Today on Health in 2 Point 00, Jess and I are at Livongo’s SIGNUM 2019 conference in San Francisco—in bobblehead form. In this episode, Jess asks me about my key takeaways from the conference, which focused on chronic condition solutions. It was really exciting to hear how the experience of patients with chronic conditions has been changed. We heard some fun stuff from Seth Stephens-Davidowitz about his book Everybody Lies and Daniel H. Pink’s When: The Scientific Secrets of Perfect Timing, and from Stephen Klasko of Jefferson University and Mark Ganz of Cambia Health about the importance of proper partnerships and innovation from traditional healthcare companies. At the end of the day, at a relatively small scale we’ve made a difference in the lives of people with chronic illness—but can we deliver this at a huge scale? —Matthew Holt
This is, of course, a relatively common scenario: aging adult moves — or is moved by family — to a new place to live.
Seamless transition to new medical providers ensues. As does optimal management of chronic health issues. Not.
Naturally, my friend is anxious to ensure that his father gets properly set up with medical care here. His dad doesn’t have dementia, but does have significant heart problems.
My friend also knows that the older a person gets, the more likely that he or she will benefit from the geriatrics approach and knowledge base. So he’s asked me to do a consultation on his father. For instance, he wants to make sure the medications are all ok for a man of his father’s age and condition.
Last but not least, my friend knows that healthcare is often flawed and imperfect. So he sees this transition as an opportunity to have his father’s health — and medical management plan — reviewed and refreshed.
This last request is not strictly speaking a geriatrics issue. This is just a smart proactive patient technique: to periodically reassess an overall medical care plan, and consider getting the input of new doctors while you do this. (Your usual doctors may or may not be able to rethink what they’ve been doing.) But of course, if you are a 93 year old patient — or the proxy for an older adult — it’s sensible to see if a geriatrician can offer you this review.
Times have changed. And it’s time they change again.
In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.
There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.
In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.
Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.
Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.
The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.
The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.
But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.
In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.
That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.
Walmart — the nation’s largest retailer and biggest private employer — now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a confidential company document.
In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”
On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”
The 14-page request asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.
Analysts said Walmart is likely positioning itself to boost store traffic – possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.
“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”
Unless you spend a lot of time around health policy wonks, you’ve probably never heard of the term “value-based health insurance benefits.” In fact, you may not even know that it’s the hottest new fad in the field.
Here is my layman’s summary: If you are like most people, you are not a very good consumer of health care. Odds are, you will fall for the latest fad advertised on TV or follow the advice you get at the bridge club instead of buying the care that has been scientifically shown to be better for you.
So as a corrective, a lot of employers are finding ways to “nudge” you into better decisions through financial incentives. Say you have a chronic condition and need to take certain medications. Your employer might drop your deductible down to zero (or may even pay your to take them) to encourage your compliance. But for services where there appears to be wasteful overuse (such as MRI scans), the employer might impose a hefty $500 deductible.
This idea intrigued me, so I turned to a rather lengthy article in the Washington Post, which informed that value-based insurance benefits are incorporated into the new health reform law, “including the requirement that new insurance provide free recommended preventive services such as mammograms and colon cancer screenings.”
In the world of big business, this idea is all the rage. One in every five employers employing at least 500 people is already doing it. Four in five employers who employ at least 10,000 workers say they are interested.
So if big business is for it; the government is mandating it; and health policy wonks like it; how could anyone possibly obj-……..Continue reading…
They are coming in fast under the radar, out of peripheral vision, in the magician’s other hand—and they will change everything. New ideas, surprising networks, stealth business models that may change health care profoundly, are bubbling up in pilot programs, experiments and full-on corporate transformations. There is something here that does not yet have a name, that no one is yet calling a movement, that no one is yet seeing as revolutionary.
While we have been mesmerized by federal health care reform, government intervention on behalf of the uninsured and government attempts to “bend the cost curve” to shave a few percentage points off medical inflation, things have been happening in the private sector for people who are already insured that result in outright medical deflation, drops in costs of 20 percent or more, all while giving people more care, not less.
