Enabling Healthy Decisions

The ideas around Population Health are certainly critical both to us as a country to eliminate the waste in our healthcare system, but they are also foundational in a move from a fee-for-service (FFS) environment to an outcomes-based payment model. Interesting, if you look at a study that was just released, it continues to show a disconnect within the provider community. (Study is Population Health Management In Physician Practice: A Call To Action.)

I believe some of this stems from the costs associated with the build out, integration, and use of these technologies in today’s environment. But, I think some of this stems from a broken connection between national policy, localized implementation, and payer coordination around key healthcare issues such as obesity.

The following paragraph from the same document is also very telling.

“With 72% of respondents reporting that they had either already adopted or were in the process of adoption a patient-centered model of care, it was interesting that only 19% of practices self-reported as Patient-Centered Medical Home (PCMH) and only 10% as an Accountable Care Organization (ACO). Considering the critical role that population health management will play in both types of practice models, the data suggest that while they are undertaking population health management initiatives, many practices may not yet be at a level of transformation to warrant presenting as PCMH or ACO at this point in time. Also interesting is that of the 11 practices that did self-report as ACO, only 5 of the 11 also reported as PCMH – showing again perhaps another disconnect or struggle with implementation and understanding. PCMH, after all, has been described as “foundational” to Accountable Care Organizations.”

A lot of this change won’t be done by physicians, but it was promising to hear in the same report that:

• 96% of large provider practices employed Nurse Practitioners;
• 70% employed Physician Assistants; and
• 91% employed Care Coordinators.

So, how are those resources being used today? And, how do these resources get integrated into an overall care strategy for the patient? Are notes shared with external care managers? How do we find the right point person? How does an external payer team for MM coordinator with the local resources for something like discharge planning?

This is one of those terms that is thrown around a lot just like Medical Management or Disease Management.

I thought it would be helpful to define the 3.

Population Health Management (PHM) is…

“Programs targeted to a defined population that use a variety of individual, organizational, and societal interventions to improve health outcomes” (Mathematica Policy Research Issue Brief, August 2011)

Medical Management (MM) is…

“The general term often applied to the practices of utilization management (UM), case management (CM), and disease management (DM), alone or in combination with each other.” (Trends and Practices in Medical Management: 2001 Industry Profile)

Disease Management (DM) is…

“An approach to healthcare that teaches patients how to manage a chronic disease.” (Disease Management on About.com)

Is that clear as mud?

In today’s world, everything is patient-centric so that doesn’t differ between the three. Obviously, DM is a part of MM, but I rarely hear people talk about MM as a part of PHM which it seems to be to me. But, I don’t think of most MM type programs taking on the macro level change that PHM implies to me. PHM implies things like public health or broad programs like BlueZones. It implies looking at things like plan design, incentives, social trends, workplace culture, and other aspects of change that are necessary to create change and sustain change.

Here’s the Care Continuum Alliance’s full description of PHM (or as they call it here – population health improvement):

Key components of the population health improvement model include:

• Population identification strategies and processes;
  
• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;
  
• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;
  
• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;
  
• Self-management interventions aimed at influencing the targeted population to make behavioral changes;
  
• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;
  
• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health.
  

The population health improvement model:

• Encourages patients to have a provider relationship where they receive ongoing primary care in addition to specialty care;
  
• Complements the physician/practitioner and patient relationship and plan of care across all stages, including wellness, prevention, chronic, acute and end-of-life care;
  
• Assists unpaid caregivers, such as family and friends, by providing relevant information and care coordination;
  
• Offers physicians additional resources to address gaps in patient health care literacy, knowledge of the health care system, and timeliness of treatment;
  
• Assists physicians in collecting, coordinating and analyzing patient specific information and data from multiple members of the health care team including the patients themselves;
  
• Assists physicians in analyzing data across entire patient populations;
  
• Addresses cultural sensitivities and preferences of individuals from disparate backgrounds;
  
• Promotes complementary care settings and techniques such as group visits, remote patient monitoring, telemedicine, telehealth, and behavior modification and motivation techniques for appropriate patient populations.
  

And, if you read articles about PHM, these macro issues don’t seem to be the focus. The focus seems to be mostly on the technology to accomplish PHM. There are obvious challenges and key success factors there. (Recent commentary on PHM.)

Medicare offers people free preventative care which includes a variety of things:

• Abdominal aortic aneurysm screening
• Alcohol misuse screenings and counseling
• Bone mass measurements (bone density)
• Cardiovascular disease screenings
• Cardiovascular disease (behavioral therapy)
• Colorectal cancer screenings
• Depression screenings
• Diabetes screenings
• Diabetes self-management training
• Glaucoma tests
• HIV screenings
• Mammograms (screening)
• Nutrition therapy services
• Obesity screenings and counseling
• One-time “Welcome to Medicare” preventive visit
• Pap tests and pelvic exams (screening)
• Prostate cancer screenings
• Sexually transmitted infections screening and counseling
• Shots:
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
• Tobacco use cessation counseling
• Yearly “Wellness” visit

(This list is from http://www.medicare.gov/coverage/preventive-and-screening-services.html.)

