How Can We Rightsize Treatment Costs? Last Week’s Hangout Participants Address Unanswered Questions

Last week, a diverse panel of experts joined us for a Great Challenges live online event to discuss how we can work towards rightsizing the business of healthcare to achieve the delicate balance between treatment innovation, accessibility, and affordability. Moderated by New York Times Senior Writer Elisabeth Rosenthal, the group explored what it takes to innovate in drug development, how we evaluate long-term treatments versus cures, and what new approaches can make novel treatments more accessible to patients while reducing healthcare system costs. If you were unable to join us, check out the recast below.

We had a so many questions come in via social media (thank you!), that we were not able to get through all of them during our one-hour event. So, we gathered the unanswered questions and  invited James Chambers, Vineet Arora, and Josh Fangmeier to weigh in and continue the conversation. Here’s what they had to say:

How does the insurance industry weigh long-term treatment versus a one-time cure? What other elements besides cost need to be taken into account?

Josh: Due to the fragmentation of the American healthcare financing system, insurers do not always have aligned incentives when it comes to paying for certain services. For example, private insurers could pay for a cost-effective therapy that reduces long-term costs for a medical condition, but Medicare, not private insurers, may capture the savings from this therapy as the patient ages. This has also been an issue for patients enrolled in both Medicare and Medicaid (dual eligible), where interventions by one program lead to savings captured by the other.

James: This is certainly a timely question given the introduction of Sovaldi. It asks questions not just of cost-effectiveness (i.e., value for the money) but also of affordability. As a cure is taken only once (or over a relatively short period of time) there is an incentive for the manufacture to charge a high premium. Even if over the life of the patient the drug represents good value for money, the high upfront cost may prove prohibitive to many patients and providers. We may have to move to alternative payment models in which the cost of a cure is spread over the period that the patient experiences the clinical benefit, i.e., to amortize payment of the drug. However, this is complex and raises many questions, e.g., who pays for the drug, and what happens if the patient shifts between plans?

Is flooding the market with more practitioners an economic strategy to lower healthcare costs?

Vineet: If practitioners means doctors, it takes over ten years to train a doctor, so its hard to “flood the market” with them, especially given the projected doctor shortage. If it means others such as nurse practitioners, there’s also a shortage there so feasibility would be hard. I don’t know how that would impact drug costs per se. Flooding the market also assumes that there is price transparency at the level of patients, and they can choose to go to the best value care – which we know does not exist. So as of yet, in my opinion this strategy would not work without these other things.

Do pharmaceutical companies have any ethical obligation to provide treatment to those who cannot afford it? Why or why not?

James: This is a very difficult question! I believe that if a patient who would benefit from a treatment does not receive it because of its cost, then as a society we have not maximized the benefit of available technology. I believe the healthcare system has the responsibility to offer a “base” level of care to everyone.

Vineet: I believe they do. We have created a healthcare system where anyone can get emergency care regardless of their ability to pay. So, as long as that exists, it means that we will be in a cycle of emergency care for chronic diseases that could be treated with medications unless we can figure out a way to cover the cost of the drugs to keep people healthy. The issue often is who is going to benefit.

How can we accurately and consistently evaluate the right approach to treatment based on the cost of a saved life or improved quality of life?

James: Other countries have national agencies/institutes that evaluate the costs and benefits of new technologies. This provides information to the healthcare system of the value of medical technology and helps prioritize the use of scarce healthcare resources. While PCORI is tasked with evaluating the comparative effectiveness of treatments (although to date it has performed very few head-to-head studies), it does not consider cost in its research. Only if we have information of the costs and benefits of alternative treatments can we use our technology most efficiently. Ironically, many of the leading methodologists on the economic evaluation of medical technology reside in the U.S., but the U.S. is somewhat unique to the limited extent that it uses these techniques.

How much stock can we put in cost-effectiveness studies? Is there a better way we could measure this?

James: There are many different types of analysis to evaluate medical technology, e.g., budget impact analysis to examine the financial impact on introducing a technology to a plan, or comparative effectiveness research to evaluate which of two treatments is most effective. Cost-effectiveness analysis is, however, the only approach that quantifies the VALUE of a technology, i.e., is the additional costs of a treatment worth its additional benefits. While some may argue that cost-effectiveness should not be the sole determinant in drug coverage policy, I believe that decision-makers should have access to this information if they are expected to make value and cost conscious decisions. Without this information, they have a hugely difficult (and maybe an impossible) task.

