Neil Carpenter headshot with teal green background of an illustration of a computer circuit board

As we step into another pandemic year, it’s important to remember all the needs the healthcare system had for change before COVID. Before the pandemic, we had a healthcare system that was brilliant but costly and inconsistent across populations and care needs. COVID demonstrated all those things were truer than we realized. If we want to focus on patients and the health of our communities in a broad way, we will need a lot more than brilliant (though burned out) clinical practitioners and creative pharmaceutical minds. We need to look at the significant obstacles to reform that existed before COVID. In this 2022 kick-off blog, I will review key barriers and solutions to the healthcare future we need.

  1. The value-based care discussion needs to be about value (economic) and values (moral, cultural). Today’s value-based care debate assumes that with financial flexibility, providers will be able to solve a bunch of problems (care at people’s homes and preventive medicine) without causing others. That is a mistake. When we free up resources out of the hospitals to do all these other things, that assumes nothing is lost in terms of the hospital. That’s just false – hospitals are bundles of public cross-subsidies. Sometimes it can be a one-for-one trade, but often marginal admissions covering a lot of fixed hospital costs keeps a Psychology (Psy.D.) or Obstetrics (OB) program at that hospital running. Between 2004 and 2014, 179 rural counties lost or closed their hospital obstetric services; fewer than 50% of rural women have access to perinatal services within a 30-mile drive from their homes. For example, my former health system invested thousands of dollars in violence prevention programs in the community – not through avoided visits but from the margins from the visits we want to take away through value-based care. Because hospitals have high fixed costs, reducing volume doesn’t reduce many costs. Let’s create financial flexibility in the system but explicitly pay for every service we want. We need to put a dollar value on physician education, research, and critical access points and fund those items directly. We can then drive value-based care to every penny of the rest of the system and reallocate dollars and jobs as needed. The hard part of this process is simply honesty. What are we willing to pay for, and what or who gets explicitly left behind? Distribution of Obstetric Providers by U.S. County map

    Source: Improving Access to Maternal Health Care in Rural Communities: An Issue Brief (

  2. More front-line staff, less back-office personnel. As this graph demonstrates, administration jobs have boomed over the last decades while front-line staffing numbers have barely moved. Obviously, our clinical staffing has been tremendously resilient throughout COVID, but let’s not forget more staff exist in the hospitals’ billing offices than in the ICU, even prior to the current nursing shortage. We need to get aggressive about the use of technology, such as robotic process automation (RPA), to reduce the back-office staffing in the payer and payee environment as well as immigration solutions to help staff our facilities. Before COVID, it was estimated we would have a 500K nurse shortage. We should launch a new visa program to help our nursing homes across America hire additional staff. Many of these nursing home roles require moderate levels of clinical knowledge, which is easy to recruit from the Philippines and elsewhere, and best of all, vaccinations can be required. Today, 77% of nursing home staff are vaccinated. This simply must be higher. Immigration and technology helped fuel the American Century and can now help solve one of our healthcare system’s biggest problems. Growth of Physicians and Administrators 1970-2009 chart graphic

    Source: Borders, Max, “The Chart that Could Undo the US Healthcare System,” Foundation for Economic Education, April 2015

  3. Robust decision support with treatment guidelines that consider the social context of the patient and evidence-based data on health behavior modification. Today we know more about how to sell people potato chips than health behaviors. There have been decades of multi-billion-dollar investment (including relentless A/B testing) on selling everything but health. Think about charges of “fake news” or other political phrases that have been built and tested to engender reactions specifically targeting certain demographic groups. We need to accelerate the effort to bring real clinical guidelines to providers but customize these guidelines based on a data-driven approach to different demographic or even psycho-demographic groups. That could also lead to care team customization based on populations served. No longer a conversation about medical home or care teams, but care pathways built on social determinants of health and rigorous testing of interventions along the way. Through this, we may even discover which providers have the most impact on different patients’ and communities’ health. That would be real value for which to pay.Flowchart showing how the social determinants of health can funnel into the healthcare system

    Source: Lightbeam Health Solutions

  4. Flexible housing. We often assume today that homes and hospital beds are interchangeable. They are not. While home-based care is ideal for patients in most if not all cases, homes are not hospitals. They lack important safety measures, both physical (grip bars) and electronic (well managed IT infrastructure), and contain dangers hospitals do not (stairs, rugs). About 90% of housing units have at least one aging-accessible feature, but less than 10% across America are safe for aging. We need investment in homes that support aging, not just for retirement but for more serious times of health challenges. Because we have not yet moved large numbers of patients from an acute setting to a home-based setting, we have yet to realize a whole rash of missing infrastructure that is needed. The economics of transforming people’s homes is quite compelling; the cost savings from a typical admission from hospital to home is $3K, with just one acute episode. We also need more home-based staff and could easily take some of those folks working so hard on billing paperwork and deploy them in people’s homes, a more physically demanding but more spiritually rewarding task.

Illustration showing how flexible housing for the aging population fits into the healthcare system


Like every other industry in America, technology can be transformative – if we change the environment in which technology operates. While in the past, our hopes and dreams did not have tactical technology to make a transition a reality, today, it can. Through a combination of clear-eyed value transparency, and a willingness to disrupt existing stakeholders and processes, we can radically improve care quality and reduce costs. The technology is now here to create a revolution to care, just like America’s prior farming and manufacturing revolution, as long as we are willing to try.

Healthcare Inequities: Social Determinants of Health hero graphic with 2 woman with hands on their hips standing in front of a background of random activities at an outdoor park
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