I spent a day last week at IFTF’s meeting on Personal Health Ecologies. These are my notes, so use these as provocation material rather than a finished argument. But something important is slowly going on here, and health care wonks and industry players should be aware.

As you know I have some affection and connection for IFTF. Their research lately has veered away from the health care system per se and is looking more at health as a lens for commerce–that is looking at the potential businesses to support consumers living their lives with a health focus. They call these personal health ecologies–more about them on page 10 of this report. The crowd at the meeting was not just the traditional health plans/pharma/services types but also financial services companies, software companies, hardware, consumer goods vendors and anyone else looking to learn more about consumers.

One major part of the research this year is looking at the behaviors of the chronically ill. Businesses are getting interested in figuring out these groups as there will be more and more of them in the future. Today’s meeting looks at the chronically ill, and how they manage their own health ecology. This doesn’t just mean their interactions with the “health care system” (plans, doctors, hospitals) but also with their relationships (family and friends), their connection with products, with technology and where they care for their health. To do this IFTF did a whole bunch of ethnographic research, following people around at home, at work and in their daily lives just managing their disease. This is all pretty intangible stuff for a business, but it’s basic research that is important for developing products and services.

So what are they looking at? Diabetes, obesity….

Rod had a “fun” scenario looking at obesity. Interestingly as Generation Y gets fatter, their rate of health spending will increase much faster (maybe in their 30s as opposed to in their late 40s). What might be evidence of this scenario? The key question is at what point will obesity and physical inactivity overtake smoking as the leading cause of preventable death. As obesity and diabetes increases there’s much more focus on obesity and prevention amongst men and children, rather than just Weight watchers as a place for women concerned about looking good.

In terms of business opportunities, there’s a lot of invisible work in tracking and managing disease–so there’s a huge opportunity for routinizing their information management and automatic data capture at home–same as in the hospital (80% of nurses work is recording data and that’s slowly being captured and recorded automatically). Also having to interpret the results of the data, which are not intuitive to the patients.

There’s a real problem for chronically ill people. They get on and off their regimens because they can’t stay there. We need something to make the treatment less miserable than the disease.

So what were the companies at the conference doing to help the chronically ill? Three examples at the meeting:

• Intel is trying to wire the home. They realize that health doesn’t live on the desktop, so how does Intel get into it? They have test houses out with RFID sensors everywhere and devices networked together, and even biometric devices that can be in the bloodstream. They’re also trying to develop mote-based sensors.
• Abbott, in its diabetes division has a wireless sensor implanted into the skin sending continuous a wireless data stream to a glucose meter on the belt, called the Freestyle Navigator.
• Health Hero has a new version of the Health Buddy out which is now both text and voice operated, and can be connected to devices like digital scales.

In many ways the potential success of this is linked to pay-for-performance or more likely some form of pay for outcomes. This is (maybe) going to drive the adoption of disease management techniques in Medcare populations, and may move some of the techniques Health Hero and others are using into the mainstream of health care delivery. We’ll see, but it’s a long transition from where we are now.

Meanwhile, the conference moved onto a riveting session about wider issues of how to change the wider patterns that cause obesity and diabetes, and made me feel very fat! What might stop this trend? Stanford Prof Christopher Gardner tells us that its the Mediterranean plant-based diet rather than the typical American diet….but how to make people change? (Here’s more on his techniques). At the moment we focus on people changing but in fact you can change the way people eat by packaging–but that’s been used so far to make people eat more. Chris recommends “Food Politics” and “Fast Food Nation” as great books that have far more impact than any moralizing professor suggesting a diet. But Susan Foerster from the California “5 a day” campaign (State of California Health dept) shows that financially there is no way to marketing-wise fight the fast-food monolith. Something like $50bn is spent on food advertising (none on veggies) versus under $400m of PSAs. The result = obesity. (Did you know there were 66 spoonfuls of sugar in a 7-11 Super Big Gulp?) And this runs to other political decisions — $72 per capita spent on roads compared to 0.55c spent on pedestrian walkways. Also limited access to fresh produce in poorer areas.

This is all depressing stuff. My view is that the cost of obesity is massive but the marketing is all pushing this one way–to more obesity and more chronic disease. The only way to break this is to divide the corporations who are paying for the costs of obesity from the food companies who are making money from it. But that’s a long way away from our current medical culture. So my bet is on more obesity and more diabetes. Interesting stuff.

More just astonishing research from Wennberg and his team. The latest study shows that whatever the US News and World Report’s ranking of a hospital, some top centers do lots more to a patient close to the end of life than others. In other words the immense practice variation that Wennberg unveiled in the early 1970s continues, even within the elite hospitals in the nation.