Might a system in which unused medicines can be returned to pharmacy (and reimbursed) help contain costs?

James: Absolutely.  A huge source of waste!  A very difficult policy to implement, though.

How much is affordable and are caps on out-of-pocket spend in ACA too high?

Josh: Increasing cost-sharing through co-pays, deductibles, and other forms of out-of-pocket spending has been a concern, especially for low-income populations. However, this has been a trend that pre-dated the passage of the Affordable Care Act (ACA). According to the Commonwealth Fund, from 2003-2011, single worker deductibles rose by 117 percent.

The ACA includes minimum value and out-of-pocket spending caps that limit the sale of insurance plans that provide little financial protection. For 2015, the out-of-pocket caps are $6,600 for an individual and $13,200. Although this is a considerable amount for many families, the ACA provides financial assistance, in the form of cost-sharing reductions, to those who enroll in marketplace plans. Cost-sharing reductions increase the value of a silver plan. For example, a Detroit resident making $20,000 would see the out-of-pocket maximum for the cheapest silver plan fall from $6,350 to $1,450, due to cost-sharing reductions.

What can we learn about drug pricing or drug coverage from looking at systems outside of the American one?

James: We can learn from other countries’ systematic approaches to evaluating medical technology. While each country takes a unique approach (some focus on comparative effectiveness, others cost-effectiveness), each formally evaluates new technology before it is introduced to the health care system. This provides information that can be used to implement value-based coverage of medical technology, and in some cases negotiate a price that is commensurate with the health benefits offered by the drug.

We can also learn that cost and cost-effectiveness can be accounted for, but not be the sole determinant in decision-making. France and Germany were previously hugely resistant to accounting for drug cost in national policy but now consider economics (while decisions are primarily driven by comparative effectiveness) in their assessment.

What new approaches can make novel treatments more accessible to patients while reducing healthcare system costs? Do we need to change our drug development models or is there change to be made elsewhere?

James: In theory, using cost-effectiveness evidence to guide coverage of medical technology will result in more efficient use of scarce resources and allow more patients access to effective technology.  However, such an approach is unlikely to be soon embraced in U.S. healthcare.

Maybe the most promising approach is value-based insurance design (VBID).  This approach aligns co-pays in a manner consistent with a drug’s value, i.e., a lower (or no) copay for cost-effective drug, and a higher copay for a cost-ineffective drug.  This approach provides an incentive for the patient to use more cost-effective care . This approach is arguably the most palatable for U.S. healthcare, as cost-effectiveness is not being used to deny or ration care, rather to encourage the use of high-value care.

How risky is it, anyway?

These days, science can tell us in incredible detail the ways our decisions are impacting our health – it’s easier than ever to discover what is going on in our bodies. We know that a poor diet or lack of exercise can have negative impacts on our heart health. We know that too much sun exposure can lead to skin cancer. We even know how diseases spread – and how they don’t. But, in the face of all of this information, we still continue to make decisions that may not be the best for our health.

In other words, many medical professionals are dismayed by the large gap between risk as perceived by scientists, and risk as perceived by the population as a whole.

As an example of this gap, some doctors and scientists point to the country’s reaction to Ebola. Though the average American is more at risk for flu, a car accident, obesity, diabetes, or heart disease than Ebola, the entry of the disease into the U.S. has brought a high level of fear. This prompts the question: How can the medical community accurately and responsibly communicate risk in a way that encourages healthy choices?

Last week, as part of the Great Challenges program, we convened a group of experts on the topic. They discussed the psychology behind risk perception and talked about strategies and tools that the medical community can use to ensure that patients receive an accurate understanding of their risks and are encouraged to act accordingly. The event was moderated by James Maskell, CEO and Founder of Revive Primary Care.

The participants all agreed that our reactions to risk are often driven by feelings before facts – and that the low level of health literacy in this country doesn’t help. Brian Zikmund-Fisher, PhD, an Associate Professor of Health Behavior & Health Education at the University of Michigan School of Public Health, noted that other elements of human risk perception include our experience (or those of others), our knowledge, our level of control, and our level of dread. He stressed the importance of understanding risk as a population-level construct.

