Navigating Healthcare – Patient Safety and Personal Healthcare Management

Digging in to Your Social Media Feed

Social Security
Digging into your Social Media Data

It was with interest I read a recent Viewpoint article in the Journal of American Medical Associations (JAMA) titled: Social Determinants of Health (SDoH) in the Digital Age, Determining the Source Code for Nurture authored by Dr. Freddy Abnousi, the head of healthcare research at Facebook, along with a couple of other authors, Dr. John Rumsfeld, Chief Innovation Officer at the American College of Cardiology (@DrJRums) and Dr. Harlan Krumholz, Professor of Medicine at Yale (@hmkyale)

They rightly point out the major contribution of social determinants of health – a fact highlighted as far back as to 1946 and the World Health Organization (WHO), but the research has been hampered by the inability to capture accurate granular data which is mostly self-reported (with the associated unreliability). We do need better approaches and the social networks offer a tantalizing look into data of this nature with a peek into online behavior, data that is posted by the millions of users who engage daily online.

They offer an intriguing potential to pre-identify suicidal ideation, “with enough advance warning and accuracy to stage a peer-driven intervention“. The opportunity to identify high risk for opioid addiction or finding those at highest risk of cardiovascular mortality and engaging with the users corresponding social network who would be “tasked with responsibilities”.

There is much to applaud in the concept but it raises some serious and challenging issues in my mind

1) Informed Consent is a major challenge and history and recent revelations do not engender any confidence that this data or insights would not be used against the patients or their families

2) De-Identification of data is already problematic – when you consider Intensity Analytics ability to identify individuals and behavior simply from their interaction with a keyboard

3) Trust is broken across so many areas and the current system is working as designed – a business. It is highly unlikely that users would ever *knowingly* give their consent

4) Healthcare consumers in the United States are struggling while the business of healthcare continues its march towards profit. Intuitively any insights from an SDoH program would have to focus on the best economic solutions which are mostly non-healthcare solutions (food, housing, income, education)

We need insights and data to provide the data to support and effect change and this idea has merit – but without some real changes to the business of healthcare, it will struggle to take off or deliver value to our population. I’d suggest a better incremental step would be to look at this data to show the underlying struggles of the users and creating a catalyst for change

 

Digging in to Your Social Media Feed was originally published on Dr Nick – The Incrementalist

Advertisements

Interoperability in Healthcare

Getting to Nationwide Interoperability

Data
Free Flow Data Sharing

Unfortunately, the existing healthcare system incentives behavior that is in opposition to the goal of scalable, nationwide, vendor-neutral interoperability. Our model has multiple groups who have a vested interest in the control and ownership of data (for example Payors, Providers, Patients). Each has their own economic and commercial drivers and in many instances, these do not coincide with the open sharing of data. In a system that is driven by activity and delivering care (Fee for Service) sharing data could mean a reduction in work and income. Until our reimbursement system moves to a more holistic care model that focuses on wellness and outcomes and incentivizes behavior that delivers better health and outcomes for patients through cooperative and coordinated care and ultimately equitably rewards all the contributors to these outcomes we will remain stuck in the quagmire of limited interoperability.

The Patient at the Center of Data Exchange

I believe as do many others that the patient is at the center of everything we do and deliver in healthcare. By placing the patient and their information at the center of care we empower them and enable a model that moves away from the historical paternalistic delivery of healthcare to patient-centered and enabled care. It does come with challenges since many people contribute to that care and the current administrative and financial configuration focus the management and ownership of data with providers, healthcare systems and payors. While many patients want access to their data and some even want to own and manage it, many do not and are ill-equipped to be responsible for this data. What may emerge are independent services and providers who aggregate, manage, secure and service patient data on behalf of patients – much as banks do with our money. There are many technologies on the horizon that offer a potential path to achieve this and blockchain represents an interesting innovation of decentralized secured data that offers individualized control and dynamic revocation options for access.

Frictionless Data Flow

The key to an interconnected care model is the free flow of data between all the various areas that are responsible for delivering care. We moved away from the single index card medical record held by your personal physician who was the focal point of your care and care coordination to a distributed team-based model of care that encompasses multiple areas and people. The only way this team can deliver excellent care is through the frictionless flow of enhanced data and knowledge. This information flow must include the patient and all their family members that are authorized, interested and engaged in their care. Data should be shared with the patient’s consent with everyone concerned and available for as long as it is needed to deliver care but this access should be flexible enough to allow it to be revoked or removed when it is no longer needed or necessary

 

Interoperability in Healthcare was originally published on Dr Nick – The Incrementalist

The NHS at 70

Healthcare, NHS

The crown jewels of British society

The NHS was the crown jewels of British society providing healthcare to every member of society no matter who they were, where they came from and what personal resources they had. It was the great leveler of society creating a single standard of care and service that was accessible to rich, poor and disenfranchised and it was well loved.
To me personally, it was my guide and educator – I was lucky to attend one of the great London medical schools – The Royal Free Hospital School of Medicine. The “Free” hospital created to treat all comers and the original medical school (The London School of Medicine for Women) for women created in an era when women were not admitted to British Medical schools

That hospital and the NHS provided me with a first-class medical school education, access to groundbreaking research that included the early work and discoveries around HIV/AIDS, Hemophilia, Liver disorders and beyond.
The staff in every department were friends, colleagues and members of a community that were family and all pulled in the same direction – that of the patient. I spent time working in different areas during my time, staffing the manual telephone switchboard, helping the porters and security staff, nurses, technologists, and maintenance and quickly realized the well-oiled NHS machine demanded a family of committed people to make it work and deliver outstanding care each and every day.

