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Experiencing a market downturn when you first begin to withdraw your retirement funds can have a dramatic negative effect over time on the value of your portfolio. As part of your overall financial plan you should "stress test" your portfolio before you retire.

Planning for the Worst for Your Retirement Portfolio

Amid rapid health care industry consolidation, a challenging cost environment, and increasing patient needs and expectations, only truly nimble health care organizations will survive and thrive.

Medical groups focused on prepaid, value-based care are better positioned to innovate, develop, and invest in technologies to respond to patient needs and market dynamics. For example, value-based organizations that bet big on 

 and remote patient monitoring technologies prior to 2019 were able to continue seeing patients remotely during the COVID-19 pandemic. In contrast, fee-for-service health care systems — which are paid per office visit, treatment, and test — struggled. As a result, a movement is now underway in health care, from volume of care to value of care.

Value-based care organizations prioritize prevention through early detection and proactive treatment of health issues. Physicians and care teams work together to manage the overall health of individuals and populations. Financial incentives are tied to keeping the patients and communities they serve healthy. Every interaction, from telehealth, 

, to in-person visits, is an opportunity to address patient needs, including access to healthy foods and community-based resources. The guiding principle is evidence-based, quality care that is cost-efficient while 

U.S. Centers for Medicare & Medicaid Innovation

 issued an ambitious goal to shift 100% of Medicare beneficiaries into an accountable care insurance plan by 2030. Given that the number of Americans 65 years and older is projected to increase more than 40% to 82 million by 2050, that announcement signals a massive shift in strategy where a huge swath of Americans will receive some form of health care services tied to value arrangements.

the future of medicine, and everyone is trying to get it right. Based on our nearly 80 years of experience, here are four innovative strategies physician leaders can adopt to advance value-based care.

Embrace artificial intelligence (AI) to help physicians with administrative tasks and improve quality care. 

With AI, physicians can get comprehensive insights into patient health, experience, and health care utilization at the individual and population levels. For example, at Kaiser Permanente Northern California, computer vision algorithms were used to identify patients at risk for breast cancer quicker and more efficiently. Also, we are using new ambient AI scribe technology to help physicians write clinical visit notes, enabling more face time with patients and reducing physician time spent after-hours on administrative tasks.

Focus on optimal wellness by delivering the right care in the right venue, including care-at-home for an aging population. 

Value-based care models allow organizations to invest in people, technology, and services that support team-based care. We currently provide at-home services in six regions across the country, doubling our commitment to this care model from 2022. Patients have told us they love recovering at home. As of April 2024, more than 320 hospitals across 133 health systems in 37 states are authorized by the Centers for Medicare & Medicaid Services to offer acute hospital at home under a 

 expiring at the end of this year. To make these programs scalable, we support a five-year waiver extension. We also want these services to be included in traditional Medicare coverage so health systems can sustainably care for the increased number of older adults.

Solve the shortage of primary care physicians. 

Primary care physicians are the first line of defense against illness or injury. However, 30% of Americans currently do not have a primary care physician due to a shortage. Policymakers should consider measures that bring a new generation of talented and diverse physicians into medicine. Increasing the number of graduate medical education slots — proposed by the Resident Physician Shortage Reduction Act — would be a good start. Additional solutions include immigration policy reforms that remove obstacles for foreign-born physicians and significant investment in medical education and training. Permanente medical groups participate in community-based programs that spark interest in medicine among diverse students at a young age. They include Kaiser Permanente Southern California’s Hippocrates Circle Program and Kaiser Permanente Northern California’s Prep Medico and Medical Scholar’s Pathway.

Identify and address health disparities and emphasize prevention.

 Value-based care focuses on quality outcomes. This encourages physicians to provide equitable care by addressing the root causes of health inequities. This is preventive medicine at its best. Through an effort led by our National Equity, Inclusion, and Diversity and Quality departments, our outcomes reporting has brought greater visibility to health disparities and their impact on patients. We use insights from this reporting to create comprehensive plans to address disparities. For example, research published in 

 showed that a decade of enhanced screening for colorectal cancer with fecal immunochemical tests (FIT) essentially eliminated disparities between Black and White Kaiser Permanente members in Northern California and that organized screening improves colorectal cancer outcomes for all our members.

Innovation thrives in prepaid, value-based care systems, which have successfully demonstrated their ability to adapt to major market disruptions. During this time of rapid change and increasing uncertainty, health care organizations will need to shift to value-based care to better serve patients and remain competitive.

Maria Ansari, MD, FACC, is CEO and executive director, The Permanente Medical Group; president and CEO, Mid-Atlantic Permanente Medical Group; and co-CEO, The Permanente Federation.

Ramin Davidoff, MD, is executive medical director and chair of the board, Southern California Permanente Medical Group; chair of the board and chief executive officer, The Southeast Permanente Medical Group; chair of the board and chief executive officer, Hawaii Permanente Medical Group; and co-CEO, The Permanente Federation.

Value-based care is the future of medicine. Health care organizations must adapt technology, venues, primary care and prevention to survive and thrive.