Glyn Elwyn, MBBCH, MSC, FRCGP, PhD, a physician-researcher, Professor and Senior Scientist at the Dartmouth Health Care Delivery Science Center and the Dartmouth Institute for Health Policy and Clinical Practice, posed a key question: “How do we frame information so that it’s easy to understand?” The group agreed that risk perception is largely about context; they stressed the importance of using language and tools to create this context – which is not always statistics. Brian shared his thoughts on the subject: “how can we give people the tools so that they can understand under what circumstances they would be at risk, and when they’re not at risk? We need to use stories to represent examples and also provide quantitative information.”

Thomas Workman, PhD, MA, the Principal Communication Researcher and Evaluator for the Health and Social Development Program at the American Institutes for Research (AIR), had one suggestion: asking patients to think about how they would feel if the health condition for which the patient is at risk occurred. He called for patient involvement in the development of these tools, asking, “How can we incorporate patients into the development of some of these tools and technologies?”

Participants emphasized the importance of the clinical encounter in creating this context. At the same time, the short time for each office visit was a concern. Thomas noted that “The conversation with the physician is just as important as the conversation with the community.” He suggested that risk and prevention discussions can take place with organizations within the community – or even within small family units. David Bell, MD, MPH, an Assistant Professor of Population and Family Health at the Columbia University Medical Center, echoed this sentiment. He stressed the need for risk information to come from a trusted source.

The participants also recognized that the media plays an important role in framing the public’s risk perception. We live in a world where we are confronted with sensationalized news daily. Glyn pointed to the low trust in public information plus dread as a “toxic mix that the media are ventilating,” while Thomas asked: “How can we create more balanced messages?” Brian noted that while individual stories may make interesting news stories, they “will never be representative of the broader range of what could possibly occur.”

On the whole, the participants concurred that, as David put it, “Every step of the way patients get different messages about their risk and we all need to be on the same page.” A tall order, of course, but one which may lead to more realistic understandings of risk – and consequently, it is hoped, the adoption of healthier behaviors.

If you missed the live event, catch the recast here: www.tedmed.com/greatchallenges/liveevent/494673, and stay tuned for our next Great Challenges hangout on Achieving Medical Innovation later this month!

Raising H.E.A.L.T.H. at TEDMED

RaisingHealth-DC-20

Among the many activities at TEDMED 2014, Delegates were invited to contribute their thoughts to “Raising Health” – ideas on how to approach some of the most broad-based, intractable issues of health today, from childhood obesity to medical costs.

On Day One of TEDMED, Delegates focused a great deal of attention in the space to the changing role of the patient in healthcare.  They were asked to discuss and respond to the following questions: How do we empower patients to make healthier decisions? What is the patient’s role from his or her perspective? What is the role of healthy people  (non-patients) in healthcare?

Answers centered on a number of themes:  What are the best ways to develop a strong doctor-patient conversation? How can we include family, caregivers and community in patient care? An informed patient is an empowered patient. What’s the best way to go about that?Screen Shot 2014-09-11 at 9.32.15 AM

“Bring intuition and knowledge of your own body to your healthcare team,” answered one Delegate. “Make the patient the source of applied innovation,” said another. And, “Ask each patient for his or her goal for each visit or what he/she wants to accomplish.”

Click here for a recap of more thoughts on this critical issue, and stay tuned as we cover more thoughts on the Challenges throughout TEDMED. You can also share your own thoughts on Twitter at #greatchallenges.

Here’s a Challenge for you: How can we Raise Health?

shutterstock_180808967We’ve seen the power of collective creativity and goodwill for a good cause recently, so we’re asking our health and medicine community to dig deep once more, this time for a thought experiment: Can we rebuild some of health and medicine’s most complex and critical issues – our Great Challenges – by creatively rethinking their foundations? What do we truly understand about these factors that limit health —and their possible solutions— today?

As we move into the third year of our Great Challenges program, Delegates on site at TEDMED 2014 in Washington, DC and San Francisco will be tackling these issues and more in a special area devoted to exploring the six Challenges we’ve focused on this year. Together, we’re aiming to shake up the status quo, rethink assumptions, and raise health to new heights to meet our evolving needs.

Your input will also help guide direction for the Great Challenges program in the coming year, so be sure to stop by.