What Could We Do Better

As we know today, and probably knew 70 years ago and before, healthcare is as much about our environment and resources as it is about medical treatments, technology, and innovation. We know that 60-80% of health is attributable to lifestyle but fail to take account of this in the NHS and in the majority of health systems from around the world.

 

We need a WellCare system not Healthcare

 

The system spends large sums of money providing medications to the population but fails to take account of the most basic needs of the population and acknowledge that food is also a drug. What we put into our bodies contributes to our health and well-being. Failing to acknowledge and manage these elements of health with sleep as the foundation and exercise and nutrition built on top has created a system that treats the failing of these issues at great financial and personal patient cost. Investing in the prevention would create a WellCare system and not the Healthcare System that the NHS is.

Manage and Allocate the Limited Resources with Transparency

It’s an unpleasant fact that few want to address or even acknowledge but the reality of treating people is that in this day and age of innovation, scientific progress and developments we could spend every last penny on treating patients. There is an unlimited supply of possible treatments and a never-ending procession of people needing those treatments. But not all treatments are created equally – some don’t work, some are harmful and in the cases of those that do work there is the wide disparity in the effectiveness and cost. Any healthcare system needs a means of assessing the effectiveness of treatments that includes the financial and resource cost linked to the improvements. The problem with a “free” (the NHS is not free – it is simply free at the point of care, paid for through taxation of the individuals) is the inducement of un-economic behavior by individuals looking for every last treatment option no matter the cost or effectiveness. That path is unsustainable and breaks the system and ultimately harms patients.

Enable Informed Decision Making for Everyone

Doctors Die Differently and do so because they understand the economic and personal tradeoffs between treatments and quality of life. In the data presented by the Johns Hopkins Study of a Lifetime we see a big discrepancy in treatment choices between doctors and everyone else. We make our choices in the context of the knowledge of effectiveness weighed against the personal cost of treatments and quality of life impact. An open an honest assessment of treatment that is clinically effective would level the disparity in treatment choices selected by patients. As a society, we struggle to discuss end of life but it is a reality that everyone faces and we must find ways to educate and support people through all aspects of life and death.

Technology and innovation is essential to the future of the NHS

The future of a scalable meritocratic system accessible to all that does not bankrupt society will be dependent on technology and innovation. Humans remain the core constituents of any compassionate caring system and technology is a supporting player. But as Michael Dell put it:

Technology has always been about enabling human potential

Michael Dell, Dell
Technology has always been about Enabling Human Potential

Technology does not replace the human beings or interaction but rather augments it in ways that extend our capabilities and improves the accessibility and economics.

It is an impossible task for humans to process the amount of data currently being generated about our patients, the knowledge derived from research and advances in science and put it into the context of treatments at the point of care when it is needed most.

We have expanded beyond the human brains capacity to absorb, process and apply the knowledge and must rely on technology to augment the brains abilities and place information into the context of the individual patient and the care choices available.

Selecting the innovations that deliver the most value

Innovation impacts each and every area of the NHS and will continue to do so but the challenge will be to select the innovations that deliver the most value to the largest number of people based on scientific peer reviews.

Innovation is not confined to the clinical treatment but extends to every element of the NHS system and the delivery of wellness care. It is changing the design of facilities to include features that improve care and outcomes – for example by adding natural light and open spaces.

Innovation is allowing patients the option to access their care team at any time and from any location – for example bringing the care team to the patient as we used to do with home visits but now using technology to extend the reach and scalability.

Innovation is building rooms and beds that can be efficiently and effectively cleaned between visits while maintaining comfort and welcoming surroundings. It is using available data to predict potential health issues before they occur and reaching out to patients helping to guide them to better healthier choices and wellness. Innovation is allowing parents to stay with their child in the hospital when they are sick and in need of care in comfortable and caring surroundings.

Innovation is offering dignity and compassion to those facing death and offering realistic options for no treatment and hospice care.

What can Britain and the NHS learn from the rest of the world?

Over 700 years ago, China had village doctors who were paid by the villagers when they were well but received no money when the patients were sick. This is the principle of wellness over sickness care. In Norway, they have a wide and uniform implementation of a digital health record that is accessible to everyone that needs it including the patient – tied together with a unique patient identifier designed for that purpose. One Citizen, one record.

The European Union allows citizens to cross borders and different health systems but to receive urgent care while traveling and administers the cross-country charges, managing fees and removing the patient from worrying about payments while they are sick and abroad.

Look also to Africa and the innovation that takes place on a continent with access to far fewer resources and technology to see what’s possible with the existing technology. Small incremental steps in using technology to boost healthcare services such as text messaging have been wildly successful and yet remain simple, easy to implement and understand and accessible through all social groups in society.

In Rwanda, they have integrated drone delivery for hard-to-reach locations, offering lifesaving support that was previously almost impossible. Expect to see more of this and bi-directional capabilities for resources, tests, and samples as well as lifesaving treatments.

Finally, in Korea, they have a culture of celebrating aging and the elderly that includes dignity in end of life and the inclusion of everyone in the family and their health. Korean culture sees the 60th and 70th birthday as a big family affair and the inclusion and the universal expectation that roles reverse once parents age, and that it is an adult child’s honorable duty to care for his or her parents’ health.”