Now, while HHS says that over 32M people used these services in 2011, this is only 66% of Medicare beneficiaries. This varies by state with 48.1% of people in Wyoming taking advantage of this benefit while 71.1% of people in Delaware take advantage of the benefit.

I’m not sure of the root cause, but I suspect a lot of it has to do with education. Beneficiaries don’t understand what’s free. They don’t understand how to take advantage of the benefit, and physicians aren’t reinforcing this.

I was just watching the Verizon advertisement where they show data in a few ways. While their charts are all basically the same, it made me think about different ways of representing the same data. We all know that this is an important thing as we evaluate the effectiveness of different programs.

Let me highlight four different ways of representing two data elements. In this case, I’m comparing two programs. The first program (A) had a yield of 20% and the second program (B) had a yield of 23%.

• I could say that Program B was 3 percentage points better than Program A.
• I could say that Program B was 15% better than Program A.

I could show the data in two different charts where I simply change the y-axis.

I love where the future of healthcare technology is going.  If you missed the Health 2.0 Conference this week, you can see a lot of the presentations now online for FREE!  It’s very cool.

At the same time, I think this infographic from the Institute of Medicine reinforces some of the key points.

I keep seeing buzz about the Big Bird comment about PBS from the Presidential Debate from last week. As always, I interpret things differently. To me, this shows Romney’s willingness to make tough and perhaps unpopular decisions (like raising taxes for the Middle Class). At some point, these things may be critical.

Sure…the PBS budget may be small, but at some point, we as a country need to focus on how we cut costs to reduce our deficit. (See US debt clock.)

This reminds me a lot of the discussions we used to have to have as a PBM with employers or labor unions about their benefits. It goes back to the basic framework of “you can’t have your cake and eat it too”. Everyone wants to have a broad network of providers. Everyone wants to have an open formulary. Everyone wants to have the broadest benefits at the lowest cost without increasing their contribution every year.

Just by cutting a drug or a provider from your benefit may seem small, but the savings add up. (Like Big Bird or PBS.)

But, this is the problem we have in healthcare. How do we make enough small decisions to add up to real savings? How do we do this without upsetting everyone and impacting satisfaction (or is that simply life)?

The statistic that I like to point out is that more people have access to mobile devices than people who have access to toothbrushes. I know that sounds crazy to us Americans, but that’s apparently a global reality (in so much as statistics don’t lie). And, people seem lost without their smartphones so they have them within a few feet of them almost 24 hours a day.

Combine that with several trends, and you can begin to understand why Qualcomm Life predicts that by 2020 there will be 160 million Americans who will be monitored and treated for medical conditions remotely.

1. There will be a shortage of doctors (at least in certain geographies).
2. Technology continues to be more and more ubiquitous. (Just look at this amazing video)
3. Telemedicine is becoming more normal.
4. Big data continues to be a huge focus with lower data costs, greater integration, and ultimately more and more predictive models to interpret real-time data.

So, as I pointed out the other day about the value of the mobile data for a healthcare underwriter, that same data can be used to create a systemic intervention system for monitoring and intervening with consumers to drive behavior change. AND, since the data and delivery method is mobile, the interventions can be highly personalized based on when, how, what channel, etc. to improve engagement rates. I can even know who influences your behavior change and how to get them to encourage you to change behavior (peer pressure) or who you monitor and can influence you based on their recommendations.

I’m not sure I’m ready to go as far as Dr. Ron Loeppke from US Preventative Medicine who said

“These mobile apps that are emerging are going to be a predominant part of how health care is delivered going forward.” (Smartphones Take Wellness Engagement To New Levels by Elizabeth Galentine)

BUT, I do believe that over time that this will become the increasingly dominant channel for interventions and behavior change. Ultimately, your mobile phone number may be a more valued data point than your Social Security number.

There are so many attention grabbing ways of beginning this post…

• Millions of parents deal drugs to their kids
• 44% of teens have friends who abuse drugs
• An increase in free drugs
• Kids are stealing their parents drugs stashes
• 200M pounds of drugs left in the open for kids to find
• 10 deaths per 100,000 people from drugs

Would you have guessed that all of these are talking about prescription drugs?

The Medicine Abuse Project (at www.drugfree.org) is trying to get this word out and find a way to change this. The basic points of their messaging:

1. Safeguard your medications…lock them up and throw extra ones away.
2. Talk to your kids about drugs and the risk of abusing legal and illegal drugs.

Despite all the articles about the changing gender roles, there is still the common belief that 80% of healthcare decisions are made by women. I guess I would assume that men would be more involved in their healthcare which either points out a major engagement issue or something more systemic (or just a self-perpetuating myth).

The She-Conomy site reinforces this fact, and I also saw it in a PharmaVOICE article (9/12) recently which highlighted the report – Seven Lenses for Marketing Health to Women.

