Enabling Healthy Decisions

If you read my interview with Michael Graves, it might have started your mind thinking about any of your visits to the hospital and all the problems you encounter. While many architects I’ve known have focused on the healthcare business over the years, I think it’s interesting to see the discussions of this topic move into more mainstream literature.

I was reading Fast Company’s article called Spaces That Heal which talks about redesigning hospitals (and it’s not their first article on this topic). It had several interesting points:

• Future rooms may all be private. (Thank goodness! And, studies show that you get more infections in rooms with other people.)
• These future rooms may move from being high tech clinically to being high tech for the consumer – moving shades, controlling the temperature, interactive walls for TV and Internet.
• While a lot of research to support this has been out there for years, it’s finally been the CMS shift in focus to patient satisfaction (i.e., experience) which is making this happen.
• Colors, shapes, art, and layout can all contribute not only to the experience but actually to health outcomes and recovery.

The article talks about HOK (where I did an architecture internship) and their project with the University Medical Center of Princeton to create a new patient room layout.

A related article goes on to provide more on the research on this topic…

Although architecture and design substantially contribute to patient and staff safety, efficiency, reduced infections, reduced patient falls, and improve patient and staff interactions, it has been found that music, aroma, and access to nature can alleviate stress for patients, families, and staff. Hospitals are increasingly providing access to green spaces or gardens, which have been proven to reduce stress (reducing blood pressure) and improve patient satisfaction for patients, families, and staff. Even viewing nature and trees has been shown to reduce hospital length of stay and result in fewer medications for patients.

If you’re like me, you get on the treadmill or other exercise equipment at the gym and see it talk about exercising at X% of your maximum heart rate. Or, you get a heart rate reading on the device and wonder what it means.

It appears that the simple answer is to take 220 minus your age. For example, if you’re 30, then your maximum heart rate would be 90.

Now, when I plugged my age into a Mayo Clinic site, it shows me all the caveats about this answer.

Specialty drugs are expected to represent 40% of total Rx spend by 2020 so guess what…they’re the focus. Generic Rxs represent 80% of the oral drugs dispensed today and are low cost. PBMs, pharmacies, and payors are and should be focusing on specialty drugs.

Of course, this is driving a shift towards price compression and medical management types of functions like PA, UM, ST, case management, and even disease management.

So…what should your specialty pharmacy be focused on?

1. Integrating medical and pharmacy benefits and data (a lot easier said than done as many have tried and failed).
2. Using technology to engage physicians including social media, iPad apps, and EMRs.
3. Providing a holistic solution that enables patients to self-manage, understand their disease, and improve their adherence to minimize waste and improve outcomes.
4. Work with providers to be part of the broader care team and subsequently the shift to P4P (pay-for-performance) from FFS (fee for service).

I think this is going to require a tighter coupling of population health companies with specialty pharmacies and potentially better leveraging pharma manufacturers as partners versus suppliers.

This is not just a cost challenge…this is about outcomes. I usually think of it in terms of “The Triple Aim” which is about cost, quality, and experience.

If you look at your specialty pharmacy partner, I think you could put them in 3 buckets:

• Dispenser – Focused on operational metrics (TAT, ASA) and lowest cost dispensing.
• Advocate – Focused on “hub” type services that address basic patient needs (mostly patient out-of-pocket costs) and look at pharmacy focused case management.
• Innovator – Focused on using technology and data (medical, pharmacy, lab) to create differentiated outcomes through patient engagement, participating in the care team, and personalizing medicine.

I got to see Dan Buettner, author of BlueZones, present a few times and love some of the insights from his research. The other day, there was a list of these nine lessons in USA Today:

1. Move naturally
2. Know your purpose
3. Kick back
4. Eat less
5. Eat less meat
6. Drink in moderation
7. Have faith
8. Power of love
9. Stay social

It’s worth digging into his research if you’re looking at how to live longer.

I’m getting a little backed up in terms of articles and ideas that caught my eye so I’m going to share a few of them here.

• Ubersense – looks like an interesting mobile app to help you with sports coaching.
• MakerBot – 3D printing for your home…how exciting!
• RedLaser – scan a bar code and find the lowest price…I have to try this.
• GenieMD – a simple interface for tracking your healthcare data in one free app
• ZocDoc – 1.8M MD appointments booked online using this app in August…seems to be getting some energy
• 19 states still allow paddling in schools (Time article – Spanking in the Schools) – seems pretty archaic to me
• Top motivators for getting vaccines (Directions Research for Walgreens):
  • 74% – pandemic / outbreak
  • 67% – doctor recommendation
  • 42% – CDC recommendation
  • 27% – preventative health measure
• Evernote – smart notebook…may be something I actually buy!
• Specialty Pharmacies and URAC Accreditation
• Using video games in cancer therapy
• CDC social media kit
• Patient Engagement Is the Blockbuster Drug of the Century – Part II
• PWC research – Healthcare Unwired
• Targeting for care management
• Steve Jacobs website – http://unitedstatesofhealth.com/
• Doctors and social media
• When The Rx is an App
• Moving beyond legacy systems in healthcare
• Stamp size blood tests for liver damage

Healthcare in 2020 by Steve Jacob is a great book. Lots of facts. Lots of relevant information. A quick read. Well referenced. If I could, I would send this to every client I’ve ever worked with to help them understand why changing healthcare is so important.