A version of this appeared previously here

The NHS at 70 was originally published on Dr Nick – The Incrementalist

Using Advanced Trauma Life Support Methodology in Population Health

 Preventative Health for Everyone

 

NewImage

This week I am talking Joshua Scalar, MD, MPH, Chief Medical Officer for BioIQ where they are working to seamlessly connect people to preventative health testing by removing the friction from the system and allowing as many people as possible to access essential, cost-effective life saving preventative testing services.

Josh had an interesting path to his current role – find out how a Saxophone playing band member became a passionate advocate for patient engagement and widespread and easy access to preventative services

Hear how Advanced Trauma Life Support (ATLS) insights offer a model and guide for the triage and delivery of preventative care that should address a problem that by some estimates has only 8% of people accessing fully validated life-saving preventative care opportunities in the United States

Like many of my other guests, Josh made the point that one of the clear incremental steps to getting patients and consumers to access preventative services is

Making the right choice the easiest choice

Hear how he and his team have addressed a basic problem of colonoscopy screening that is an effective and well-tested method of picking up and preventing untimely death from colon cancer but is still poorly adopted. As he points out – colon cancer killed 50,000 people in 2017 – that’s more than the opioid epidemic did but it continues to lack the focus and attention warranted.

Listen in below to find out how this can be applied to Diabetic Retinopathy – preventing blindness that is a high risk for Diabetic patients


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


 

Listen along on HealthcareNowRadio or on SoundCloud

Using Advanced Trauma Life Support Methodology in Population Health was originally published on Dr Nick – The Incrementalist

Making it Easier to do the Right Thing

Behavioral Health for Positive Impact

Behavior

This week I am talking to Matt Wallaert (@mattwallaert), Chief Behavioral Officer at Clover Health. I have listened to Matt on a few occasions, most recently at the FitBit Captivate event in Chicago so I was excited to get to talk to him one on one.

Matt plays an unusual and atypical role in Clover Health – he is their Chief Behavioral Officer, a title and role that is not commonly found. He is a Social Psychologist who focuses on Judgement and Decision Making and is most well known for applying behavioral science to practical problems.

We explore behavioral health influences and how we can create interventions that will have a positive impact. How do we create incremental steps and test these and then roll out of programs to have a positive impact on health? He wanted to have an impact and wanted to make things better for people and over the course of his career has managed to do so in many places but is now focused on healthcare and specifically personal health. There’s a recurring theme in many of my INcremental interviews and I heard it again from Matt:

Assume you are going to fail

As Matt puts it – “don’t set up a durable process – for example, if you are doing a mailing do that yourself vs getting your marketing department to create the mailing”. Then head out to the next step – a Test. It is not hard to find behavioral changes that work – but that’s not the only requirement as the change has to work well enough and are scalable enough that you really want to roll them out widely.

Incremental Step to Behavioral Health

It’s not just finding good behavioral changes but rather things that are worthwhile and scalable

“If behavior is your outcome and science is your method – then you are a behavioral scientist”

As Matt says we have to make it easier to do the right thing and not blame individual choices and health behaviors when we make poor health, decisions. Listen in to find out why there are significant cultural differences in flu vaccination take up rates and what incremental steps can be taken to improve on that and hear why it is important not to blame people for poor health behaviors. Learn how they are behaving like Netflix or Pandora that can can match you to the right videos or music we should be able to match you to the right doctor

 


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

Making it Easier to do the Right Thing was originally published on Dr Nick – The Incrementalist

The Healthcare Huddle

 Delivering the Care Patients Want

NewImage

This week I am talking to Dr. Jay Mathur, Associate Regional Medical Director for Caremore Health Systems in Connecticut. A program that started 25 years ago in California and has now expanded to multiple states and has been in Connecticut for a little over a year. This is the medicine that we went to medical school to practice, the opportunity to deliver the care that patients and families want.

We know that the poor typically live alone and quite often socially isolated and their zip codes play a part in their health status but sometimes it can be their shopping experience and availability of food not just their zip code that is a key determinant of health. We talked about some of this in my interview with Dr. Won Chun from Carrot Health

Team Sport
The Healthcare Huddle

Listen in to hear how they select the hardest patients with the most complex diseases and chronic conditions as and learn the key elements in their success that are tied to the early morning huddle where everyone shares the upcoming day, tasks and resource allocation getting everyone on the same page. All I could think of was the scene from The Replacements and Shane Falco’s huddle:

Huddle Fight

They have a range of team members with their Clinical Partners as the glue that keeps everything together and others on the team including Social Workers, Psychiatrists, Case Managers and physicians playing a supporting role to each other

Glory Lasts forever

From a patient standpoint, it all starts with a detailed assessment and importantly introducing all the team members to the patient using a range of technology tools to facilitate and improve efficiency

Their Incremental steps to improvement include the huddle but listen in to hear what other incremental steps you may be missing that has added significantly to their team-based approach, coordination and success


Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next two weeks at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.


Listen along on HealthcareNowRadio or on SoundCloud

The Healthcare Huddle was originally published on Dr Nick – The Incrementalist

Future Failure Guaranteed in Healthcare

 Medical School Candidate Selection

MedEd Books Education books
Are we are selecting the wrong candidates for medical school and not teaching them the skills they really need to be good doctors?

I’m a doctor first – anytime anyone asks me what I do the first words out of my mouth are “I’m a Doctor”, followed by a follow-up explanation of my role today outside of day to day clinical medicine and the laying on of hands-on patients.