Four strategies to advance value-based care

There is no doubt that American health care is in crisis. Tens of millions of Americans are in medical debt. Hundreds of thousands are injured or die each year from avoidable health care errors and hospital-acquired conditions. Insurers categorically deny patients the appropriate treatment and medications in a misguided approach called “prior authorizations.” Employers have been asleep at the wheel for decades, allowing the system to unnecessarily jack up the costs of health care.

The U.S. is the only developed nation in which life span is decreasing, and we have, by far, the worst disparities in health care and health outcomes. Burnout and demoralization amongst clinicians and staff now adversely impact nearly half of the American health care workforce.

If we are to solve the dire dilemma in American health care, it is clear that the approach will have to be radically different from those we’ve taken to date. Over the past decade I’ve been studying visionary leaders who are thinking and acting differently. There are replicable lessons we can learn from these divergent leaders – approaches that we can adapt and scale. Below are three foundational principles and three examples we can learn from to humanize healthcare.

If you’re not actively and intentionally 

, then you're fostering distrust. When people talk about trust, I ask (1) How are you defining it? (2) How are you measuring it? (3) How are you operationalizing it?

Address health inequities and disparities. 

The immediate goal is to eliminate inequities in health care and disparities in health outcomes. What we must do is replace all of the systemic ‘ism’s: racism, sexism, ageism, ableism, classicism – with humanism - and again, operationalize and systematize it.

The evidence is overwhelmingly clear. More preventive primary care in a community leads to greater health and lower costs. 

 is fundamental to achieving any effective and sustainable health care system. This also includes attending to the emotional, relational, and psychosocial aspects of an individual’s life.

There are several examples of these principles in action. Unbeknownst to most, the Veterans Administration (VA) has become one of the most innovative and transformative epicenters leading the way in humanizing health care delivery. It’s also the largest health care system in the US – with approximately 150 hospital centers, 1,400 ambulatory care centers, and over 400,000 employees providing care to over nine million veterans annually.

In 2016 the VA instituted a “Trust Index.” Quarterly, they send out a survey to measure veterans’ perception of the value being delivered to them by the VA. The survey has three statements – each measured on a five-point Likert scale – that address ease, effectiveness, and emotion, plus an overall trust statement.

Ease - “It was easy to get the care or service I needed.”

Effectiveness - ”I got the care or service I needed.”

Emotion - ”I felt like a valued customer.”

Overall trust - “I trust VA to fulfill our country’s commitment to veterans.”

The VA publicly reports their trust index results quarterly (

), breaking down results by gender, race and other demographics. This transparency clearly adds to the trust they’re building with their employees and patients.

When they first began the survey in 2016, they discovered that only 55% of veterans trusted the VA, which they felt was unacceptable. In response, they used the insights they gained from this and other surveys, and launched numerous patient-facing initiatives as well as efforts amongst clinicians and staff to improve trust. As of Q4 2023, their score had improved to over 79% – best in class compared to other public and private sector healthcare delivery systems in the U.S. Their goal is over 90%. In order to reach that percentage, they have already begun mapping out veteran patient journeys and creating personas that capture the pain points, challenges, and bright spots for veterans as they utilize the VA.

The VA has also launched a national Whole Health Initiative (

), which has been extensively studied. Its goal is to provide more holistic wellness care, complementing traditional clinical and social care. The program is based on decades of research demonstrating that non-clinical factors play a significant role in the health outcomes of individuals. These factors include issues such as housing, financial stability, employment, education, transportation, nutrition, sleep, stress, relationships, and neighborhood and environmental safety. What’s fascinating is that this program also addresses issues such as loneliness and an overall sense of purpose in one’s life – factors now known to contribute not only to emotional and mental health but also to physical health and longevity.

The VA Whole Health program is multi-faceted and operationally complex, but it boils down to two essential questions which, I believe, other organizations can adapt and apply immediately. First: “What is most important to you in your life right now?” And second: “What can you and we do to assist you in achieving or attaining what’s most important to you in your life?”

The final example comes from a provider organization called ChenMed, whose focus is to provide VIP care to older patients who have either Medicare Advantage or are dually eligible for Medicare and Medicaid. ChenMed has been recognized as one of the best provider organizations in the country, with demonstrably superior quality, safety, health outcomes and experience scores.

Dr. Faisel Syed is a practicing internal medicine physician and clinical leader at ChenMed. One day he noticed the way he and his team were describing some of their patients. For those who work within provider practices, you’ll be familiar with the term “walk-ins.” The term has a negative connotation because patients who walk in without an appointment disrupt the schedule. It’s a term that does not elicit a lot of warm, fuzzy feelings from providers or staff in a clinic setting.

Syed recognized that it was also a somewhat dehumanizing term, not in keeping with the overall mission and culture at ChenMed. He reminded himself, his colleagues, and his staff that these patients were calling or coming in for an immediate appointment because they had an urgent medical need. So he asked his staff to change the term “walk-in” to “person in need.” It was nothing more than that, but that subtle shift changed everything for the team. It established a renewed sense of empathy, compassion, and kindness.

