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Archive for Prevention and Health Promotion

Messiness and Health Management to Change the World

by Scott MacStravic

I was struck by what I assume was an unintended connection between two recent posts to this blog – one by Nick Jacobs on “Change the World”, and the other by Fred Fortin on “Miscellany, Messiness and Medicine”.  To these I add an article noting a plan for fixing health care, published in WIRED in May [K. Philipkoski “Intel’ Andy Grove Pitches a Plan for Fixing Health Care” Wired.com May 2, 2007]

Andy Grove sees information technology as having a huge potential in fixing health care, along with efforts to “shift left” such care by moving it toward care that is not expensive, does not require hospitals and other institutions, but empowers consumers and innovative approaches to serving them such as retail clinics to take on otherwise highly expensive care.  High-tech gadgets can be used to monitor and manage the care of chronic disease and elderly patients at home, keeping them out of institutions.

Retail clinics can provide care in inexpensive “kiosks” or inexpensive retail and drug store space, and keep people out of hospital emergency rooms.  His other suggestion is the use of information technology in the form of electronic medical records which could be made portable all consumers carry their own with them at all times, making access to them when needed universally available, to ensure the quickest and best diagnosis and treatment of patients possible when they need hospital or physician care.

For some reason, however, Mr. Grove has little good to say about “prevention” as a way to fix healthcare, despite wide agreement among both health gurus and presidential candidates that prevention is an essential element for both reducing healthcare costs and enabling universal insurance coverage.  His objection to prevention is that it requires changing individuals’ behaviors, and he doesn’t think we have the capacity to do this yet in a cost-effective manner, although it is, theoretically, at least, in his view “…absolutely the right answer…”.

I can only conclude that Mr. Grove, as CEO of Intel, has not yet encountered the applications of information and communications technologies to prevention, rather than traditional physicians’ annual checkups, immunizations, and usually unsuccessful or overly expensive coaching for patients.  The search for cost-effective prevention has already concluded that technology innovations are essential to its realization.

Fortunately, such innovation is well under way and already in use.  While I know of no healthcare organization, in the traditional sense, that uses such innovations, the new brand of organizations usually deemed wellness, risk and disease management vendors are well underway.  Examples such as HealthMedia, Inc. and Thomson Healthcare, both in Ann Arbor Michigan, are already using online health risk assessments (HRAs) and customized online feedback therefrom to promote wellness, prevent or reduce risks, and manage chronic diseases.

They have also recognized that commercial or government insurance plans are not the best customers for such innovations.  Employers are, because they gain dramatically more positive impact from having healthier employees than do insurance plans from having healthier members or beneficiaries.  Employer gains include the full range of insurance costs combining healthcare, workers compensation and disability.  Moreover, healthier employers are absent less, produce more output and perform better across the balanced scorecard of business performance, realizing many multiples of sickness care cost reductions.

Instead of or augmented by physical examinations and screenings, online HRAs can be inputted directly into computers and automatically translated into individualized feedback, recommendations and continuous coaching, for a few dollars per employee per month in many cases.  These same HRAs can be used to estimate the productivity and performance value, as well as the extent of employee behavior changes and health status improvements.

The technologies used by most vendors, as well as most traditional healthcare organizations, have tended to emphasize, if not be exclusively devoted to professionals interacting one-on-one with patients in managing disease.  This is often cost effective, when the right patients, diseases and professionals are involved, but usually quite expensive.  Witness the costs of fifteen vendors and healthcare organizations involved in a Medicare DM demonstration project whose costs per participant ranged from $80 to $440 per month! and whose effects were generally negative in terms of savings vs. costs.

As far as I know, none of the new-technology-enabled approaches to affordable prevention have been tried with commercial insurance plans and either Medicare or Medicaid beneficiaries.  It may be that vendors who employ such technologies are focusing on employer clients whose pockets can be more generous, given their already demonstrated significant savings, even without counting the full economic benefits of employee health.

In any case, it would be a shame to characterize the entire armamentarium of “prevention” as not yet cost effective.  The new information and communications technologies available include many that are indeed “messy”, including consumer-directed communications with each other in support groups, and by the full array of wireless technologies, not merely the ones most providers seem to have tried.  And this approach to prevention still does have the capacity to “change the world”, since it can be used world wide as even underdeveloped countries are finding at least some of its technologies affordable.