Many years ago I decided to give up my daily medical practice and it was a difficult decision. While I loved taking care of patients, I’d been beaten up in a system that pushed me to my limits and I did not like what I felt and saw in myself as I existed in a sleep-deprived haze courtesy of a 152-hour working week aka a 1 in 2.

I believed that the healthcare system was creating barriers for doing what patients really needed. And too much of my time was taken up with things that didn’t really matter. By moving into the world of technology and focusing on medical technology development, I hoped to create new tools that would improve our ability to help patients in the ways that they wanted to be helped.

My emotions about this move were conflicted, and I sought out a colleague who had been a mentor to me and shared my decision and mixed emotions about that decision. His response bewildered me.

“That’s terrible,” he said. “You never should have been allowed into medical school.”

From his point of view, the fact that a doctor was leaving the profession was not a sign that anything about the healthcare system needed to change. It just meant that the selection process for medical students was wrong and I was a flawed candidate that never should have been allowed to study medicine.

That unwillingness to examine the status quo is not uncommon in the world of medicine, especially when it comes to medical education. The current curriculum has changed very little over the past century. While science has been updated, the basic structure of medical education hasn’t changed. The daily practice of medicine, however, has changed. And it has changed a lot. Medical education isn’t preparing new doctors for the challenges they will face, and many of the skills they will need are never addressed during the four years of medical school.

But there is an even bigger problem with the medical education system: acceptance into medical school isn’t based on characteristics that are important in medical practice. We have become very focused on academic perfection and MCAT scores, with little consideration for the personality traits that lead to highly effective and compassionate physicians. We get lucky with many people, who have the academic performance and the needed personality traits, but we also train people who are not inherently suited to the practice of medicine or who have what compassion they had entering the system crushed out of them with debilitating academic testing with multiple choice questions systems. And we exacerbate the problem with a system that encourages isolation with a monstrous amount of academic study and rote learning. To excel or even survive the rigors of the system you diminish social interactions and limit them to others who are stuck in the same academic sinkhole.

We are failing to train medical students in the skills and thinking habits that make good doctors.

Recruit for compassion and intelligence, not academic perfection

The first step in getting this right is recruiting students who have more than academic skills. Perfection in academic performance is often accompanied by self-involvement verging on narcissism. To attain perfect grades in college, you have to have enormous discipline as well as intellectual ability. You also have to sacrifice time spent in other endeavors – experiences that might broaden your worldview and increase your sense of compassion. This intense focus on your own goals can create a sense that you are more important than others.

MedEd MedicalStudentID

I watch this first hand with my daughter, who makes me proud on a daily basis with her dedication and focus towards her goal – which she has had since the tender age of 5 – of getting into medical school and qualifying as a doctor. But every step towards medical school moves her inexorably away from the compassion and caring she has demonstrated on her journey thus far. Like her peers, she fears that if she doesn’t keep an intense focus on academics she will fail in her study of medicine. I know I want her as my physician but wonder if the obstacle course she must complete will change her beyond recognition.

Medical Education

 

Teach medical students skills, not just facts

Medical education is like drinking from a scientific fire hose. Few students retain more than about 50% of that data, and we neglect other skills that are more important. Doctors can instantly look up any medical fact they need so this attempted brain download of scientific detail isn’t necessary.

What isn’t taught is how to think about health, illness, and people. Medical students should be learning root-cause analysis and the ability to connect disparate pieces of data and understand the meaning. They need to learn data search skills, listening skills, problem-solving and how to be a continuous learner. They need to flex their compassion and objectivity muscles and learn the patience that will help them understand people who are different from themselves. And they need to learn leadership and how to work with others as in a team and as a team leader. These are the skills that are hard to acquire but are crucial to accurate diagnoses, more effective treatment decisions and effective management of chronic diseases.

The change is beginning

Medical schools are starting to respond to the need. In 2013, the American Medical Association gave $11 million in grants to medical schools that are developing flexible, competency-based pathways. They are making changes that will narrow the gap between how physicians are trained and how medicine is practiced. As of 2015, grants have been given to 32 medical schools, each with an innovative approach intended to prepare students for the real world of medical care. None of these programs are focused on the science of medicine, but rather the thinking, leadership and management skills needed to effectively use the science of medicine.

This is a great start, but there are 141 accredited medical schools in the U.S., and nearly 2,500 worldwide, many still using a curriculum developed more than a century ago. I hope the leaders of these schools are paying close attention to the innovations being tested under the AMA program. We all need them to do a better job of recruiting and training medical students who have the right stuff for the medical environment of this century, not the last.

Some Early Progress

The Dell UT Medical School which was funded in part with support from the Michael and Susan Dell Foundation and by a vote from local residents to increase their personal taxes to fund the development and ongoing management of this facility. They are trying a new funding model that gets rid of the conflict of interest that hamstrings many medical schools that are dependent on fee-for-service hospitals for revenue. The financial model will emphasize outcomes and cost-effective care overpayment for individual procedures and the medical school is taking a different approach to education while still encumbered by the need to meet the regulatory requirements to satisfy the medical education definitions and allow their students to compete on the current playing field for medical education the United States Medical Licensing System (USMLE) testing system

What do we need in Healthcare

More accurate diagnosis early in the disease process (12 million people annually are misdiagnosed, and about a quarter of those errors are life-threatening)

MedEd Costs

86% of healthcare spending in the U.S. was used to treat patients with one or more chronic conditions, and most of that goes for treating complications due to poor management.