Below, find 18 critical questions as determined by our community.  Answer them, validate them, reframe them. We need your input, so please respond here, via Twitter #GreatChallenges, on Facebook and Google+, or on our tumblr.

Impact of Poverty on Health

What’s the best way to invest in poverty reduction to improve health?

Are other people’s health problems everyone’s business?

How should doctors “treat” socioeconomic factors that impact health?

Reducing Childhood Obesity

How can we change our 24/7 food-everywhere culture?

Obesity risk begins in the womb. How can we deliver this message?

How much of obesity is about personal responsibility?

Achieving Medical Innovation

When should patients get to enter higher-risk clinical trials?

How can we align public and private interests to drive innovation?

How can patients be partners in medical innovation?

Making Prevention Popular

Where could health policy go farther to nudge preventive behavior?

Why do we so often do what we know isn’t good for us?

Is prevention about individuals, populations, or both? Why?

Role of the Patient

How do we empower patients to make healthier decisions?

What is the patient’s role from his or her perspective?

What is the role of healthy people  (non-patients) in healthcare?

Addressing Healthcare Costs

How do we create smart “healthcare consumers”?

What kind of system adapts to the changing needs of healthier patients?

How can we align stakeholders to reduce healthcare costs?

Special thanks to the Robert Wood Johnson Foundation for their support of this program.

New York City and Philadelphia: A Tale of Two Obesity Declines

By Risa Lavizzo-Mourey and Nancy Brown

“Severe Childhood Obesity Shows a Decline in New York City.” You might have seen the headlines earlier this month.

It wasn’t long ago that we never saw stories like that.

For decades, it was nothing but bad news – one story after another about a rapidly growing epidemic. Just two years ago, the Robert Wood Johnson Foundation and Trust for America’s Health predicted that, if trends continued the way they seemed to be going, more than 60% of adults in 13 states would be obese by the year 2030 – and have the extremely high medical bills to prove it.

But now, we’re finally starting to see signs of progress against an epidemic that was once feared to be unstoppable. Overall childhood obesity rates have stabilized. For the first time in a decade, data show a downward trend in obesity rates among young children from low-income families in many states. And, we’re seeing reports from cities and states that their overall rates of childhood obesity are decreasing: from California to West Virginia; from Anchorage, Alaska to New York City.

New York is a great example of a place taking a comprehensive, community-wide approach to reducing childhood obesity. The city has required group child-care centers to improve nutrition and nutrition education, increase physical activity, and limit screen time. “Health Bucks” enable lower-income families to maximize their purchasing power for fresh fruits and vegetables at local farmers’ markets. The city’s Department of Design and Construction provides architects and urban designers with guidelines for designing buildings, streets and urban spaces that support physical activity. Chain restaurants are required to post calorie information on menus, enabling customers to make more informed decisions. The education and health departments have collaborated on the “Move-to-Improve” program, which helps teachers incorporate physical activity through the school day.

We’re thrilled that these approaches appear to be paying off, but here’s the thing about that recent study on the most severe obesity cases: White children saw a more significant decrease than Latino or African-American kids.

This was true for overall obesity rates as well: Childhood obesity rates among White K-8 students in New York dropped from 17.6% in 2006 to 15.4% in 2010 – an impressive 2.2 percentage point decline. But the drop among Hispanic and African-American students was far less, just 0.9 and 0.4 percentage points, respectively. The disparity among upper- and lower-income students was even greater, a 1.4 percentage point decline compared to 0.7 percentage points.

This means that despite the overall progress, the disparities gap may actually be widening in New York.

In this respect, New York City truly illustrates where we are in this epidemic. Progress is possible, and happening, but this progress runs the risk of leaving some of our young people behind, and too many of those at greatest risk.

There is one notable exception to this rule—Philadelphia.  In Philadelphia, they’ve managed to reduce childhood obesity prevalence while also reducing obesity-related disparities.

Philadelphia Decreases Childhood Obesity: Learning to Eat Healthy

 

Like New York, Philadelphia has addressed the obesity problem from many angles. The city, along with groups like the Food Trust, pioneered new financing strategies to bring full-service grocery stores back to underserved neighborhoods. The city improved food and physical activity in schools, and was one of the first jurisdictions in the country to remove all sodas and other sugar-sweetened drinks from public school vending machines.  In schools with American Heart Association Teaching Gardens, children grow their own healthy produce, and learn about the value of good eating habits. Complete streets policies make it easy and appealing for people to walk and bike throughout the city. More farmers’ markets are opening all the time across the city, and they use smart incentives to help lower-income residents afford fresh produce. Corner stores are offering healthy products and using in-store placement and marketing techniques that are boosting sales.

