HJBR May/Jun 2024

collapse. Where I truly believe that health plans are currently underperforming the most is in the execution of their own fifth P — their purpose. Purpose is often conveyed through a mission statement that articulates that organization’s fundamental reason for their existence, for ex- ample, one that espouses to improve the health and lives of their members. Until both a health plan CEO and the board that governs their de- cisions are held accountable for truly improving health in significantly meaningful and impact- ful ways, a dream of clinical excellence in the proverbial bridge to tomorrow will never even come close to becoming tomorrow’s reality. In the next issue of this journal, part B of our discussion on CKD will delve into the down- stream complications of CKD, like worsening hypertension, anemia of CKD, CKD-associated mineral bone disorder, and metabolic acidosis, all eventually culminating in the downstream progression of kidney failure to ESKD. At this point, a patient is faced with painful decisions, like whether to go on dialysis, which type of dialysis to choose, or whether to go into hos- pice with palliative care instead. Sadly, and un- fortunately, it is not until they get to this point that they become eligible for Medicare, which removes them from commercial health plan coverage. At this point, they become eligible for a Medicare Advantage plan, which offers a risk-adjusted population payment to finance their care. This different form of payment un- leashes the power of new business models where new and innovative companies work to enroll these patients in comprehensive pro- grams aimed at keeping them as healthy as possible to reduce avoidable emergency room visits, admissions, and further complications of their CKD. While good for these patients at that point in their lives, these innovative solu- tions come far too late to enable them to enjoy the same level of capability as if their CKD had never progressed to ESKD. The commercial health plans, meanwhile, currently lag in their capability to move beyond the simple process- ing of transaction-based claims and toward a risk-adjusted population-based payment for primary care that enables new business mod- els to discover innovate ways of delivering improved health. I do believe they are aware of the problem and have been sincerely and actively trying to come up with novel solutions of how to build a structurally sound bridge to tomorrow. But their current payment capabili- ties are acting as one of the single greatest im- pediments to progress of innovative solutions that demonstrably improve the health and lives of their members, thereby blocking today’s dreams from becoming tomorrow’s realities. And those traditional health systems and pro- viders that refuse to embrace new forms of payment also act as impediments to progress. While it may sound like I’m assigning blame, I’ve already stated in a prior article that I know most people working for these health plans and health systems are wonderful, smart, dedicated, hard-working people who truly do want to improve the health and lives of their members and patients. But we cannot afford — both literately and figuratively — to continue to accept the status quo without shining a bright light on the large structural cracks in the current bridge to tomorrow. n REFERENCE 1 Commonwealth Fund. (2023, January). US Health Care: A Global Perspective 2022. Re- trieved from https://www.commonwealthfund. org/publications/issue-briefs/2023/jan/us- health-care-global-perspective-2022 “Where I truly believe that health plans are currently underperforming the most is in the execution of their own fifth P — their purpose. … Until both a health plan CEO and the board that governs their decisions are held accountable for truly improving health in significantly meaningful and impactful ways, a dream of clinical excellence in the proverbial bridge to tomorrowwill never even come close to becoming tomorrow’s reality.”