Clinicians are under increasing stress and committing suicide at extraordinary rates (A systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population)

Incremental Steps to Improving Medical Education

  1. Let’s start by acknowledging the current system and trajectory is not matched to the requirements of our future doctors
  2. Find one element of the curriculum suited to a different method of teaching and change the approach. Match this with an approach to changing the testing methodology to match this more closely
  3. Enlist support to bring about change with the examining board, the clinical teachers and mentors and recently graduated doctors who can all provide relevant insights on the deficiencies of training in preparing for a medical career and what can and needs to be changed

 

Do you think I’m wrong – is our system well suited to the current requirements and just in need of some minor tuning? If I am right – what changes can we work on immediately to change the course and direction for the students now to bring about lasting improvements?

 

Future Failure Guaranteed in Healthcare was originally published on Dr Nick – The Incrementalist

Healthcare – Its Personal

The Great Healthcare Debate

Healthcare is personal and front and center in our minds not just because we all intersect with it in some way but it employs 1 in 9 people in the United States. With the current state of our media and political system with polarized debates, he said she said talking heads on the media, the echo chamber of social media and the 24/7/365 barrage of news and fake news it can be hard to see a pathway out of the quagmire we find ourselves in. But we all want to see that path. I just don’t believe that people get up in the morning wondering how they can decimate the healthcare services and the lives of their fellow human beings. We don’t get up out of bed every day wondering how best to punish people who may have made bad choices in their lives or who find themselves in unfortunate positions though geography (the zip code effect) or genetics. I know I don’t and I don’t think you do either.

Yet the stream of coverage and what we read, see and hear online and sometimes even in person suggests that this is the case. I can’t answer the reasons why but I’ve read a string of articles and reporting that variably suggests its always been like this to this is the fault – and then insert the name of your favorite whipping horse. Ultimately it does not matter – unless you believe that people wake up with malintent every morning it’s better to start with an understanding of the problem and then thinking about possible solutions and how we can apply them quickly and effectively

So Let’s Start with some of the fundamental problems in our healthcare system – to be clear we are not alone in the world. I have seen and heard from many others in different countries who are all struggling to varying degrees and with different focus and priorities the same issues. If I had to boil it down to one issue I would say

Limited Resources and the Prioritization of the Allocation of those resources

It’s a familiar equation to anyone trying to balance their budget or allocate their time. If you are like me you may find there are just not enough hours in the day for the task list you created in the morning and wishing either to stretch time (time dilation) or perhaps be able to turn time back with the Wizarding world’s  Time Turner. There are two basic options available – reduce the inputs or reduce the outputs. In the vernacular of budgeting – either spend less or make more money. Both may be viable and depend on personal circumstance but undoubtedly there will be easier and harder solutions. Ultimately we all have to make our own personal decisions – so one solution or size does not fit all.

Photo from jenga.com

It would be foolish to suggest that this covers all the complexity of the healthcare system as we all know healthcare is incredibly complex and always reminds me of the game Jenga.

 

This does not cover everything and there are many other elements in play but it is certainly a start and one that individuals and organizations can focus on to start to make incremental improvements.

As one Chinese proverb states:

Every journey starts with a single step

And turning that step into a habit is one of the best ways of setting a path to improvement.

Demand Side of Healthcare

This is the access and use of the system and the burden does not just fall on the individual. But it does start there as it is out personal choices to access and use available services that creates demand. Historically in the United States, the cost and payment of this access have been disassociated from the individual. When you visit the doctor or pharmacy you don’t pay the actual cost of the service – your insurance carrier does. Ultimately we do all pay for this through our insurance premiums and for many the contributions made on our behalf by our employer that is part of the compensation we receive for working for them but at the point of care, we are disconnected from the price and cost of a service.

Patient Accessing Care

To a varying degree individuals have some form of co-pay – a personal cost that is defined by the insurance coverage and is shifting increasingly to the individual under the new insurance plans called High Deductible Health Plans (HDHP). One of the intentions of this policy is to make the individual responsible for this cost in an attempt to influence behavior and decrease unnecessary access. But this comes with the inevitable unintended consequences with cost avoidance strategies by individuals who knowing they will be held responsible for the full cost of a visit, drug or test may elect to decline to have or use the service.

 

I’d count myself in that crowd having been on a HDHP plan for several years. I can point to several decision where I have declined tests, treatment and access to care because of the nature of my personal responsibility – I have an associated health savings account (HSA) which should cover the capped amount of cost for the year. But the crippling nature of potential costs associated with a catastrophic medical problem – a serious accident, cancer, heart attack are all so terrifying that I see the HSA as a buffer against the potential of medical insolvency that might result especially when you consider the impact on a family with one source of income that would be impacted by any medical disability.

 

Insurers Paying for Care

Insurers want to reduce their costs – and even the non-profits have to make money so are focused on the bottom line if they want to continue to serve their customers and population. So they look to find ways to reduce the unnecessary access to care imposing barriers and limits. There was a gate keeper concept that requires a referral letter from a primary care physician before you can access s specialist – that service by the way costing you additional fees to see the primary care provider. There are formulary requirements that exclude certain drugs from coverage and attempts to limit access to specific doctors and networks to strengthen the buying and negotiation power of the payor with the providers in the system.

