I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.
Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.
Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.
Sean Duffy, CEO of Omada Health, proves why his company is one of those digital health startups everyone’s watching in the chronic condition management space. Never mind the buzz around their latest massive funding round or Livongo’s IPO, the real story here is Sean’s idea about building a “completely digital” care provider for folks with pre-diabetes, type II diabetes, hypertension, and mental health issues — or, at least that’s the goal for the next decade. What does a “full-stack view of supporting someone’s care look like? How do you get there? Tune in to find out about Omada’s proprietary tech-testing litmus test, “The Sean Duffy’s Mom Test,” and some good advice for other health tech startups about what it takes to win over clinicians with your tech.
Filmed at Health 2.0 in Santa Clara, California in September 2019.
Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt. Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.
It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.
When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.
What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.
The drought is over! On Episode 93 of Health in 2 Point 00, Jess and I talk deals, deals, deals. Ginger, which provides digital mental health services, raises $35 million and is growing quite fast; VillageMD, one of numerous companies who are trying to figure out a new way to do primary care, raises $100 million; Health Recovery Solutions, which does remote patient monitoring, gets $10 million. In other news, Livongo’s stock price collapsed a little bit, but it was crazy when it first came out so now prices are more “normal”; uBiome files for bankruptcy, and Tula Health’s $2.5 million raise gets quite possibly the best press release we’ve ever seen (you’ve got to hear this). —Matthew Holt
New Scientific Breakthroughs Can
Provide a Longer Healthier Life
Twenty-one years of follow-up comparing usual care with a protocol-driven team-based intervention in diabetes proved that healthy life in humans can be prolonged by 8 years. These results were achieved at a lower per patient per year cost. Aging researchers have been confident that we will soon be able to prolong healthy life. This landmark study shows this ambitious goal can be achieved now with lifestyle intervention and a few highly effective proven medications. These medications interfere with the core molecular biology that causes chronic disease and aging. These same medications will likely produce similar results in patients with congestive heart failure, chronic kidney disease, arterial disease, history of heart attack, hypertension, and angina. Simple medical interventions can extend healthy lifespan today.
Better Chronic Disease Management
Can Improve Health and Lower Costs
90% of health care costs come from chronic diseases and aging which are both related. The same biochemistry that causes aging causes chronic disease. Eating processed food, gaining weight, smoking cigarettes, and sitting on the couch accelerate aging and chronic condition development. Those activities switch on genes that should be quiet. Eating real food, avoiding cigarettes, activity, lisinopril, losartan, atorvastatin, metformin, (and spironolactone) are now proven to extend healthy life by 8 years in patients who are at high risk of health catastrophes and early death! These medications all cost $4 a month except for atorvastatin which is $9 a month. The benefits continue even when best practice treatment stops probably because these treatments block signaling from dangerous genes that are inappropriately and persistently turned on.
Progress Will Require Extensive
Health System Reengineering
Having better health and reducing health care costs can happen today. Surprisingly, the biggest barrier to progress is our current health care system. It is arranged around catastrophes, organ systems, and hospitals. These concepts are 100 years old. Chronic disease begins decades before the catastrophe, and it is related to aging. Age is the greatest risk factor for a heart attack. The same biochemistry that causes accelerated aging also causes heart attack and strokes. It makes little sense to see a cardiologist for a heart attack and a neurologist for a stroke. They are caused by the same molecular biology. The leading health care systems are beginning to recognize that. The interventions that slow aging and chronic diseases development impact every cell in the body. Every young person who is overweight or smokes has activated genes that make accelerated aging and chronic disease more likely. If these genes are switched on prior to having children, that risk is passed on to the next two generations.
Primary care teams organized to address chronic conditions and more rapid aging will provide lifestyle advice and medication that interfere directly with the biology that is causing the problem. The further upstream these individuals are when identified, the easier it is to slow aging and delay chronic disease onset. The path to better health at lower cost lies in the outpatient setting with primary care teams that are well-versed in molecular biology.
I have a bias, I admit it. I am sensitive to studies with a subtext of “those stupid patients, what are we going to do about them?” Read the following rant with that in mind.
A pharmacy benefits manager a/k/a PBM funds a study of patients nonadherent to chronic prescription medication. The premise of the study, Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial (hiding behind a paywall, by the way), is that “forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.” Thus, the intervention consisted of sending a population which included folks taking meds for schizophrenia and bipolar disorder either “a pill bottle strip with toggles, digital timer cap or standard pillbox” along with their mail order meds. There was of course a control group who received neither notification or a device. Surprise, surprise! Getting a prize in your Crackerjack box from your PBM does not improve medication adherence. Those stupid patients! Why won’t they do what’s good for them?
The wellness emphasis in the Affordable Care Act is built around the Centers for Disease Control and Prevention’s (CDC) 2009 call to action about chronic disease: The Power to Prevent, the Call to Control. On the summary page we learn some shocking statistics:
“Chronic diseases cause 7 in 10 deaths each year in the United States.”
“About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.”
“More than 75% of health care costs are due to chronic conditions.”