That article had several interesting facts in it. One which caught my attention was the following…

“30% of Facebook users in this study said receiving brand messages from a pharmaceutical company via Facebook would be a good way to communicate with them.” (That seems really high to me.)

On the flipside, I tend to believe the data point that 78% of respondents would feel more in control of their health with a mobile app to provide information…making the case for Happtique even more important.

I found the following in a Kaiser Family Foundation report. (KFF often being a source of truth for me.)

Women are the health care leaders for their families. Women take charge of the vast majority of routine health care decisions and responsibilities for their children, and on top of their everyday family obligations, over one in 10 women care for a sick or aging relative. Meeting these multiple obligations is demanding and leaves many women concerned about meeting all their family and work commitments as well as managing their own health.

• Eight in 10 mothers/guardians say they take on chief responsibility for choosing their children’s doctors (79%), taking them to appointments (84%), and ensuring they receive follow-up care (78%). Mothers are also primarily responsible for decisions about their children’s health insurance (57%).
  
• Similar to men, one in four women feel a lot of stress from career (24%) and financial concerns (23%). Women are significantly more likely than men to be very stressed about managing their own health needs and those of their parents.
  
• One in 10 women (12%), compared to 8% of men, cares for a sick or aging relative, often an ill parent. The majority of caregivers report that they perform a range of tasks, including housework (91%), transportation (83%), and various financial decisions (66%). Many also assist with medical and physical care, such as administering medicines or shots (58%), as well as routine activities such as bathing and dressing (42%).
  
• Caregivers themselves contend with a host of health challenges. Four in 10 are low-income, nearly half (46%) have a chronic health condition of their own, and one in five non-elderly caregivers are uninsured.
  
• A sizable share (29%) of caregivers provide assistance full-time, spending more than 40 hours per week as a caregiver. This is even more common among low-income caregivers, 44% of whom report assisting their relative for over 40 hours weekly.
  

Interestingly, this ties into a discussion I was having the other night about whether men or women are more adherent to their medications and whether that is a relevant segmentation factor in designing an intervention strategy. The data I’ve seen says women are less likely to be adherent than men, but the company I was talking to believed their data pointed the other way. Here’s a few articles on the topic:

• http://www.pharmatimes.com/article/12-03-20/US_women_prescribed_more_drugs_than_men_but_take_less_study.aspx
• http://eurjhf.oxfordjournals.org/content/11/11/1092.full
• http://well.blogs.nytimes.com/2011/06/20/keeping-score-on-how-you-take-your-medicine/
• http://scholar.harvard.edu/nkc/files/2011_caregiver_adherence_j_am_pharm_assoc.pdf

And from the CVS Caremark 2008 Trends Rx Report –

I know lots of people are skeptical or against healthcare reform.

A report that just came out says that Romney’s plan would lead to 72M uninsured by 2022. I have no idea if that’s a reasonable analysis, but any more uninsured should be a problem for us as a country. They wait to get care leading to bigger long term issues under Medicaid and Medicare. They over-utilize the emergency room. And, as a first world country, we should want to have everyone getting a basic level of preventative care to prevent long-term issues and higher costs and improve out quality of life.

I’ll admit that I was initially a skeptic of healthcare reform, but I think it’s a reasonable solution. Not perfect. As I’ve argued for a while, it only focused on quality and access but not cost. I would have started with access first. But there are several very positive parts of healthcare reform regardless of what some people believe.

• Support for technology
• Support for preventative care
• Accountable Care Organizations
• No lifetime limits
• No denial of coverage due to pre-existing conditions
• Pharma reimbursement during the donut hole
• At least 85% of what you pay for healthcare must be spent on medical costs (not administrative)
• No single payer

WorldOne Interactive has some interesting data from provider surveys on their website. This one jumped out at me.

• 87% of MDs polled would recommend a text message based adherence solution to their patients
  

At the same time, I also thought this one was really important since the question is always whether the physicians want to know adherence data or not. Based on my old post, I didn’t think that MDs would want this type of data since they generally don’t seem to value PBM interventions.

• 80% of MDs polled would find it useful to get periodic e-mail reports about their patients therapy compliance.
  

I thought this was an interesting factoid which I got today and is from The Physician’s Foundation report.

Here are a few other findings…

• In the next one to three years, over 50 percent of physicians plan to cut back on patients, work part-time, switch to concierge medicine, retire or take other steps that would reduce patient access to their services.
• Over 59 percent of physicians indicate passage of the Patient Protection and Affordable Care Act (i.e., “health reform”) has made them less positive about the future of healthcare in America.
• Over 82 percent of physicians believe doctors have little ability to change the healthcare system.
• Close to 92 percent of physicians are unsure where the health system will be or how they will fit into it three to five years from now.
• Over 62 percent of physicians said Accountable Care Organizations (ACOs) are either unlikely to increase healthcare quality and decrease costs or that that any quality/cost gains will not be worth the effort.
• Physicians are divided on the efficacy of medical homes, and many (37.9 percent) remain uncertain about their structure and purpose.
• Over 47 percent have significant concerns that EMR poses a risk to patient privacy