And the differences within this elite group are very large. To get a quick summary look at the this AP story. For example, at Mt Sinai in New York LOS was twice that of the Mayo Clinic, while at Cedars-Sinai in Los Angeles, sick patients stayed in the ICU three times as long as at the Mass General in Boston. There’s much more in the full article in Health Affairs. Something is clearly wrong when the best medicine in America is so different from the best medicine in America.

Another article from part of the same Dartmouth group (led by Elliott Fisher, and including Jack’s son David Wennberg) looks at the impact of ICU services in those same elite hospitals on patient outcomes, and it comes up with this pretty stunning conclusion:

Major U.S. AMCs differ dramatically in the overall intensity of services they provide to similar patients. The increased intensity does not appear to be associated with higher quality of care or to result in better survival. Patients in the higher-intensity hospitals simply spend more time in the hospital and intensive care unit (ICU); have more frequent physician visits (especially in the inpatient setting); have more specialists involved in their care; and receive more imaging services, diagnostic testing, and minor (but not major) procedures. The similar results achieved with markedly different levels of resource inputs imply large differences in the longitudinal efficiency of chronic disease care across these hospitals.

Given that they are handing out Nobel prizes at this time of year, is there a more important body of work in economics that has yet to be recognized? In case you wondered, here’s a list of Nobel prize winners in Economics and even though his formal training wasn’t in economics, I think Wennberg would fit right in with this group.

iHealthbeat reports that a couple of patient safety bills are stuck in Congress with little prospect of getting out. Basically the House version would allow errors reported to be used in legal proceedings, while the Senate version would not. The politics of this dispute are starting to get into public consciousness.

While the IOM To Err is Human report is 5 years old this November, a recent Harris interactive poll of the public’s view on patient safety shows that the people are becoming more aware of this issue. It’s not exactly as high on the radar screen as drug reimportation, but there is concern. 63% of Americans are concerned about medication errors in hospitals, and 55% are concerned about surgical errors. I’m not sure that it’s good news for hospitals that more than half of their potential customers are worried about what happens to them when they get in there. After all a hospital is supposed to be a place that you go to get better and a place where you should feel safe. Even though I personally know all about the iatrogenic illness story, I didn’t think that it would happen to me (which it never has!). But it appears that I’m in a minority. And more importantly nearly 30% of Americans believe that hospitals do only a fair or poor job in preventing these errors (and they’re right) which is only slightly fewer than the number who think they do an excellent job.

If you listen to a leader in this area, like Intermountain’s Brent James (who’s talk on this subject earlier this summer I posted about here) you’ll realize that plenty can be done relatively simply to improve patient safety, improve outcomes and generally do this all better. A great example is the use of discharge sheets form InterMountain. A 6 year study shows that giving cardiac patients discharge sheets, and making sure that they take actual drugs (not just a prescription) with them:

Brent Muhlestein, director of cardiovascular research at IHC said the discharge policy seems a simple enough solution, but not every hospital follows it. He hopes other health care facilities will follow IHC’s lead, and he eventually wants to expand the program to patients with diabetes.

It’s about time that every hospital put this to the front of its agenda. Yes, CPOE is complex, but some process change — like those discharge sheets — is relatively simple and doesn’t require too much technology, just a determination on the part of executives and clinicians. And if they need inspiration, well Congress may just be ready to provide it if the issue gets more publicity after the election.

Other than (probably falsely, but if someone knows the truth please tell me) claiming that I was in the group that back in 1997 invented the expression in a health care context, THCB readers will also know that I am somewhat optimistic about the pay for performance concept. There’s a very good Wall Street Journal article about P4P in California on Firday, and luckily it’s been reprinted in a place where you don’t have to subsribe to the WSJ to get it, so go read it.

A little more scuttle-butt from my source on that Tenet sub-contractor THCB wrote about a while back.

Disarray abounds at the small healthcare IT company that Tenet has chosen to support its Core Measures JCAHO submission requirements. The company recently was denied JCAHO “listed” Core Measures vendor status because JCAHO’s Board didn’t feel that the company should be permitted to sell to hospitals directly. Although the company is still permitted to support Tenet, Tenet (as the JCAHO listed entity) is wholly responsible for data submission screw-ups: something that has occurred every quarter, so far.