I applaud anyone who is asking themselves, “What can I do to humanize health care?” I would suggest that rather than trying to boil the ocean, start small. Start by talking about it. Start by asking questions that challenge the status quo and the incrementalism that has taken over healthcare delivery. Start by sharing examples of humanism in your practice and organization. Start by making your workplace more humane for clinicians and staff. Start by noticing the words you use.

The most important thing is not to allow the system to overwhelm, dismiss or demoralize us. Each of us is a leader – no matter what our role is – and we all need to be leading a humanistic transformation in American health care delivery.

) is a health care executive, author and nationally-recognized thought leader. His second book,

Beyond The Walls: Megatrends, Movements, and Market Disruptors Transforming American Healthcare

 was published in September 2023. He has over 15 years of experience in leading enterprise-wide programs and developing innovative, forward-thinking strategies. Dr. Neuwirth produces and hosts the popular podcast series 

 He speaks and consults to healthcare systems, boards, medical societies and national associations.

If we are to solve the dire dilemma in American health care, our approach will have to be radically different from those we’ve taken to date.

Topics

What can I do to humanize health care?

One visit to an emergency department, or even an annual checkup, can leave patients with a lot of information to process, including diagnoses, treatment decisions, prescriptions, instructions for care, and critical steps that need to happen between visits. Following their appointment, patients may feel overwhelmed, confused, or simply unable to remember what needs to be done to continue managing their care. 

 don’t remember their physicians’ recommendations and treatments unless prompted.

But this interval between appointments is an important part of care management and contributes greatly to positive outcomes. When patients wait long periods between appointments and don’t track and report their health measurements, they and their providers are forced to fill in the gaps, often guessing what caused changes—or trying to remember what happened—between visits.

Without a window into ongoing patient health, physicians must wait until they see the patient again weeks or months later, leaving them with a blind spot in disease management and potential medical issues. These blind spots can quickly snowball into poorer 

, particularly when worsening symptoms aren't quickly addressed.

The importance of patient self-monitoring

 the impact of self-monitoring comes into focus. Most chronic disease and illness management is performed 

 by patients themselves. Patients need to be able to identify symptoms, manage medications and/or equipment, and know when to call or go to their care provider. In theory, they should be actively self-monitoring between appointments and working with their physicians as needs arise.

We know that patients who track their health and communicate data with providers are 

. Patient self-monitoring also helps physicians 

, but in a system based on health management through appointments (whether virtual or in-person), even if a patient is regularly self-monitoring, they often 

lack a way to communicate data with their provider

Fortunately, digital health advances make it easier for patients to self-monitor, manage medications, and share this information directly with providers. When patients use technology to track and share their health data between visits, providers have the insights they need to manage and better understand the patient's care journey so they can help improve outcomes and experiences.

Data tracking and sharing between visits is a powerful practice for all stakeholders, leading to better everything:

 Routine provider-patient communication, made easy by platforms designed to streamline this information flow, saves time to discuss drivers of health, as providers already have progress notes and can be better prepared for the appointment. In-between-visit communication can also expedite time to diagnosis and the right treatment path.

 and increase economic burdens for both the patient and health system. Routine tracking can assure providers that patients are adhering to their treatment plans and 

 to health management approaches. Those who track their health information and communicate these updates with providers are more likely to have 

Self-monitoring and data sharing also results in significant 

 and hospital readmissions, also reducing the burden on emergency care services.

Self-monitoring between visits also increases patient awareness and engagement, helping ensure they understand their condition and medications and are equipped to detect fluctuations and side effects that need immediate attention.

Using technology to connect patients and providers

Previously, patients often would be relied on to remember to record health updates on their own, sometimes using a paper journal to share those notes at the time of the next appointments. Even when data recording software or programs became available, they provided no direct connectivity with providers, continuing to ignore the component of care between visits.

Now, both patients and care providers can use technology that has the ability to track specific patient conditions, prompt patients to record timely health measures and share this data with their care provider, as well as alerting patients to contact their provider if there is an anomaly or potential emergency. This technology is key not only to enabling patients to better understand and engage with their health, but helping to build a bridge between patients and physicians.

Such communication is vital to effective care. If patients are diagnosed early and adhere to treatments, they have better outcomes. If patients and care providers have a better connection and more time to speak, there is better engagement and flow of communication. Engaged patients are more likely to participate actively in their care and better understand how to manage outcomes.

To succeed, the technology used to self-monitor and report needs to have two components: connectivity, which is foundational for ensuring the transfer of information, and AI, which is becoming a force in symptom identification and monitoring for specific health issues against existing patient data. On the physician’s side, technology should assist by speeding up the analysis of information, presenting primarily what they need to make rapid and appropriate decisions.

The easier it is for patients to report their information directly to their providers' systems, the faster we can achieve better outcomes and experiences that impact the entire health care system.

Ongoing communication with care providers enables earlier detection and treatment of health problems 

How self-monitoring and data sharing produce better patient outcomes

Physician and patient perception: What doctors think about patients

A cognitive psychologist discusses causal beliefs, patient decisions and disclosures, and how those affect health care.

Janet Critchley

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