Plummeting health scores…

by Nick Jacobs

Thanks to the Associated Press, our national egos can rest uncomfortably knowing that our health score as a nation continues to plummet.  You’d think that at over $2 trillion in health care expenditures nationally or nearly $6000 per capita, the score card would be better, but we have now dropped to 42nd in life expectancy worldwide.

Drunk drivers took the lives of almost 17,000 on the roads, and an estimated 510,00 are injured annually from alcohol related accidents. That works out to about one person per minute. Another part of the problem may be because we have so many guns. Every year it is estimated that more than 30,000 people are shot to death in murders, suicides, and accidents while another 65,000 suffer from gun injuries in the United States.  Defective automobile tires may have killed about 103 people over a number of years, but firearms kill about 85 people every day in this country.  How about obesity? The AMA estimates that nearly 300,000 people are dying annually due to obesity.

We may also rank 42nd because we have not used enough sun screen, have had too many household accidents and because the vast majority of medical centers are not dealing with their infection rates.  (The national average is a 9% infection rate, our medical center has been below 1% for nearly a decade.  They can be controlled.)

The bottom three spenders in healthcare dollars annually are the United Kingdom, Japan and Finland and Finland, Luxembourg and the U. K. are at the bottom as a percentage of GDP.  Guess what countries are included in the list that do better than the United States?  Remember, 41 countries are helping their citizens live longer than us and a few include: Finland, Luxembourg, Japan, the United Kingdom and Cuba?

The AP article pointed out that the country with the longest life span was Andorra?  Andorra is a tiny country between France and Spain where the people live nearly seven years longer than us.  Of course, the contrast to Andorra is Swaziland where the average person lives to be about 34.

Interestingly enough, after having spent time in Europe recently, It seems relatively apparent to me that the reason we are under performing so dramatically is that we don’t invest in preventative care, don’t really embrace public health and have never had a health policy for this nation.  Only about 4% of our trillions goes to prevention in this country.

Please forward this blog to our public officials.

Does “Prevention” Save Money?

by Scott MacStravic

The federal government and various “think tanks” it has hired have consistently found mixed results when asking the question: “Does Disease Management Work?”.  This has always been a ridiculous question to ask, since DM is not a single “treatment” whose efficacy can possibly be gauged in the way that particular drugs or medical treatments can.  DM is a wide range of different approaches, delivered by a wide range of different providers to a wide range of different patients with a wide range of different diseases.

A recent newspaper article attempted to ask and answer a similar question about “preventive medicine”, which includes DM, but goes far beyond that already broad and mixed bag of interventions.  It comes up with a number of arguments, though no data, to conclude that “prevention” will not save money, once its costs are factored in, and certainly will not save enough in terms of total sickness care costs to enable the country to finance insurance coverage for the currently uninsured. [D. Leonhardt “Free Lunch on Health? Think Again”, New York Times Aug 8, 2007]

It notes that the current “system” does not pay providers to keep people healthy, in fact perversely adds to sickness care costs by paying only for treating them once they are sick.  It concludes that studies usually find that prevention makes people healthier, but costs money, not saves it, overall.  After all, physicians and nurses have to spend time to get people to change their behaviors to healthier options.  Moreover, they are likely to be dealing with those who have not been persuaded to adopt and maintain healthy lifestyles through current services and strategies, so they are likely to be the toughest and most expensive to “reform” now.

The author cists a Stanford University School of Medicine study that estimates an anti-obesity program would have to treat five people, with interventions that are not cheap, to prevent just one new case of diabetes.  Prevention has to invest in interventions that will not have any meaningful impact on many of its participants, since they would not have become sick, anyway, while others do so in spite of participation.  Moreover, prevention increases the lifespan of population, and people contract more sickness as they get older, so lifetime sickness costs end up being increased.

In effect, because we have to “treat” many more times as many people through prevention as would have to be treated for sickness in order to prevent sickness, the costs of continuously treating those who would not have become sick overwhelms the savings produced by preventing the few cases of sickness that would have resulted.  The article concludes that: “Preventive care saves real money only when it replaces existing care that is expensive and doesn’t do much if any good.”  And it notes that as long as patients think the care they get will do them good, which they must or otherwise they wouldn’t get it, even preventing such “futile” care is a difficult task.