Adding to the dysfunction is the removal of this company’s CEO and founder by its board and the departure of the company’s CFO, VP of Engineering, VP of Sales, Director of Marketing, and several senior engineers in the past few months. One wonders why Tenet would entrust something as important as JCAHO accreditation to a company that JCAHO refuses to certify…

I have some really juicy stuff on this waiting in the wings, but I probably need to get the as yet non-existent THCB legal counsel on the case first.

So the fight over cancer drug reimbursement is getting quite nasty. The doctors, who as we’ve explained in TCHB many times, have done very well over the last decade or so by dispensing drugs and charging Medicare and private payers a whopping margin, are crying foul as the details of the current price cutting by CMS emerge. Apparently they believe that the overall cut will be 15% as opposed to CMS’s stated 8%. There’s much more in this AP Article.

There’s actually some real money at stake here. About $600m is being cut from the chemo drug budget. ASCO claims 20,000 members but my mole in the business tells me that there are somewhere around 10,000 oncologists (or docs dispensing enough chemo to be counted as oncologists) in the US with an average income in the high-$300,000s of which roughly half comes from the drug mark-up. So you could argue that actually 30% of the doctors’ drug income (i.e. their margins rather than total drug spending) or around $60,000 per physician, is on the table. So expect the fight to continue, and of course have ramifications downstream on the pharma companies, and upstream on the patients.

Meanwhile, back on the subject of chemo, Harvey Fry writes concerning the post last week by Greg Pawelski on chemosensitivity testing.

I fought for chemo-sensitivity testing of cancers over 20 years ago, and finally lost because of the problems with the tests. First, it’s often hard to get a representative sample of tumor cells by biopsy. Then it’s hard to get them to grow. Then you’re not sure whether the cells that grew out are the tumor cells, or normal matrix, like fibroblasts. Then there’s the delay in starting treatment while waiting for the cells to grow out. Then there’s the question of whether cells in metastases have the same response as those in the primary. But the killer was that the clinical response was not that well predicted by the cell survival tests in the lab. And of course, there was the expense.

Unless there has been some major advance in the intervening years, I can understand the reluctance of some oncologists to go back to it. Alternatives to growing the cells and seeing what kills them may now exist, but they are only surrogates for the real end-point of interest.

Sidebar: I was struck by an amusing wrinkle in the end of the chemo article which showed how close the two sides are politically, even if they are fighting over money:

Ketchum Communications, the public relations company working with the cancer doctors to call for a change in the Medicare law, also is the principal contractor employed by the administration to promote that same law. The administration has spent $87 million on television ads, mailings and other means to promote the new law, most of it to tout prescription drug coverage that will be available through Medicare in 2006, the Health and Human Services Department said.

Contributor Gregory Pawelski is back with another look at the chemotherapy market. He’s writing about a wrinkle in the use of chemo drugs that has some big implications. The Sept 1 Press release at this site has the science behind the issue. I’m in no position to judge any of the science being disputed, but the implications for pharma, Medicare, insurers, the taxpayer and oncologists are obvious.

Without information provided by Chemosensitivity Testing (assay-testing), oncologists have the freedom to choose between a multiple of different drug regimens, all of which have approximately the same probability of working. Some of these regimens are highly profitable to oncologists. Other regimens are much less profitable. Assay-testing takes away a lot of this freedom to choose and narrows the selection to those drugs that have the highest probability to be successful but may have lower profitability for the oncologist. This cuts into the oncologist’s bottom line, though it benefits the patient.

Many of these less profitable regimens are oral-dose. As I reiterated in my previous article in office-based oncology practices the core activity in medical oncology is the provision of infusional chemotherapy. The entire structure of the practice revolves around this activity and is what distinguishes medical oncology from most other specialties.

The new Medicare bill offered patients benefits they did not have before. There is now “some” coverage for oral-chemotherapy drugs, which were not available before. Since April of this year, $200 million was available so that some Medicare cancer patients would have transitional coverage for these drugs, until the bill goes into full effect in 2006. Providing some compensation for oral-chemotherapy drugs was a major emphasis for a number of cancer support groups. Although some benefit was realized, more might have been achieved if ASCO (American Society of Clincial Oncology) and other groups had lobbied as much for the oral-chemotherapy drug issue as they did for office-practice expense reimbursement.

ASCO fought long and hard to retain the Chemotherapy Drug Concession and never once suggested the need for a clinical trial to show when drugs were selected with and without the presence of profit differential (which included oral-dose drugs), clinical outcomes would be the same. It is a real credit to oncologists who utilize assay-testing in their management of their cancer patients, despite the fact that their use constrained their freedom to choose and doubtlessly reduced their incomes.