And guess what? Childhood obesity there fell 4.7 percent – and the biggest declines were reported for African American boys and Hispanic girls: 7.6 percent and 7.4 percent, respectively.

The challenge for all of us is this: How do we make the Philadelphia story everyone’s story, in every community?  How do we give every child in America an equal opportunity to grow up at a healthy weight?

On July 22, we’ll be addressing those questions and more at a TEDMED Google Hangout. Here’s who will be speaking:

  • Risa Lavizzo-Mourey, President and CEO of the Robert Wood Johnson Foundation
  • Nancy Brown, CEO of the American Heart Association
  • Don Schwarz, former Health Commissioner and Deputy Mayor for Health and Opportunity, City of Philadelphia
  • Elissa Epel, Associate Professor, UCSF School of Medicine
  • Lisa Simpson, President and CEO, Academy Health

Our conversation will be moderated by Richard Besser, Chief Health and Medical Editor for ABC News.

Do you have a question or comment for the speakers? A story about what’s happening in your community to promote healthy eating, or physical activity? An idea for helping kids achieve and maintain a healthy weight? We’d love to hear from you! Just comment on this post, or tweet using the hashtag #GreatChallenges.

We’re really looking forward to a lively, candid chat, and we hope you’ll tune in and contribute to the conversation!

 

Live online event: A candid conversation about childhood obesity

On Tuesday, July 22nd at 2pm ET, TEDMED will host a special live online discussion with our nation’s forward-thinking health leaders to take measure of the progress and challenges in our ongoing struggle with childhood obesity. Guests include representatives from Robert Wood Johnson Foundation, the American Heart Association, Academy Health, the University of California, San Francisco and the City of Philadelphia. Dr. Richard Besser of ABC News will moderate.

Screen Shot 2014-07-15 at 1.30.35 PM

The national childhood obesity rate has leveled off. Cities and states that have been taking on this issue comprehensively are starting to see their childhood obesity rates drop. A CDC study published in February showed that national rates may be declining among our nation’s youngest children.

This is good news, but challenges remain. Rates are still far too high overall, and racial, ethnic, and socioeconomic disparities persist.

What needs to happen to show bigger results, faster? How do we make sure all children can grow up at a healthy weight? What are some of the underlying environmental and societal causes that must be addressed? What could corporate, community and policy leaders do to further address this critical public health issue?

Click here to RSVP for the Hangout and view more information on this important conversation. We’ll be taking audience questions via #greatchallenges and will answer as many as possible on air.

Community hospital starts its own patient-centered innovation center

Nick Dawson, who moderated last week’s Great Challenges Googe+ Hangout on medical innovation, is also the new Executive Director of Innovation at Johns-Hopkins Sibley Memorial hospital. He’s helped to run a new onsite Innovation Hub, a cross-disciplinary design studio set to launch this fall at Sibley. We talked to him about the Hub and its goals.

TEDMED: What are the Hub’s goals?

Dawson: The Hub will primarily foster a culture of patience and human centered innovation for everybody in the organization to take part in problem solving, improving processes and thinking about how we do our day-to-day work. The Hub will also engage in cutting and leading edge innovation and design work in health care to improve everything from patient experience to clinical process flow. We maybe even invent new products and services.  We’ll be changing culture plus doing classic innovation and design work.

Sibley's Innovation Hub features new perspectives: Pictured: Nick Dawson and Joe Sigrid

Sibley’s Innovation Hub features new perspectives: Pictured: Nick Dawson and Joe Sigrin


TEDMED: Why now?

Dawson: There are some pragmatic realities. Healthcare costs have risen. Clinical quality, despite really well intentioned and impactful work, can be improved.  We may not have enough providers the future,  Above all, it’s become part of our collective discussion to question if we are delivering truly human centered healthcare and meeting the needs of our population, making them healthier and keeping them from being admitted to the hospital and from having serious chronic conditions. We’re having that conversation as country, and we ought to have that conversation within health systems.