 

Providers Delivering Care

On the provider side the clinal professionals delivering the care all arrived at this point having selected the expensive assault course of education to train and qualify to be able to deliver care. For doctors, it’s persistence and endurance that win out. The barriers to entry are high and tied to economics. They all have the same desire to help patients – but economics and the burden of the educational system can overwhelm just about anyone and they have bills to pay both for their education but also the infrastructure they must use to be able to both deliver care but also bill and be paid for delivering. They want to reduce their overhead and spend as much of their time and resources on the delivery of care but to survive in the system must allocate significant amounts of money to non-clinal systems and activities. Estimates of these costs suggest that at least 30% of the healthcare costs we as a society pay in the United States are tied to administrative and billing functions. The data’s still lagging but projections for 2016 put the total healthcare bill at $3.207 Trillion (thats $3,207,000,000,000 or more than $10,000 per person in the USA)

Healthcare Administrative Cost: $962 Billion Dollars

$962,100,000,000

 

Reconciling the Differences

Credit Imgur

The difference of opinion often centers on what is unnecessary – in the eyes of the patient they need and want the care they think is appropriate to them. Some of this is fed by a constant stream of information that even for an well informed clinically experienced specialist can be difficult to comprehend and make informed decision. We want wants best for our personal health and the health of our family and loved ones. But sometimes what the patient may think is best may not be – a great example is the steady stream of requests for antibiotics for treatments of minor infections. Not every sore throat or cough demands the use of antibiotics and in fact, in many cases, their use is damaging as we face a future where this line of defense is increasingly being overrun with smartly adaptive bacteria who develop resistance with terrifying speed.

 

Payors Perspectives

The same is true of payor and insurers – they face a rising tide of costs associated with care that is increasingly complicated and expensive and struggle to balance their budget.Faced with one patient who’s costs for treatment might be hundreds of thousands of dollars or more so they limit or decline this in favor of treating multiple other patients where their cost of treatment is thousands of dollars or less? The utopian answer is treat everyone but we they like each of us do not have unlimited budget or resources and have to make hard decisions. And the problem with healthcare fundedfor the population but access individually.

 

Healthcare is funded for the population but access individually

 

Clinicians Perspectives

Clinicians also have a view on what’s appropriate – and the vast majority act with total integrity (I would like to say all of them but sadly there are occasional stories of clinicians and healthcare professionals who game the system – sometimes with simple prescription based fraud or other times over treatment of stenting in cardiac cases). Sadly for a profession that is so dependent on trust the rare cases of fraud and abuse unfairly tar everyone with the same brush. As I said above – I believe everyone gets up in the morning with the best intentions and this is true of the clinal professionals who each and every day battle a system to deliver the care and compassion they set out to deliver when they took the path into healthcare. They want to say no to unnecessary treatment but the personal pressures applied and the underlying compassion and the innate drive that was the foundation of why they entered the profession can influence them to order and prescribe because they are unable to explain the lack of value and offering this option makes their patient happier and comfortable.

So how do we reconcile these differing opinions

 

Economics and Making Choices

Which path is best

There’s a sad fact in the US healthcare system – we do not talk about cost effectiveness. Its not just a taboo subject but also a forbidden topic, As Aaron Carroll (The Incidental Economist) noted in his piece Forbidden Topic in Health Policy Debate: Cost Effectiveness we avoid talking about cost-effectiveness in the United States.

Some think that discussing cost effectiveness puts us on the slippery slope to rationing, or even “death panels.”

As he points out – if there was a pill available that could extend your life by one day but costs a billion dollars, most would accept this as an unacceptable trade off and decline it. But that’ extreme – as you decrease the cost where does that line become blurred?

what’s to stop us from deciding that spending a couple hundred thousand dollars to extend grandma’s life for a year isn’t worth it either?

More troubling is the shackles that have been placed on the Patient Centered Outcomes Research Institute – who were founded but explicitly prohibited it from funding any cost-effectiveness research at all! How can an outcomes institute assess healthcare if cost effectiveness is not part of the equation?

“We don’t consider cost effectiveness to be an outcome of direct importance to patients.”

In fact, we in the United States are so averse to the idea of cost effectiveness that when the Patient Centered Outcomes Research Institute, the body specifically set up to do comparative effectiveness research, was founded, the law explicitly prohibited it from funding any cost-effectiveness research at all. As it says on its website,

PCORI was established to fund research that can help patients and those who care for them make better-informed decisions about the healthcare choices they face every day, guided by those who will use that information.

 

Quality-Adjusted Life Years

As he points out there is actually a fairly robust strategy and measure that can offer insights into the value of measuring health outcomes – QALY’s (Quality-Adjusted Life Years) which the National Health Service has been using fro some time in the National Institute for Health and Care Excellence (NICE) that provides guidance, advice, quality standards and information services for health, public health and social care. Also contains resources to help maximise use of evidence and guidance. There is no doubt they are imperfect but very little in life is perfect and perfection should not be a barrier to progress. The use of this is not a sole determinant – but offers some measure of science and data to making what are incredibly difficult tdecisions

So in the current debate of what health system we need to put in place I would advocate the inclusion of cost effectiveness as one of the factors that must be considered and the QALY and perhaps even the Incremental cost-effectiveness ratio (ICER) as part of this difficult discussion.

I’m all about incremental changes and while including a cost effectiveness as a measure may seem a bigger stretch I feel it is a smaller step in the right direction. Can we achieve this? Is there a better incremental step we can take to resolve the challenges of our healthcare system? Leave your thoughts below.

