The Central Tendon


By: John Anderson, MD, FACS, Senior Vice President, Navvis Healthways

As a young surgeon some years ago, I had wonderful teachers and mentors who imparted to me a number of fundamental principles of practicing medicine. Though initially intended to be applied in clinical settings, a number of these principles I learned early on have sensible application to the complex domain of healthcare more broadly defined than traditional medicine and surgery. I’ve discovered this as I’ve increasingly devoted my career in recent years to the administrative side of medicine and healthcare.

For example, one mentor used to say that every patient – and more specifically, every surgical patient and every operation – had a “central tendon” which, when identified and “clipped,” made everything else seem minor and secondary. I quickly learned that this principle was significantly true in a clinical setting and have since realized it has much broader relevance.

As the Patient Protection and Affordable Care Act, aka ObamaCare, has swung into full gear with the opening of the exchanges and the expansion of Medicaid in 2014, virtually everyone believes that the healthcare industry has crossed into a very different place. This new reality has already begun to challenge our market’s brightest and most innovative minds to generate solutions that will position the American healthcare system as one to be emulated, rather than one that lags behind in virtually every imaginable dashboard metric. We as a country can do better…much better.

That said, here are a few observations regarding the current situation that I believe to be essential, beginning with my own view of what the “central tendon” might actually be. This short list is by no means intended to be comprehensive, rather just one person’s view of a few things that should be top of mind when thinking about how we fundamentally change and innovate our way out of the current reality with all of its issues.

Issue 1 – Physician Engagement

Others might have a different view, but I believe that “physician alignment” or perhaps preferably, “physician engagement” is just that central tendon issue, from which most all else in healthcare flows. Still the most respected and admired profession in the world, doctors always have and always will have a distinctive and irreplaceable role in the so-called conscience of the healthcare debate. (That in no way is meant to disrespect or undervalue the role of so many other healthcare professionals, especially that of nurses who will forever be the most intimate of partners with physicians at the sharp end of care. Enough said on that lest I be misunderstood.)

While not everyone will agree with me, I for one believe that our historically bifurcated payment schemes have ­– more than anything else over the last 75 years – driven doctors and hospitals further apart. Doctors ran the doctor business, and hospital administrators did likewise for facilities. Meanwhile, patients always thought of their care as “integrated,” and likely didn’t fully understand the distinction between professional and technical services. Nevertheless, we collectively have messaged within the industry something like this: “You take care of your business and I will take care of mine.”

The economic reality of where we are today, with our total healthcare spend being in excess of $2 trillion, cannot – and should not support – that kind of inefficiency and misalignment. We need the collective insight that both, really all, parties bring to the table. It is my belief that those hospitals and healthcare systems that “crack the code” when it comes to solving the physician relationship and engagement issue will be advantaged in the marketplace, regardless of local market forces and dynamics. The models for such alignment are numerous and certainly not confined to full employment and all should be fully explored.

Issue 2 – Healthcare Leadership

Second, and very much tied to the issue above, is the whole topic around leadership in healthcare. No, we don’t just need to train up an army of physicians with graduate business degrees to take over and fix what needs to be fixed. Rather, we need to thoughtfully and respectfully look at how leadership in healthcare has evolved and how narrowly focused we’ve been – something I think has happened from natural progress and isn’t anyone’s fault.

Regardless, our thinking about what healthcare is, where does it start and stop, who are the crucial stakeholders, where are the boundaries, and not least the question of role clarity are critical. We need to be intentional about leadership re-design, and we need to be bold. We need to build upon the strengths of the current leadership model, but not be constrained by it.

Much is said in today’s environment about taking risk, and most of the time we are talking about financial risk associated with the healthcare premium dollar. But we also need to think about bold risk-taking around leadership, empowering leaders to boldly redesign a model that is better suited and adaptable to where we are going, and not where we have come from. What are the skills and competencies that we need to anchor around? What perceived, but outdated, strengths do we need to jettison? Simply put, where do we need to build muscle, and how do we get the new muscle to work with the old.

This kind of change won’t just happen on its own, but needs to be led by a few brave organizations that will take it head-on. I believe that those organizations will be advantaged in the marketplace. In considering this challenge, organizations should think about the following three things:

  1. Are our leaders currently equipped with the necessary skills and competencies to navigate the changing environment?
  2. Is our leadership and shared governance model the right one for us?
  3. Who do we need to engage to help us get from where we are to where we need to be?

Issue 3 – The Role of Boards

And one final thought: who is going to be the primary catalyst for change even if the only change we focused on were the two issues above? I for one believe that it is those who govern. One thing that has NOT changed in the current whitewater of healthcare is who has the final accountability for the long-term welfare of the organizations that make up the bedrock of our American healthcare system – our boards.

Given their connection to local communities, as well as their fiduciary responsibility to do what is best for those same communities, who else is better positioned to drive the challenging, and sometimes uncomfortable changes, that must take place? No longer can boards simply rely on what they learn from management regarding the current reality. They’re going to have to move into a posture that perhaps might be a little uncomfortable for all parties and begin to truly embrace a shared governance model. This shared model will more frequently challenges the status quo and isn’t reluctant to take the organizations that they serve to places that might seem a little daunting at first. A board might ask, “How much must we own, manage or control in order to have the kind of influence that we want to have on healthcare in this (our) market?” Make no mistake, boards will have a key and critical role in how the system of tomorrow is shaped.

As you see, the list is woefully incomplete, but we have to start somewhere. Many believe that the traditional players in healthcare cannot transform an industry as large and entrenched as is ours. I respectfully disagree and believe that real transformation from episodic acute care to true population health and comprehensive well-being can and should most effectively be led by those same people.

So as for me ….

  • Transformational physician engagement partnered with a …
  • Transformational leadership paradigm that is insisted upon by …
  • Transformational boards of governance willing to push the envelope

Not a bad place to start and we’re happy to help out!

This article will also be published on the Navvis Healthways blog and appears with permission of the author.

As senior vice president for Navvis Healthways, Dr. Anderson provides strategic counsel, planning and implementation support for physician integration and alignment, accountable clinical management, and strategic planning for the organization. Before joining Navvis Healthways, Dr. Anderson served as a senior vice president and chief medical officer for Baylor Health Care System in Dallas from 1995 until 2004, and held the same position at Catholic Health Initiatives (CHI) in Denver from 2004 until 2008. Dr. Anderson’s clinical background is that of a general and vascular surgeon. He holds an M.D. from the Baylor College of Medicine and a B.S. from Baylor University.

Topics: Healthcare Medical Costs & Utilization