TEDMED: Do recent statistics about poor outcomes in the U.S. fuel the fire, despite all the money we spend on healthcare?

Dawson: They are disappointing, and I’m certainly one to help beat that drum and say we need to be doing a better job. At the same time, [numbers] can be misleading because we really do some things incredibly well.  We pioneer techniques and procedures and we’re innovative as a medical community. For example, laproscopic procedures were developed in part right here at Sibley Hospital. A lot of new drug therapies come out of American pharmaceuticals.  So, while we do need to be having a serious discussion about outcomes, we should be proud taht we do have a high performing healthcare system.

TEDMED: You’ll have an embedded innovation team. Who’s on it?

The idea of “team” is loosely defined for us. Dr. Chip Davis, the CEO here at SIbley, and his team deserve the credit for championing the Hub’s vision, and having it be the first community hospital in the nation to have an embedded, well-thought through and resourced innovation center.  There are two of us running the Sibley Innovation Hub, myself and a colleague, Joe Sigrin, who is our Innovation Experience Advisor, and an advisory board.  We’re also developing a physician advisory board to provide clinical direction, and then we have the goal of trying to create widespread culture change. If we’re successful in our job, the whole organization will be part of the team and will be doing mini-projects and even full blown design on their own. We have a wonderful space I which to going to grow that army of design thinkers. It’s a space for everybody that comes into Sibley, whether they’re staff, medical staff or patients.

TEDMED: Will patients be involved?

Dawson: One of our driving goals is including patients in the process, and not just as end users, but as part of the design team.  Frankly, that’s the only way innovation is going to work. Once you co-design, it just feel so right.  It’s the only way that makes sense.

TEDMED: Who or what do you credit with launching a design revolution in healthcare?

That’s a fun one to ponder. There are the IDEOs and the Stanfords; we’ve seen design and innovation centers in many large academic institutions. They gave prominence to the idea.

Another partner, though, and one who ought to get more credit, is patients, those who have said, ‘My health and my condition, and my experience and my interaction with my doctor — that’s my responsibility, and here’s what I’m going to do to own it.  I may have to hack the system.’  They’re designing for themselves ultimately.

And then there are nurses.  All you have to do is shadow any nurse and they have hacks and workarounds for everything.  They don’t call it design thinking, but they have empathy for their patients and their peers and they’re always thinking about how to make things just a little bit better. We see that in doctors, too. Some doctor said, ‘I’m going to try this laproscopic thing, and I’m going to invent a prototype for it.’

There’s a culture in health that who has always existed.  It’s just now becoming a formal process.

- Interview by Stacy Lu

Q2 Checkup: What Is Shaping Digital Health Innovation in 2014?

By Aman Bhandari

With 2014 halfway behind us, it’s time for a bi-annual look back at digital health innovation so far.  What have been our major influencers?

Six months is a very short time span in which to say anything is shaping a sector, but it’s also a good time frame for a snapshot. It wasn’t until I started thinking about what’s happened recently that I realized how dizzying the activity has been across the spectrum and potentially at scale. This is critical. In this year alone we are seeing some of the biggest players make bets and shifts, from the Office of the National Coordinator for Health Information Technology (ONC) to Apple, which means the digital health ecosystem will be impacted, and it could happen at scale.

-1First, look at the activity and record levels of venture funding in the digital health space; $700M in Q1 2014 alone, an 87% year over year increase according to Rock Health. This recent Harvard Business Review piece nicely summarizes why the time to be in digital health is now. There has (finally) been some chatter that we are approaching bubble territory in digital health, and while that may be true, there are at least three areas of optimism thanks to the infrastructure and ecosystem evolving at all levels: Continued Federal activity, Fortune 500/Wall Street involvement, and diversified venture funding.

