By Debbie Ahl on November 24, 2021

A Seat at the Table: The Person Missing from Important Healthcare Decisions

Something is missing. SOMEONE is missing. Tables and tables of healthcare payer executives, hospital system and operations executives, clinicians, and boards work across the nation to improve the efficacy and efficiency of healthcare. These conversations abound with intellect, insight, influence, and experience.

But we still don’t have it right. 

We talk about innovation, empowerment, and engagement. We know the impact of social determinants on health — non-medical factors that impact people’s access to care and their health outcomes. We understand that, when it comes to population outcomes, social determinants of health have more influence than the best quality clinical care.

We possessed an intuitive knowledge of these factors for a while, and now we have named them and created strategic initiatives surrounding them.

But something is still missing.

Where my suspicions began

The idea that something, or someone, is missing from the healthcare tables began to take shape in my mind many years ago. It started during my work as an 18-year-old ward clerk in the local emergency room. During my night shifts, I observed people who could no longer speak for themselves.

Years later, I worked as a Medicare Advantage health plan CEO. I listened to case managers share stories about members whose physicians and even family who wouldn’t acknowledge their wishes regarding which medical services they wanted and/or didn’t want.

A new perspective

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Perhaps this understanding came to light most concretely while taking my elderly mother to her healthcare appointments during the last years of her life. 

When I arrived at her house one day, she greeted me with “I don’t want a mammogram. Let’s go out to lunch!” 

My mother was a retired registered nurse who understood the value of a mammogram. Despite this, I patiently reminded her that she was a bilateral breast cancer survivor and therefore annual mammograms were part of her care plan. 

“I don’t want to go,” she responded. 

Something clicked. “Mom,” I asked, “if they found you had breast cancer again, would you have chemo or radiation?” 

She didn’t blink. “Absolutely NOT,” she said. 

And we went out to lunch.

The second time it happened

A couple months later, I accompanied my mother to anothe appointment she did not want to be at. It was a biannual appointment with a hematology oncologist who was monitoring her for chronic lymphocytic leukemia. I asked the oncologist how high my mother’s white cell count could go before he recommended treatment. He gave me a number that was far off in the future. I asked what treatment he would prescribe at that point. His response: chemotherapy. 

I looked at my mom. For the most part, she’d always expressed that she wanted to live forever. I asked her if she would accept chemo treatment if it came to that point. 

“Absolutely NOT,” she proclaimed. 

And we went out to lunch.

Making space for another voice

There were many other episodes. I remember when the medications prescribed by my mom’s urologist for urinary incontinence seemed less effective than desired. My sister accepted an ultrasound appointment to address the issue. When I joined my mother for the appointment, I watched her lie on the exam table. Already anticipating her response, I explained it would be an invasive procedure. She was pretty quick to hop off that table. 

We had many enjoyable lunches throughout those years. 

It has been estimated that 42 percent of Medicare beneficiaries experience one or more overuse events per year, amounting to billions in wasteful spending. This overuse is no doubt due to a variety of things that can be identified by clinical analysis about healthcare efficacy.

Yet we may be missing the obvious: The person we forgot to invite to the table. 

      • We talk about “reducing waste” 

      • We talk about “providing better care”

No one ever stops to ask, “from whose perspective?”

A patient's point of view should matter

Why don’t we just ask our Medicare beneficiaries what they value? And then do everything we reasonably can to make sure healthcare interventions align with their values?

Advance care planning (ACP) is often considered an end-of-life practice, relegated to those in their last six months of life. To think of it this way means that, once again, we’re missing the obvious.

Digital ACP gives the most important people in healthcare a seat at the table. It elevates the voice of the individual, creating true engagement between them and their clinicians. It starts conversations that can identify what individuals truly value in healthcare delivery. And that puts the real value in value-based care.

Debbie Ahl is the Senior Lead of Payer Strategy at ADVault. She’s an impactful leader within the insurance industry, with a focus on Medicare Advantage, Medicare Supplement, and employer plan markets.

Published by Debbie Ahl November 24, 2021