Healthcare – Its Personal was originally published on Dr Nick – The Incrementalist

Wise Up to Hidden Healthcare Fees

It’s perverse but the healthcare system in the United States is making you sick. Don’t believe me – then maybe you have a high-end plan with no deductible and full access and no ceiling. But there are not many of those and for the rest of us, I imagine your interaction with the system is as frustrating and stressful as mine – probably on a spectrum depending on your plan (High deductible plan or the more traditional Preferred Provider Organization (PPO) and co-payments.

 

Fee for Service Healthcare

The cynical view might be this is deliberate since our system remains firmly stuck in a fee for service model – healthcare providers are paid to do something…anything. From its original development, this made sense – our capacity to treat conditions was limited and the cost of these treatments in line with our ability to pay for them. But along this journey science and in particular the incredible progress of medical research got involved and we have been on a veritable tear of progress and innovation, or as the Exponential Medicine group would say Exponential progress.

Original from Foundation Teaching Economics

There is a continued push towards a more robust and accountable model – Accountable Care Organizations have been set up and these models of total care and coverage and responsibility tested for effectiveness and economic effect. There is lots of disagreement on the success or failure of ACO’s and it is fair to say that the jury is still out. But intuitively we know that taking care of the complete picture and being responsible for the total care of patients health is better for the patient and for outcomes. I have seen it time and again where individual mandates or focus induce unwanted/unexpected/unintended consequences elsewhere in the whole system.

Discharging Patients Early – Unintended Consequences

Discharging patients from the hospital early typically results in better outcomes. Early programs that incentivized this behavior and rewarded programs that got patients out of the hospital early were deemed successful but failed to take account of the downstream impact of readmissions resulting from too early a discharge and subsequent complications for that patient that could have been avoided.

Fixing a Broken System

The recent book “American Sickness” by Dr Elisabeth Rosenthal “An American Sickness” takes on the existing system and is filled with strategies for patients faced with mounting medical bills, an intractable and aggressive healthcare system that is unflinching in seeking payment and by many estimates the leading cause of personal financial crisis and insolvency. While the figures remain under debate my own personal reality living with a High Deductible Plan that has found me

  • Self-treating Fractures
  • Becoming my own compounding pharmacy and
  • Spending months and many hours fighting multiple bills

 

In the case of one screening procedure, that under the current regulations are fully covered but thanks to either mistaken coding or perhaps even deliberate coding, remains outstanding and in two of the three cases, the billing organizations despite my attempts at regular communications, response and protests were handed over to debt collection agencies.

So I am with Dr. Rosenthal and “breaking down the monolithic business”.

The situation is far worse than we think, and it has become like that much more recently than we realize. Hospitals, which are managed by business executives, behave like predatory lenders, hounding patients and seizing their homes. Research charities are in bed with big pharmaceutical companies, which surreptitiously profit from the donations made by working people. Americans are dying from routine medical conditions when affordable and straightforward solutions exist.

Employer Sponsored Insurance

Central to the challenges is the arcane concept that you access to healthcare and health insurance should be linked to your employment. As one friend of mine commented, “There are some who believe this is a deliberate policy on the part of employers to lock in employees to jobs they may not want but have to take because they need the health insurance and can’t afford the challenge or cost of changing (health insurance”. I don’t quite go down that rabbit hole and think Dan Munro’s explanation in his great book “Casino Healthcare

that detailed the history linked to the war effort and the need to find other incentives after they introduced: “An Act to further the national defense and security by checking speculative and excessive price rises, price dislocations, and inflationary tendencies, and for other purposes.” (EPCA) in 1942 – wages were frozen to stop inflation but as is so often the case left the door open for unintended consequences that found employers looking for ways to compete for a shortage of labor. And as they say what follows is history – Employer Sponsored Insurance (ESI) was born.

History of the NHS

It is interesting to note that the NHS model was also a product of the war that found the wounded servicemen and women in need of healthcare. A need that was serviced by the “Emergency Hospital Service” (aka Emergency Medical Service) that provided a model and experience to the country that became the model for what is now the NHS established in 1946.

But whatever the history, reasons, and background – this remains a millstone around American’s. It can add to job reductions and General Motors have stated that their employee healthcare costs add $1,500 – 2,000 to the price of every car they produce. It makes us less competitive internationally and crippling many with overheads that add to the cost of goods sold. It also puts employers at the table on healthcare decision making for their employers that present potential conflicts of interest given their need to service their share holders and remain profitable.

Finding a pathway to resolving this big intractable healthcare mess is going to take some major re-thinking and compromise on all sides. In the meantime, I suggest focusing on individual incremental approaches locally.

 

Incremental Steps to Coping With Healthcare

The list of 6 Questions to ask your doctor before your appointment and 5 questions to ask before you stay in a hospital are excellent resources from Dr. Elisabeth Rosenthal, that are featured in the book and on the website. So in the spirit of the incremental approach, I offer up two credit card size templates containing the

  • 5 Questions to Ask During Your Hospital Stay
  • 6 Questions to Ask Before Every Doctor’s Appointment

 

Formatted in a handy Avery 5371 White Business Card Template that can be printed – double sided and put in your wallet: Questions When Using Healthcare Avery Template 5371

Do you have any tips or suggestions in dealing with the healthcare system? Disagree with any of this – feel free to leave your comments or reach out.

Wise Up to Hidden Healthcare Fees was originally published on Dr Nick – The Incrementalist

Population Health is a Team Sport

Designing an Effective Population Health Program

Population health is the topic du jour for the health care industry, and I’m glad to see us all focusing on this important issue. But there is a lot of confusion as to what, exactly, constitutes population health. Or more correctly, an effective population health system.