1. Federal Government: Continued Data Liquidity Push
The federal activity from this year is across the board. Some highlights that will challenge entrepreneurs to develop a continued drive for enhanced data and information liquidity with an improved consumer experience over the long run include the following:

  • ONC releases 10 year interoperability vision
  • ONC re-organizes and creates an API committee. This wouldn’t have happened as recently as two years ago.
  • Medicare announces an historic data release of physician payment data revises other data related guidelines, potentially opening more access to commercial entities
  • FDA Open Data releases millions of files to entrepreneuers in a more accessible format
  • Healthcare.gov helps enroll millions of people

2. Digital Health at Scale: Fortune 500 Involvement

Following on CMS data transparency efforts, some of the largest health insurers, including Aetna, United Health and Humana, announced they will release payment data to consumers. And speaking of consumers, technology companies including Intel, Samsung, and Apple have entered in a big way, and it’s clear that wearables have gone mainstream. The Fortune 500 are paying attention and are also forming collaborations across silos, such as the Apple Epic and Mayo partnership, including:

  • Intel’s $100M+ acquisition of Basis
  • Samsung’s $50M digital health fund + S Health launch
  • The Apple Health Kit
  • Health insurance giants making payment data public

3. Startup Diversification & Investment: New Entrants

The third signal flare from 2014 to watch is the increased diversity of players including some who haven’t been as involved previously. This includes investments this year from venture funds Social+Capital and Andreessen Horowitz (a16z). Some of the new entrants are driving record amounts of funding and are bringing greater assets to bear.  Here are some highlights of startup activity:

  • Flatiron Health had one of the largest series B rounds in the digital health space ($130M)
  • Omada Health gets $28M series B lead by a16z
  • Better raises $5M from Social+Capital
  • Nant Health receives $100M from the Kuwait Investment Authority
  • 16 digital health acquisitions to date

Digital health innovation is still the wild West, admittedly, and there are many hurdles. What’s clear is that these three areas have backing from actors who can scale and bring on the best talent in the world. They’re creating a robust ecosystem that is shaping innovation in digital health. Across the board, there is a larger theme taking shape of capturing, aggregating and democratizing access to data, which is spurring entrepreneurial activity and the consumerization of health. In addition, novel cross-silo partnerships are forming. Collaboration across the health and tech sectors is no longer an option; it is a necessity if we are going to drive meaningful change in healthcare.

Which three things would you point to as harbingers for 2014?   TMIcon

 

Aman Bhandari has worked in corporate, non-profit and government organizations. He formerly worked for Todd Park, the US CTO, at the White House, where he helped to launch a variety of global and national health policy initiatives at the intersection of health IT, data, and innovation. He also co-launched the Health2.0 code-a-thon and developer challenge series. Follow him @GHideas.

 

Reshaping the healthcare workforce: Two case studies

Healthcare is calling for all hands on deck.  Most pundits are anticipating a primary care shortage thanks to greater usage of primary care under the Affordable Care Act.  And with the rise in demand comes increased costs from an already bloated system.

What’s the remedy?  Among suggested strategies on how to add workers, like making it easier and less expensive to train doctors, are innovative initiatives that address the problem from inside out:  Making better use of the staff already in place – like allowing nurse practitioners to practice independently – or adding help at the clinician or community level.

Following are two case studies of care systems that have overhauled delivery with significant results.

Union Health Center: Modeling the A-ICU

Audrey Lum, Chief Clinical Officer of Union Health Center (UHC) in New York City, began reforming Union’s health care team along with Union administrators following a 2005 white paper from the California Health Care Foundation talking about how to serve the highest-cost patients – those with chronic health conditions – who were also under- or uninsured, low-income and not eligible for Medicare or Medicaid. Could these patients be better served, while reducing overall health costs at the same time?

The paper offered a solution: the Ambulatory Intensive Care Unit (A-ICU), which uses nurses, medical assistants, health coaches, community health workers, pharmacists, dietitians and others working at the very top of their capabilities and licensure as the front line of patient assistance and coaching, to allow physician and nurse practitioners to do more of what they’re best at: diagnosing, prescribing and managing care of complex cases.

Audrey Lum and Troy Trygstad discussed their patient home models on a recent Great Challenges Hangout about rethinking the healthcare work force.  Watch a recap:

TEDMED Great Challenges: Shifting Work: Can rethinking the healthcare workforce drive down medica…

UHC was the perfect petri dish for its experiment, a health center with diverse patient base and unique history. Established in 1914 by the International Ladies’ Garment Workers’ Union, its patients are mainly still union members – laundry workers; porters; doormen – and unions subsidize their care, including operations costs. Around 30 percent of their patients are privately insured.

The center created health care teams staffed by physicians, patient care assistants, two health coaches, assistants and support staff. Teams work off of patient education templates created by clinicians, with input from all.

