All discussions of payment reform require an alert and attentive provider community. Physician burnout is clearly an impediment to this attention. It is estimated that 50% of physicians either have, or are at risk for burnout. The manifestations are protean and apparent to families of the providers and coworkers in the workplace. Not only do the effects impair patient management, but the willingness and enthusiasm to participate in health care reform to guide the engagement pathway from estrangement to emancipation. The Innovation Initiative and the Tenncare Episode of Care model, illustrate a successful program that is an ideal vehicle to accomplish this and show the way to more comprehensive models that will emancipate physicians.

At the heart of the critical realist interpretation of cost containment is to understand the difference in two patient centered approaches to data analytics. The reductionist approach is structured, and the holistic approach is agnostic to how the data is accumulated, or in realist terms the latter approach is open and unstructured. Putting the patient back together again requires a free form method where there is no reason not to draw conclusions from patient centered data because of concerns about statistical significance at the population level. Being unstructured the patient level data can create populations that reflect the holistic approach, in a bottom up method. This is an inversion of the top down approach in the reductionist method that characterizes patients as averages of the predetermined population.

TennCare has released participant commentary on its Technical Advisory Groups. If you are unfamiliar with TennCare’s Episode of Care Program I’d encourage to view TennCare’s Introduction to TennCare Technical Advisory Groups and read my January blog Episode of Care Tenncare which discusses its success and potential to be a model for other Medicaid programs just as it has been for Tennessee’s CMS Innovative Initiative.

This Congress was an assembly of seven summits. These included: Care Coordination and Transitions, Connected Health: RPM and Telehealth, Bundled Payment, ACO Population Health Management, Merit-Bases Incentive Payment System (MIPS), Health Plan Chronic Disease Management, Provider Strategies on Community Health and Social Determinants of Health.

I consider the present phase of health care the time of Babylon, the time of many languages; the next the enlightenment where the healthcare communities look outside of their comfortable boundaries to understand context. The next is the phase of modernity where the high dimensions inherent to HCn3D are presented to all players in simple understandable ways.

As a local State program, Tenncare under the leadership of The Medical Director Dr. Vaughn Frigon, with the assistance of the McKinsey consulting team, has demonstrated exemplary success and is a model for other Medicaid programs. The secret of their success has been careful physician engagement in episode details, due to given the design of the State of Tennessee's program, and transparency of information. Given the success of the episodes program, the question arises of what can be done next?

An important game changing article that puts Value in a new light is in the NEJM Dec 21, 2017 issue by Green and Loscalzo. The title is "Putting the Patient Back Together - Social Medicine, Network Medicine, and the Limits of Reductionism". Many widely known and emergent tools are explained that can bear on the current understanding of Value in the healthcare context. Most importantly this article shows how holistic patient centered approaches are not only cool, but doable and can be effective in achieving a broad range of goals on behalf of patients and populations.

The PCMH Congress met for the third time in Orlando (Nov 3-5 2017); the program is catching on, there are now about 1000 accountable organizations of record, including ACA's and PCMH's.

I will be presenting the “Pyramid of Value” in the Poster Hall of the 2017 PCMH Congress, November 3rd & 4th, Regency Ballroom, Hyatt Orlando Florida. For more information please visit the PCMH Congress 2017 page and/or the PCMH Congress website.