It quotes Jonathan Gruber, an MIT economist, as saying: “…if you’re going to control healthcare costs, it involves denying people care they want – or things they’ve been trained to think they want.”  Somehow,
”prevention” is equal to “rationing” as defined by the article.  But this is simply a “straw man” definition, as is defining prevention as a kind of medical care requiring the expensive services of physicians and nurses, in the same way as sickness care does.  In effect, the argument is that prevention would simply change what expensive providers do for patients, but still cost as much as treating sickness.

But the article ignores a host of preventive strategies and tactics, and a wide range of interventions, that do not require the use of physicians and nurses at all.  And it ignores the growing accuracy of preventive modeling in terms of identifying which people currently at risk represent sufficient risk/reward potential to warrant which kinds and costs of preventive interventions.  Both predictive and preventive technologies are improving dramatically, and both can often be applied on a population-wide basis, rather than the traditional one-to-one physician or nurse visit.

Predictive models can analyze collections of data on past sickness care claims, individual attitudes and behaviors, personality factors and perceptions, as well as on worker productivity and performance, to identify the risk/reward potential of individuals with increasing accuracy.  Individualized interventions aimed at multiple risk behaviors or conditions, or at preventing the emergence of such behaviors or conditions, can be generated automatically by computers, and communicated online of via mail for ten or twenty dollars a year per participant.

By tailoring prevention strategy and tactics to accurately predicted risk/reward potential and individual receptivity, and doing so inexpensively where necessary, plus intensively where justified, “prevention” can be as cost-effective as it needs to be in order to achieve its intended results.  And when it is applied to workforces, its benefits are often two to five times as great as the value of reduced sickness care costs.  Moreover, if it is applied to the young, it can deliver benefits over a lifetime, not just in the short run.

It is impossible to say that prevention does work, just as it is impossible to say that it does not.  “Prevention” is simply too vast an array of different challenges involving different people and intervention modes plus costs to come to any overarching conclusion.  But that is the point, after all – it is simply a silly question to attempt to answer simplistically and finally.  There have been thousands of successful applications reported, and perhaps as many unsuccessful attempts made but not reported, since failure rarely prompts as frequent and as loud reporting as does success.

We are ill-served by attempts to answer such a silly question, regardless of what narrow evidence and arguments are used to support the answer, since the question simply cannot be answered.  The challenge is not to try to reach a simplistic yes or no answer, anyway.  It is to study, identify, and promote what does work, and continuously improve the science and art of prevention, and continuously monitor/evaluate how much we can improve it and enjoy as a result.

Evaluating Health Management Results: Therapeutic Specificity?

by Scott MacStravic

When evaluating results of any “medical” intervention, including proactive health management (PHM) efforts involving medical care providers, the question must always be asked: which “results” can logically be attributed to the effort, as contrasted to any number of confounding factors at work?  In the past, both vendors and customers of PHM interventions have tended to ascribe everything good that happens after the intervention to their efforts, where at least some such results may be totally unrelated.

Once the PHM evaluation has avoided or controlled for the most common causes of overestimating results, namely “regression to the mean” with before/after comparisons, and self-selection bias with side-by-side comparisons, a third control is often recommended: “therapeutic specificity”.  This involves making sure that the changes in valuable metrics discovered can logically be attributed to, i.e. have some known connection with the intervention.

The origin of this demand for therapeutic specificity was curative medicine, where rigorous clinical control studies are needed to evaluate new drugs and medical procedures.  Unless the physiological effects of such treatments are known to produce specific consequences, any other consequences discovered in patients so treated should not be considered to result from such treatment.  For example, if asthma patients are found to improve their IQ scores after treatment with a particular drug, this improvement should not be attributed to the drug unless there is an established connection between it and mental performance effects.

In evaluating diabetes management, for example, one proponent of therapeutic specificity made a strong case for not counting among the effects of such a disease management effort any reductions in hospital admissions or other sickness care use and expense not directly linked to diabetes.  Specifically: “It should not be assumed that an intervention targeting one disease will impact another”. [A. Linden “What Will It Take for DM to Demonstrate an ROI?”, Disease Management Colloquium May 2006 (www.ehcca.com)]

When considering the cost savings from diabetes DM, evaluations may focus solely on sickness care use/expense reductions where diabetes was the sole cause, include it plus known co-morbidities, or at least conditions known to be directly related thereto.  But “therapeutic specificity applies to the “therapy” used, not to the disease targeted alone.  For example, diabetes is not merely a disease, but a known risk factor for a host of other disease, of the eyes, hands and feet, kidneys and heart.  For this reason, diabetes DM often includes explicit attention to blood pressure and cholesterol, in addition to blood glucose control.