I’m going to share a handful of things from the book here. Even if I could provide you with a detailed summary, I wouldn’t. You need to read this book.

• Estimated MD shortage by 2020 is >90,000 and nurse shortage is 600,000-1M.
• A great quote from two bioethicists (Daniel Callahan and Sherwin Nuland):
  • The medical system’s “main achievements today consist of devising ways to marginally extend the lives of the very sick … for a relatively short period of time – at considerable expense and often causing serious suffering to (the patient)”.
• Of the 30-year increase in US average life expectancy in the last century, only 5 years can be credited to advances in medical care. The rest is from public health measures.
• The number of people 65+ will double to 1.3B globally by 2040 and the elderly will outnumber children <5 for the first time.
• The percentage of people who work out 12 times a month dropped from 53% in 1988 to 43% (in 2009).
• Doctors advise only about 1/3^rd of their obese patients to lose weight.
• The most frequently reported “moderate activities” by US adults are food and drink preparation and lawn and garden care. [Not particularly high on the calorie burning schedule.]
• Nearly 3 out of 4 cancer deaths are attributable to smoking.
• In a 2009 report, about 75% of adults 17-24 were ineligible for the military because they had:
  • Failed to graduate high school
  • Were physically unfit or
  • Had a criminal record
• 1 of 3 homes in US metro areas have at least one problem that can harm health:
  • Water leaks
  • Peeling paint
  • Rodent infestations
• Cancer screenings find lots of pseudo-disease – i.e., abnormalities that meet the criteria of being cancerous but will never grow to become harmful.
• Surveys show a lack of participation in programs:
  • ½ hadn’t been screened for colon cancer.
  • Only 7% used nurse help lines
  • <5% of people eligible used smoking cessation or weight management programs
  • 3 of 4 people didn’t get a flu shot
• Use of decision aids has reduced rates of major elective surgery by ¼ without affecting patient outcomes or satisfaction.
• A physician would need to practice 18 hours a day to provide all the recommended preventative and chronic disease controls to their patients.
• A 2005 study found that nonclinical staff does the most effective job of managing patients with diabetes.
• Per the IOM 2005 report, 30-40% of healthcare spending represented “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.”
• The FBI estimates that 3-10% of healthcare spending is lost to fraud.
• In a research study, parents with sick children saying they had Medicaid or CHIP coverage where turned down 2/3rds of times and had to wait 22 days longer for an appointment than those with private insurance.
• About 40 US surgeries a week are performed on the wrong person or wrong body part.
• 1/3^rd of families lost most or all of their savings because of a terminal illness.

Some scary data points. This book was a great reinforcement of some of the projects I’ve been involved with trying to accomplish the Triple Aim – Quality, Cost, Experience.

The same Wired article had some highlights from their Wired Health Survey. Here’s a few data points that caught my attention:

1. How many caffeinated drinks do you consume a day?
   1. 0 = 16%
   2. 1-2 = 56%
   3. 3-4 = 22%
   4. 5-6 = 4%
   5. 6+ = 2%
2. Most popular exercise types:
   1. Walking 62%
   2. Weight training 42%
   3. Running 37%
   4. Cycling 34%
   5. Yoga 21%
   6. Swimming 18%
3. 73% of respondents take a supplement.
4. On average, how many hours of sleep do you get each night?
   1. 3-4 = 2%
   2. 5-6 = 39%
   3. 7-8 = 55%
   4. 9-10 = 4%
5. 78% of respondents say that tracking their personal health metrics has helped them reach their goals. (Quantified Self) Here’s what they track:
   1. Height or weight = 64%
   2. Fitness or activity level = 46%
   3. Blood pressure = 39%
   4. Cholesterol = 33%
   5. Heart rate = 28%
   6. Vision or hearing = 26%
   7. Sleep habits = 26%

I was reading Wired Magazine (Oct 2012) last night, and I came across this article “Living By Numbers: The Wired Guide To Health”. It gives “18 data-driven ways to be happier, healthier, and even a little smarter.” In my words, it’s a nice cheat sheet of some basic things we should all know (and many of which I’ve blogged about over the years).

1. Conserve your willpower: it runs out.
2. Shorten your workouts. (high intensity interval training)
3. Make a sport-specific playlist. Music is the ultimate motivator. Choose your workout tunes carefully.
4. Learn to read a scientific report.
   1. Causation versus correlation
   2. True size of the effect
   3. Statistical power
   4. Conflicts of interest
5. Don’t ignore data.
6. Check your genome.
7. Sleep or else.
8. Know whether to caffeinate or nap.
9. Be a discerning pill popper.
10. Eat this meal. Load your plate for maximum nutrition not maximum taste. L
11. Beware of food trends.
12. Do the right things at the right time. (circadian rhythms affects sports)
13. Heighten your senses with a call of duty. (gaming can make you quicker and more focused)
14. Get to know your poop bugs.
15. Dial in your happiness.
16. Avoid unnecessary procedures.
17. Get a standing desk.
18. Learn to live longer. (Blue Zones)

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?