Shocking, that is, in how misleading or even false they are. Take the statement that “chronic diseases cause 7 in 10 deaths,” for example. We have to die of something. Would it be better to die of accidents? Suicides and homicides? Mercury poisoning? Infectious diseases? As compared to the alternatives, it is much easier to make the argument that the first statistic is a good thing rather than a bad thing.
The second statistic is a head-scratcher. Only 223 million Americans were old enough to drink in 2009, meaning that 60% of adults, not “nearly 1 in 2 adults,” live with at least one chronic illness — if their language is to be taken literally. Our suspicion is that their “133-million Americans” figure includes children, and the CDC meant to say “133-millon Americans, including nearly 1 in 2 adults, live with at least one chronic illness.” Sloppy wording is not uncommon at the CDC, as elsewhere they say almost 1 in 5 youth has a BMI > the 95th percentile, which of course is mathematically impossible.
More importantly, the second statistic begs the question, how are they defining “chronic disease” so broadly that half of us have at least one? Are they counting back pain? Tooth decay? Dandruff? Ring around the collar? “The facts,” as the CDC calls them, are only slightly less fatuous. For instance, the CDC counts “stroke” as a chronic disease. While likely preceded by chronic disease (such as hypertension or diabetes) and/or followed by a chronic ailment in its aftermath (such as hemiplegia or cardiac arrhythmias), a stroke itself is not a chronic disease no matter what the CDC says. Indeed it is hard to imagine a more acute medical event.
They also count obesity, which was only designated as a chronic disease by the American Medical Association in June–and even then many people don’t accept that definition. Cancer also receives this designation, even though most diagnosed cancers are anything but chronic – most diagnosed cancers either go into remission or cause death. “Chronic disease” implies a need for and response to ongoing therapy and vigilance. If cancer were a chronic disease, instead of sponsoring “races for the cure,” cancer advocacy groups would sponsor “races for the control and management.” And you never hear anybody say, “I have lung cancer but my doctor says we’re staying on top of it.”
Last week’s announcement by the American Medical Association’s (AMA’s) council on science and public health cheered me. It said that the AMA should not designate obesity a disease, because doing so was unlikely to improve health outcomes and because the most widely utilized obesity metric — the body mass index or BMI — was simplistic and flawed. It’s a reasonable and principled stance, which should have been the first clue that it was doomed.
The AMA’s board and delegates proceeded to snatch defeat from the jaws of victory by ignoring their own scientific council and labeling obesity as a disease. To be clear, the decision is almost purely symbolic; it has no legal force or authority, but it does up the ante in the debate with insurers and employers over what care elements should be covered and reimbursed. In other words, this is about money. Obesity: the new ATM for the health care system.
Were US physicians blindfolded as they encountered patients growing incrementally larger with each visit? Were they keeping their mouths shut about the obvious — gee, I really think you should get out for some walking and limit the snacks — because they were awaiting a chance to make more creative use of ICD and CPT codes?
“Speed kills,” warns the traditional highway sign about the dangers of haste and traffic deaths. Now, we know that stress kills, too.
Toxic stress, at any rate. The human body’s response to normal amounts of stress—say, a bad day at the office—is likely to be brief increases in the heart rate and mild elevations in hormone levels. But a toxic stress response, stemming from exposure to a major shock or prolonged adversity such as physical or emotional abuse, can wreak far more havoc.
In children, science now shows that toxic stress can disrupt the developing brain and organ systems.
The accumulated lifelong toll of stress-related hormones sharply raises the risk of chronic diseases in adulthood, ranging from heart disease and diabetes to depression and atherosclerosis.
Thus, the message from a panel of experts to the Robert Wood Johnson Foundation’s Commission to Build a Healthier America was at once simple and challenging: Create a healthier environment for—and increase coping mechanisms and resilience in—the nation’s most vulnerable and stress-ridden children and families.
At a June 19 meeting in Washington, DC, the commission heard testimony from a child development specialist, an economist, and community development professionals, among others. Together, they described more of the social and economic effects of toxic stress, but also the evidence that significant investments in individuals, families and communities can turn the tide.
Robert Pear wrote in the Times that the refusal by “states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance…” Indeed, the refusals will do that, as well as worsen what instead should be remedied. In the following I present a graph of two chronic diseases over the 50 states. Those states which have opted out of the Medicaid expansion are identified. Additionally each state’s poverty rate is indicated. The take-away is that populations in greater need are being further disadvantaged. A conjecture is presented as to why.
Please understand that refusal to expand Medicaid is not about state expenditures. Over the ten years, 2013-2022, every state would gain far more than it would spend for expansion . Were all states to opt-in, the total ROI for the states combined would be almost 10,000% ($8 billion state expenditures in return for $800 billion federal).
Empirically health is associated with income, so if you’re poor you’ll likely have worse health. Also it’s well known that chronic conditions are often comorbid, that if you have a chronic disease, you probably have more than one. Additionally, chronic disease is a major contributor to total health care costs. Continue reading…