“It’s about educating patients and helping them learn how to take care of themselves.  If you have a chronic disease, you live with it 365 days a year; you only go to the doctor when you’re very sick. How could we incorporate the preventative part of that in our care model?” Lum says.

Hiring culturally proficient health coaches and assistants helped make patients feel comfortable; the staff seem to be de facto community health workers. Staffers speak Spanish, Chinese and Creole, among other languages.

“They’re in the same neighborhoods and they shop in the stores, so there’s that separate connection. It speak to the relationship model of,  ‘We’re in this together. Let’s get better as a team,’ “ she says.

Results are good. A 2014 case study review found that the total per member, per month costs for UHC as of 2013 were 17 percent lower than non-UHC patients, and that emergency room costs were 50 percent less. Patient time in the office decreased from 2 hours to an average of 48 minutes.

Training workers was an investment, Lum allows. It takes up to nine months for assistants to complete, with time dedicated specifically for staff to train with nurses and nutritionists. Union had the help of a grant from The Hitachi Foundation to set its change in motion. Still, the results beg the question: Why aren’t more practices doing this?

“It takes a lot of effort, and it takes a lot of time. People don’t realize that when you give a lot upfront, you get it back at the end.  But when you’re trying to see as many patients as possible and get your fees-for-service, you want instant gratification,” Lum says.

Community Care Workers Calling

In the Community Care of North Carolina (CCNC) model, the patient home extends to the front door. In 2008, the state initiated a population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. Today, the community-based program establishes a medical home for more than 1.4 million patients.

Under the program, care managers follow patients, including home visits, with a special eye to medication adherence, reporting back to a primary care medical home; 90 percent of primary care providers in the state – and every hospital – participate, as do local health and social services departments. Physicians oversee care and share data on a dedicated network.

“We need health workforce reorganization to move from ‘when a patient who has a problem, they come to me’ to ‘a patient has a problem and we’re going to manage it no matter what.’ It becomes more about what happens outside of an encounter with a physician,” Trygstad says.

CCNC patient admission rates are consistently 40-50% lower than non-CCNC Medicaid patients. In a study of patients hospitalized during 2010–11, CCNC found that those who received transitional care were 20 percent less likely to have a readmission the following year compared to clinically similar patients who received usual care.  As measured in 2011, resulting four-year savings to the state for hospital costs and other services were estimated at nearly $1 billion.  In fact, North Carolina is the only state with consistent declining growth rates in medical spending over a decade.

Oregon, Colorado and Oklahoma have similar programs, but Troy Trygstad, Vice President of Pharmacy Programs for CCNC, says:

There were three key ingredients in the primordial goo in North Carolina that resulted in this DNA. There’s a strong historical culture of primary care and public health and population management by virtue of a strong emphases on rural health, supported by medical centers and big universities.

The second thing is that it happened early enough that a lot of the traditional barriers of entry weren’t established. There are certain stakeholders in health system that want to do care coordination and control infomatics, and they’re not going to be interested in an organic provider model that can take on risk.

The third thing is true championship. If you didn’t have strong personalities going to battle over time you wouldn’t be able to maintain [a program like this].

Live event: Can rethinking the healthcare workforce help drive down medical costs?

There’s no shortage of news, or worry, about the coming scarcity of healthcare workers. But is there really a problem? What if we’ve got enough hands, but just need to align tasks better?

shutterstock_172496525According to a study from the Annals of Family Medicine, one doctor can reasonably help 983 patients in a year working solo. As part of a team and delegating some tasks to others, that same doctor could potentially reach 1, 947 patients.

As Ed Salsberg, a research professor at the George Washington University Center for Health Workforce Research and Policy, said:

How we use workers also directly impacts costs, efficiency and quality. If we only allow highly educated practitioners to provide certain services…we are likely to drive up costs and may limit access. If we allow a lesser-educated caregiver to provide services, it may be beyond their skills and training. So how do we know who is qualified to provide what services?

What needs to happen on all fronts to make that work? How can we handle rural and under served areas? Who should play bigger roles: Nurses, pharmacists, technicians? What would that mean for costs? What are our future healthcare needs, and how can we meet them?

Join a TEDMED Great Challenges live event this Tuesday, May 20 at noon ET with Salsberg and others on the forefront of rethinking the healthcare workforce. Kick off the conversation today by tweeting your questions and comments to #GreatChallenges and we’ll discuss them on air.