Moreover, since diabetes is known to be “reversible” through lifestyle changes alone, nor merely medications, diabetes DM often includes lifestyle modification efforts.  If these are successful, patients are often able to control this chronic condition without relying on medications anymore, saving themselves and third-party payors significant prescription drug costs.  The same has been shown to be true for heart disease, and may be true even for prostate cancer. [D. Ornish, et al. “Can Lifestyle Changes Reverse Prostate Cancer?” Preventive Medicine Research Institute April 2002 (www.pmri.org)]

The “rule” of therapeutic specificity is clearly intended to apply to the therapy, not necessarily the disease involved, particularly with diabetes, since it is also a risk factor for so many other diseases.  The focus in evaluation should be ensuring that the DM or other PHM intervention is logically related to any results claimed to be due to it, even when the results are not directly related to the disease specifically targeted.

Moreover, medications often have unexpected, even unintended consequences, that can either be negative “side effects” to watch out for, or “serendipitous” added benefits that add to their value.  For example, many of the statin drugs used in reducing cholesterol levels have been linked to reductions in cancer risk.  Recent research in the UK has indicated that controlling people’s heart disease reduces older people’s cognitive function declines. [A. Harding “Heart Disease Tied to Mental Decline” ReutersHealth.com July 27, 2007]

The rule of therapeutic specificity only argues that no connection between an intervention and a result should be assumed, not that none should be credited to a disease-specific or risk-specific intervention.  Fortunately, there are many good “side effects” of both medical and lifestyle interventions, and both should be counted in both benefits and costs of DM and PHM interventions.  While care is needed to avoid “over-attribution” of positive effects to such interventions, equal care is needed to be sure of avoiding “under-attribution” as well.

If there are effects from treating diseases or risk conditions that go beyond the specific disease being addressed, these can justify counting at least the risk-reduction effects of DM and PHM interventions.  This can easily be expressed as a probable percentage reduction in sickness care costs, absences, productivity and performance impairment related to the calculated risk reduction effects.  While a deliberately myopic insistence on limited effects may prevent over-attribution and over-investment in DM/PHM, a more realistic and open-minded approach can prevent both under-attribution and under-measurement, and thereby under-investment.

Are We Approaching “Critical Mass” in Managing Health?

by Scott MacStravic

I have heard and read reports with a wide range of conclusions regarding the future of managing health, in contrast to and competition with treating sickness.  Some have suggested that the consistently unenthusiastic evaluations of disease management, the most widespread example of managing health, portend the demise of at least this narrow range of “solutions”.  Others have predicted that the “wellness” or “healthy living” market will reach the $1 trillion a year level within the next few years or decade.

Just as the original “health maintenance” and “managed care” organizations ended up focusing almost entirely on managing costs, so managing health has a major focus on reducing costs, though with a far broader range of “costs” than either HMOs or MCOs.  It includes the costs to patients in terms of health and life quality as well as longevity of life, for example.  And it includes the costs to employers and the overall economy of the absences, reduced performance at work, turnover, shortened work life, and other effects caused by “unhealth” in general.

While the “healthcare system”, and hospitals, in particular, are fond of describing the value they represent to their communities in terms of jobs and total economic impact on local economies, which naturally add up to the total costs of the system, over $2 trillion each year.  But the illegal drug industry could as easily brag about its economic impact as well, if only the money involved were used to measure it.  The real point is that the healthcare system has done extraordinarily little to promote the health, prevent and reduce disease risks, and manage patients with chronic diseases so as to reduce the crises, complications, and worsening thereof.

But there are signs that the larger health system, which includes the entire population and its health, all providers, all payers, and all other stakeholders that are affected by and affect the health of the population, are approaching a “critical mass” or “tipping point” level in terms of a far different balance of health management vs. sickness treatment.  Developments in essentially all stakeholder categories are moving in that direction, at least.