Take an example of ovarian cancer. After 25 years of prospective, randomized clinical trials to identify the best treatments to give to the average patient, there has been absolutely no progress. A meta-analysis of all trials showed that there was no difference. During those 25 years, Taxol came along. Two large clinical trials showed that Taxol/Platinum combinations were better than single platinum regimen. And Taxol became one of the most remunerative cancer drugs of all time. So Taxol/Platinum became “standard” therapy.

But then two more very large trials were done, showing that there was no advantage to giving Taxol/Platinum over single agent platinum (like Carboplatin). And Taxol/Platinum also wasn’t any better than another non-Taxol combination (not previously tested against Taxol/Platinum). But Taxol/Platinum remained “standard” therapy. Now that Taxol is going off patent, some academic oncology groups have (as their major ovarian cancer project) clinical trials to show that Platinum/Taxotere (a drug like Taxol, but still on patent) can now be the new “standard” therapy.

All the while doing this, ASCO is refusing to suggest clinical trials of “cell death endpoint” chemosensitivity testing, because, lacking something patentable or proprietary, all assay-testing laboratories can offer is free assays and not the millions of dollars that someone like Bristol-Myers-Squibb can offer to push its Taxotere trials.

The present system exists to serve the clinical investigators and the clinical oncologists, but not to serve the best interests of the cancer patients. I think it is time to set aside empiric one-size-fits-all treatment in favor of recognizing that breast, lung, ovarian and other forms of cancer represent heterogenous diseases, where the tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient’s cancer.

I was gobsmacked when I heard this on the local news today. A patient at San Mateo Medical Center (San Mateo is the small county immediately south of San Francisco and north of Silicon Valley/San Jose) died after being given 10 times the correct chemotherapy dose. We all know that medical errors are a problem that still exists, but this error was exactly the same as that which killed Betsy Lehman, the health columnist of the Boston Globe at Dana Farber cancer center in 1994. Betsy’s death was part of the groundswell that ended up 5 years later in the IOM “to Err is Human” report.

Nearly five years after the report and ten years after the tragedy in Boston, it’s clear that this is still a frequent occurrence. San Mateo Medical Center will hold an enquiry, but it’s almost certain that a miscommunication between the nursing, medical and pharmacy staff, without adequate process or technology back-up systems, is to blame. And there’s been plenty of time for the health care system to call attention to that, but as Michael Millenson says it’s mostly been silence.

A while back I wrote about the VA and its care management program and in that post I noted that DSM appeared to be getting bigger but wasn’t sure as to whether it was a big deal. I took that discussion over to the very active DM Forum list-serv and it spawned a great deal of posting, which by now has veered off into the realm of Chaos Theory and non-iterative prisoner’s dilemmas. But in the brief period before the philosophers took over and while it stayed on message there were some interesting responses.

The most interesting was from Al Lewis who’s Disease Management Purchasing Consortium essentially owns the research and RFP-type consulting in the space. As no one else is really looking into this as a research business, I find that to be a proxy for it being a small market. I suggested to Al that as Gartner, Forrester, Advisory Board, Harris, Datamonitor etc hadn’t made much of run at it, as a derived anecdote, it suggested that this isn’t that much bigger an area of focus than it was 5 year ago. Al responded to me that “the field has been growing at 22-25% annually and for 2004 will exceed $800-million (including postacute patient mgmt). “ The recent news that market leader American Healthways has seen its revenue in 2003 grow 35% to $165m probably bears out Al’s estimate. In another reply later he suggested that the internal use of DSM was broadly equivalent to that spent externally. So one can guess that roughly a little under $2bn is being spent on disease management programs. To put it in perspective, if the entire DSM business was a drug, it would be less important than the second ranked Cox-2 inhibitor. You can get much more data and information from Al (although it will cost you actual money–as it should!). He also noted that:

The reason these other orgs haven’t made a run at it (or me) is that I pretty much own the space. The DM companies are private for the most part–I’m the only one who can estimate their revenues because I get their RFPs with average pricing and # members. And in the case of the Advisory Board at least, this isn’t their market–no one on the hospital side will spend a lot of money to learn about this field.

Again that’s all true, but if the market was ten times the size Al would find more competition in his niche. But the bigger question is even if it’s growing relatively fast from a small base, has DSM lived up to its promise of becoming a real market? On this broader point Al writes:

The Disease Management Purchasing Consortium tracks revenues by vendor and has been doing so since well before “Monica Lewinsky” was a household name and I can tell you with drop-dead certainly that the field has been growing roughly 25% a year.