A good population health program consists of four major components:

  1. Identification and stratification of risk within a discrete population
  2. Dissemination of information to physicians, care coordinators or others designated to contact patients and arrange follow up.
  3. Appropriate follow up to further understand the risks for individual patients, identify gaps in care and design a care plan to help the patient improve his/her health status.
  4. Ongoing care individualized to each patient’s need. That might be coaching, medication reminders, telehealth visits, remote monitoring or other strategies customized to each person’s condition and socio-economic environment.

The key to making a population health program effective is ensuring that all four components are in place and working well. If there is a break anywhere in the chain, you lose the opportunity to improve patients’ health. The best analytics in the world are useless if the results do not quickly and easily pass into the hands of the people who can take action. And very good follow up and care planning can be ineffective if the ongoing support is lacking.

Friction

One of the biggest barriers to effective population health improvement is friction in the flow of information between health plans, hospitals/health systems and physicians. This has been a constant source of difficulty for the entire healthcare ecosystem for years, but with the new focus on population health and improving outcomes, it has reached a new level of urgency.

African heart disease is much lower
African heart disease is much lower

In traditional African societies coronary artery disease is virtually nonexistent, but in the migrant population to Western societies the rates are similar to those of the local population indicating that the primary determinants of these diseases are lifestyle and diet and not genetic. These indicators are a key asset in changing our healthcare system and addressing the current 75% of our healthcare spending that is focused on patients with chronic conditions which have their roots in lifestyle choices and behaviors. To address these challenges we need a way to better target our limited healthcare resources more cost effectively for maximum effect and identification and targeting with a robust population health system is no longer a nice to have – it’s a must.

To help patients improve their health, not just react to a situation that has already developed, requires information and insights. But in a survey of primary care physicians by The Commonwealth Fund, only 31% of U.S. physicians said they are notified when a patient is discharged from the hospital or seen in an emergency department. This is important information for primary care physicians, and is not that difficult to fix. All you need is standard protocol in place and a mechanism for notification. It could be a standard action that happens at every discharge. It could even be automated. If the retail industry can automatically send an email to confirm an order, hospitals and health systems should be able to send an automatic email to a physician with discharge information. But hospitals and health system executives haven’t made it a priority, so it doesn’t get fixed.

Get to know your team mates

This is just one example of the inward-looking approach that still permeates much of healthcare. Hospitals, nursing homes, skilled nursing facilities and other care providers pay attention to what happens within their organizations, but they neglect to look beyond. Organizations act as though the care they give is the only care patients receive. They forget that there are a multitude of other professionals who are also responsible for care and need to know what’s going on. We don’t just have data silos in healthcare, we have attitudinal silos that make data transfer and exchange an afterthought at best.

It’s like each care provider is a golfer alone on the course and the patient is the ball. As long as that lone golfer moves the ball forward, it’s all good.

The reality is that healthcare is a team sport, more like football (or soccer as it is called in the US) than golf. If you can’t make an accurate, effective pass to your team mates, you lose the ball.

Population Health a Team Sport
Team Sport

But patients aren’t balls, they’re human beings. When one member of the healthcare team fails to inform the rest of the team, a human being gets lost in the confusion with poor outcomes and frustrated patients.

In population health improvement, you have to play on a team, because it takes a wide variety of skills to make this all happen. And you have to be aware of all the other players on the team. The successful population programs include everyone who is part of the community – not just the healthcare system and resources but all aspects of the community. Dell Medical School held an inaugural event to crowd-source their population health strategy, coming up with areas of focus and metrics for success that included input from a wide range of stake holders. This is the kind of team based approach to population health that will help the whole community win – getting people healthy and staying healthy.

 

It starts with leadership

Most healthcare organizations are at least partly aware of the problem and are making efforts to solve it. But it is a complex problem, involving, as I noted above, attitudes as well as technology. To make data flow freely to those who need it, you have to have effective technology to integrate, manage and analyze the multitude of data streams in healthcare, and you also need leadership who prioritize data sharing over the competitive interests of conflicting health delivery systems. With free flowing information routed to all the interested parties including the oft forgotten but all important patient, in understandable and actionable form that includes the insights and management options we can successfully identify those at risk and develop appropriate interventions. By including the patient and personal care team that typically includes multiple family members we capitalize on underutilized resources that are both essential and highly effective at improving the trajectory for the patient’s outcome.

 

Custom Communication and Targeting

Traditional systems and methods have targeted the existing clinical systems and communications which, while suited to some, fail to adapt to the changing world of technology and the fact that people no longer go online – they live online. This doesn’t just apply to patients and their families; it’s increasingly true for clinicians. It can be as simple as a text based reminder for medication, timed to coincide with the patients personal schedule and preferences or as complex as an automated avatar with augmented intelligence that engages with the patient to assess their status and determine the need for additional intervention or personal follow up by the care team.

 

Each year HealthIT week raises awareness of technology in healthcare, bringing together innovators and key healthcare leaders who are diligently working together to make the best use of information technology to improve the healthcare systems and ultimately our each and everyone’s individual health. This past year we lost one of the titans whose personal journey of uncoordinated care she shared in her attempt to correct the system – Jess Jacobs (#UnicornJess). It might be too late for Jess but let this be the year we move past the individual approach in healthcare driven by underlying economics and focus on the team sport of population health and democratize access to the best possible care and outcomes to the widest swathe of people…worldwide.

 

This post originally appeared here

Population Health is a Team Sport was originally published on DrNic1