools, and having to make new friends. If Service Members at least know that Healthcare is stable, particularly for family members with chronic disease or other chronic problems, it goes a long way toward increasing their peace of mind and military readiness.
We might also consider setting families up with regular touchpoints with a practitioner throughout the longitudinal health journey. Telehealth and other technology tools can help with that. It might also make sense for each family to have a long-term case manager, perhaps a nurse or social worker, who can remain a resource in the family’s lives, interacting with them for as long as a decade or more, wherever and whenever they move. By building a long-term relationship and familiarity with the family, the case manager can help coordinate local care and make sure the family’s needs are met.
What can be Done about the Social Determinants of Health?
Give me a ZIP code and I can give you a good prediction of a Service Member’s quality of and access to Healthcare and his or her ability to get fresh groceries, clean water, and good education. We know that these environmental factors have a big impact on Service Members’ health and the health of their families. Can we in Healthcare do something about those factors? Absolutely. The Healthcare industry should be able to do more than order blood tests and prescribe medications; it should also play a role in ensuring that these broader environmental and social conditions are improved. In many cases, these conditions have an even bigger impact on health outcomes than traditional Healthcare services.
We know we can gather data on the social determinants of health, but, unfortunately, not all Healthcare entities have the tools or knowledge required to do much with that information. In the current environment, what can I do with the knowledge that my patient doesn’t have a car and misses appointments due to lack of transportation, lacks adequate childcare, has no local grocery supplier other than a gas station convenience store, or struggles financially to afford the medication required for better health? This problem relates to what I indicated earlier, that the Healthcare industry in this country is largely designed and incentivized to deliver acute episodes of care that treat immediate, urgent patient needs rather than focus on long-term outcomes and longitudinal care. Of course, that is a broad generalization and there are excellent examples of Healthcare providers using clinical, social, and behavioral factors to truly improve the care continuum for their patients. If more Healthcare entities focused on social and behavioral determinants of health, and they were financially incentivized to embed those determinants into the care process, then we would likely see an overall improvement of the longitudinal care provided to Service Members and their families. Moving to a value-based care system will be a big step toward making that happen.
About Dr. Kosiak
Dr. Kosiak is an Army Veteran who completed multiple deployments in support of global military operations. He is a Colonel in the Army National Guard and serves as the Senior Medical Adviser to the Adjutant General for the State of South Dakota.