It’s a little like soccer. How, might you ask, is disease management like soccer? Well, when I was a kid all the big tough kids (the ones who were getting to third base in sixth grade but who now mostly sell used cars, or, if they are lucky, quality pre-owned vehicles) played football at school. Our school offered soccer to the rest of us, to keep us off the streets (since we listened to the Monkees, that’s how cool we were, I’m afraid the streets would have had little to fear from our being on them in any case). Well, when one of our parents friends or some other random adult asked what sport we played and we said “soccer” we had to explain what soccer was. Likewise, seven years ago when you said you were in “disease management” you had to explain to people–even people in managed healthcare–what disease management was. Now, even ordinary cocktail-party-type people kinda sorta know. That, my friend, wouldn’t be happening if the field weren’t growing by leaps and bounds.

Now Al’s current style belies his alleged 6th grade wimpiness. I grew up playing soccer in the UK–it’s a real hard man’s game there–and there are plenty of fat, bald middle-aged men limping around London who wish they hadn’t run into a dirty central-defender called Holt in their youth. And for that matter, if you saw the Olypmic women’s soccer final, you might have noticed some pretty rough stuff being dished out by both the Americans and the Brazilians, and The Guardian indicated that the Americans kicked the Germans off the field in the semis. That’s what less talented but very determined teams do to win in sports. (England’s 1966 World Cup Win is a case in point)

However, to return from that little digression, you might think of taking Al’s point about DSM and soccer getting more important in the US together. But it would have been more convincing if it hadn’t been tested by another poster who said that “I was at a cocktail party just last night and happened to mention disease management and the general response from folks was: ‘but, isn’t that what doctors do?’“ David Tinkelman, MD from the National Jewish Medical and Research Center backed up the cocktail party folks:

Some times, people who work in the provision of healthcare services called “Disease Management” forget the reality that this small intervention is but a part of the larger world of management of disease. In that world, the reality is that the principal relationship is between the patient and a physician (not necessarily an ongoing relationship, as in those who primarily seek their care in emergency rooms and clinics). It is in that relationship that medications are prescribed, care is administered,prevention is applied and presumably trust is established. Most external entities who provide “disease management” services do not provide medications directly, hands on care, and take direct care and responsibility of emergency and life threatening situations. These have been and are the roles of the physician community. To believe that outside entities really provide management of disease without direct physician input is putting on blinders to the reality of the healthcare system as we know it in the United States.

But on the other hand Robert M. Ross, MD wrote:

I am not completely convinced that physicians “have” to be the lynchpin in the process. I have been involved in too many DM programs that achieved remarkable results without and sometimes despite physician involvement. However, for those that cannot live without them, there is no option other than Pay to Play programs. Yes, there are some physicians who will strive to do everything for their pts, but for most, it is not practical or financially sound.

So–assuming that DSM programs aimed at patients outside their interactions with physicians can only get us so far–it appears that we’re stuck in a world in which the doctors can’t or won’t get involved, but are needed to make the big changes. So what do the doctors need? Obviously incentives is one thing. But another is technology to support DSM in the clinical workplace. The CHCF had a roundtable looking into IT use in Chronic care management which reported this week.

Funnily enough the report was written by my colleague Robert Mittman who spent the 1990s being the most pessimistic person I know about the adoption of IT in the clinical setting, and may have been too optimistic! The report is an excellent summary of the state of play, and it basically says that in the small to medium sized physician’s practice–that is where most Americans get their health care–we are nowhere. Or rather we are just starting on incomplete disease registries, and hoping the eventually they’ll get built into the ever-coming but not quite here electronic medical record.

Now there is a very important reason that these efforts should continue, and Medicare can help by changing the way it pays for DSM but that’s a tricky process. In the meantime we have more independent confirmation in Health Affairs from Ken Thorpe that 15 big disease categories consumer most of the money we spend on health care, and many of them like diabetes, heart and lunch disease are in the wheelhouse of DSM’s successes to date.

But I hate to remind Al that while around the world soccer is just getting bigger and bigger as a sport and as a business, in the US the women’s pro league folded last year, and the men’s game is a sickly 7th or 8th in terms of TV time and fan importance despite a 1/4 final-round appearance in the 2002 world cup for the men, and sustained success for years for the women. So just because something should be a big deal, it doesn’t mean it is. But let’s hope it will be.

Healthleaders has an interview with Robert Wachter in which he stresses the need for procedural, technology and cultural changes to end systemic medical errors. Go read. great stuff. And not a mention of Michael Millenson in a post about patient safety.