Compounding
fragility and aging

Anyone who has cared for an aging loved one has witnessed the challenges of fragility—the heartbreaking loss of strength, dexterity, and independence that comes when our vitality begins to dissipate. When it comes to healthcare, fragility can be considered on three levels, each with profound implications for health system capacity, solvency, and ability to reduce the burden of illness and disease.

Individual
At the individual level, morbidity and mortality have been rising among middle-aged and younger Americans since 2010, especially among white, non-Hispanic men and adults without a four-year degree. Researchers attribute this increase to cardiometabolic diseases resulting from obesity as well as increases in drug and alcohol abuse. At the same time, the US population aged 65 and older has grown almost 40% in the last decade, and the health system is ill-equipped to care for the aging population. To address individual fragility, we must expand our capacity for caregiver services while exploring new pathways for care coordination and residential care. Cross-sector collaboration will also be imperative to take care of our most vulnerable populations, as the social determinants contribute to the widening gap in health outcomes.

Layers of fragility permeating healthcare

Health system
From a health system perspective, we are seeing breakdowns ranging from the healthcare workforce crisis to crushing administrative burdens and mounting reimbursement challenges. Ongoing efforts to advance value-based care continue to hold promise, but the up-front costs are making it harder to drive adoption among primary care providers. Healthcare behemoths have sought to overcome the payer/provider chasm through vertical integration and scale but have come under scrutiny based on accusations that they are increasing profits at the expense of patients and providers.

One option for reducing payer-provider abrasion is to evolve Joint Operating Committees into Joint Value Committees (JVCs), shifting the focus from dispute resolution to value realization. JVCs apply strategic value management to derive a balance between healthcare needs, resource requirements, service delivery, and quality based on a continuous value cycle.

Institutional and social

The final layer involves real or perceived institutional and social fragility engendered through factors including political polarization, demographic pressures, and climate change. The Fragile States Index score for the United States rose ten points over the last decade, with the highest increases attributable to “factionalized elites” and “group grievance.” We have seen these factors play out in healthcare through disinformation and politicization, often with dire consequences on morbidity and mortality. Researchers at the University of Michigan captured several lessons learned to strengthen public health in the future:

More communications training and experience for healthcare leaders
Increased partnership within and across healthcare and community organizations
Restoration and reinforcement of shared responsibility as a cultural norm
Long-term investments in public health data systems
More adequate and consistent public health funding

The chart below defines each layer and includes key factors and opportunities to address rising fragility. Ultimately, strengthening each layer within the paradigm will reinforce the industry as a whole, creating a more equitable and sustainable healthcare system and improving the well-being of individuals and communities.

	Description	Factors	Opportunities
Individual fragility	A multidimensional state of reduced energy reserves, fitness, cognitive ability, and health that makes individuals more vulnerable to stressors	Aging population Mental health crisis Substance abuse Obesity	Augmented care coordination Caregiver services Health promotion
Health system fragility	Breakdowns between the community and the health system caused by interactions that are void of trust, stigmatizing, iniquitous, biased, and reinforcing power imbalances	Rising costs Workforce shortages Payment reform Industry volatility	Value management Health service transformation Revenue cycle modernization
Institutional and social fragility	The exposure to risk and insufficient coping capacities of the state, system, and/or communities to manage, absorb, or mitigate those risks	Political polarization Great power conflict Demographic pressures Climate change	Community engagement Sustainability planning Health equity

Slalom contributor: Jacque Myers