Help me out here. This picture is just forming, the Ouija board is still in motion, but I think what we may have here is some truly big news about the future.
The Difference Is Integration
First, consider the huge regional differences in health care costs. Think about what it means that it costs twice as much for patients in the last six months of life to be involved with Cedars-Sinai in Los Angeles, UCLA Medical Center or New York University Medical Center than it does for them to be involved with Mayo Clinic in Minnesota or the Cleveland Clinic; or that Medicare spends half as much per patient per year in Temple, Texas, as in McAllen or Harlingen or Brownsville, Texas; or why Medicare spending per patient per year in the top and bottom quintiles of hospital catchment areas differ by 60 percent.
These are vast differences—and the more expensive areas show no better outcomes than the less expensive ones; in fact, for some conditions they show worse outcomes.Continue reading…
As we work to change health care in America, we must recognize the need to dramatically change diabetes. Twenty-four million Americans have diabetes at a cost to our nation of an estimated $218 billion for diabetes and pre-diabetes, according to a series of studies recently published in Population Health Management. Imagine the effects diabetes will have on our health and economy in the future if we don’t take action now. The prevalence and economic burden of undiagnosed and pre-diabetes make the case for the importance of policies that promote early diagnosis and prevention. About 25 percent of Americans with diabetes aren’t even aware they have the disease. And, those with undiagnosed diabetes result in $18 billion in health expenses, or $2,864 per person each year, according to one of the studies mentioned above.
I am a 65 year old retired ad exec and also an insulin-dependent
diabetic. I have other medical complications, but taking care of the
diabetes is the big one.
Every day I test my blood glucose
levels as many as ten times. A box of test strips retails for between
$40-$60 and lasts less than a week…. you do the math. In case you
were not aware, your glucose levels are in a state of constant flux
depending on your intake of food and exercise. Bottom line, keep your
levels, "level" and you'll lead a more normal life.
Now with all the
talk about raising taxes to pay for the rising cost of health care I
hear absolutely no discussion about reining in the unjustified
increases of medical supplies and equipment. Just ten years ago I
could buy test strips for $10. Now they come in slick PVC canisters,
wrapped in four-color labels and packed in plush slick cardboard boxes
stuffed with layers of "instructions" and phony code strips. Remember
all you need do is stick your finger an put a drop of blood on the end
of the strip. How hard is that?
So, for $2,600 a year I get to
stick my finger ten times daily, throw a pile of unread and expensive
packaging in the trash, and pay increasingly higher health care
While Congress is debating health reform and struggling to accomplish the apparently competing goals of reducing costs while improving quality, I am part of a program that does both. As co-director of the Washington Hospital Center’s Medical House Call Program, I visit the sickest, frailest Medicare patients who consume a wildly disproportionate amount of Medicare dollars. Not only am I providing better care for my patients, I’m doing it where they want it — at home. House calls allow me to better manage their chronic conditions by seeing their medications, diet and home life and enabling me to better support their caregivers and coordinate their medical care. The math is simple: the better I do, the happier they are and the fewer times they need to visit an expensive hospital or nursing home. Shockingly, this proven approach that reduces unnecessary spending is being overlooked in the current reform debate.
Take one of our patients, Mrs. C, who has heart failure and pulmonary disease. She is chair- and bed-bound. She relies on her daughter for all her basic needs and cannot easily get to the office. Through our program, a team of doctors, nurse practitioners and social workers can visit Mrs. C at home and provide care on-site. We can manage her heart and lung problems on the spot, rather than having to wait until her symptoms are so severe that she has to go to an emergency department by ambulance. Additionally, avoiding the hospital means Mrs. C is less likely to face medical complications from a hospital visit. The accrued savings pay for a year’s worth of house calls for eight patients. Our program has shortened the hospital stays of 600 patients by a quarter, and reduced hospitalizations at end of life by 75 percent.Continue reading…