For example, “Revolution Health” has most recently partnered with Medco Health Solutions to empower consumers with a personal health record to better manage their own health and healthcare expenditures.  This adds to its investments in health spas, the RediClinic chain of retail clinics, which is the one I know of with a significant focus on “Stay Well” as well as “Get Well” services, and its own online health information memberships. [“Revolution Health and Medco to Partner on New Portal” E-Health Trend Watch July 26, 2007 (www.healthleadersmedia.com)]

Disney has joined in the effort to reduce the promotion of unhealthy behaviors by banning depictions of smoking in its movies. [“Disney Films to Ban Depiction of Smoking” MSNBC.com July 25, 2007 (www.msnbc.msn.com)]  Google and Microsoft are both competing for the e-health market, with Google focusing mainly on consumers, and Microsoft on patient/physician interaction and information therapy. [“Google vs. Microsoft e-Health in Medical Search War for Big Profits” DirectTraffic.org July 26, 2007

Positions on controlling chronic disease costs through disease management and preventing current epidemics in new cases are being taken by both liberals and conservatives.  And most of the daily increasing number of presidential candidates seem to have a position in favor of health promotion and disease prevention, as well as disease management as essential to the solution of the “healthcare cost crisis”. [T. Pugh “Curbing Chronic Diseases New Issue in Health Care Politics” KansasCity.com July 26, 2007]

Canada is taking essentially the same position, with British Columbia complaining how far it has fallen behind other provinces in its investments toward preventing, rather than waiting to treat and pay for sickness. [“An Ounce of Prevention” Straight.com (Vancouver, BC) July 26, 2007]  Employers are shifting toward “value-based approaches to employee benefit design, health plan purchases, which promotes by reducing financial barriers to employees obtaining prevention, early detection and disease management services.

Intel, Inc.’s Digital Health Group is focusing R&D efforts on finding better ways to use computer and communications technologies to enable consumers to protect and enhance their own health over a “health lifetime” as a way to promote both physical and financial independence. [S. Love “Intel in Health Care” Intel.com July 2007]  Cell phones will soon be able to store individual’s medical history for access by providers in both sickness care and health management. [“New Cellphone Projects to Save Lives with Medical History Information” World e-Report/Disease Management Alliance July 12, 2007 (www.dmalliance.org)]  Physicians are poised to join health management vendors and health insurers as providers of proactive health management services, based on the “medical home” model agreed to by primary physicians’ associations. [V. Kuraitis “Disease Management and the Medical Home Model” Disease Management & Health Outcomes 15:3 2007 135-140]

And these are but a few of the literally hundreds of examples of just about every stakeholder in the “system” poised to or already heavily involved in attacking the healthcare crisis proactively.  Some focus just on short-term gains from disease management, while others look longer term at health promotion, risk prevention and reduction.  But all are persuaded that proactive interventions that will reduce the incidence and prevalence of disease and injury, along with the crises, complications and worsening of existing chronic diseases are clearly an essential component of any serious and potentially effective solution to the crisis.  And instead of merely calling for such interventions by others, almost all stakeholders are implementing their own.

It’s Time to Extend Child Development to a Health Lifetime

by Scott MacStravic

The model of lifetime patient relationships with healthcare providers was much in mode when I was born, when people tended more to stay in one place and use the same collection of providers, hospitals, and physicians in particular, throughout much of their lives.  Rural communities, in particular, had physicians who delivered multiple generations of babies in the same family and hospital.  This model still occasionally appears in movies, though fiction has more freedom in creating stories, and reality has changed almost completely.

While it is recognized that “it takes a village to raise a child”, we have not looked past “child development” to its logical extension of “lifetime development” with a focus on health, talent, and whatever other personal assets are needed to achieve and maintain “life excellence” in individuals, and “community excellence” in populations.  Since healthcare is my main experience base, I will restrict my discussion to what is in the way of lifetime health development, and what could be done to achieve it.

Hospitals compete strenuously for each other’s patients, while individuals change physicians at the drop of a hat — or at least of employer changes in insurance, insurers’ changes in provider networks, physician’s changes in location, etc.  In few cases did individuals ever spend their entire “patient lifetimes” with the same providers, anyway, as babies outgrew their pediatricians, women switched to an obstetrician during childbearing years, and seniors sought out geriatricians in their later years.

At the same time, the benefits of a “continuous health lifetime” are increasingly being recognized.  People are far better off if they begin with providers who supervise and support their “health development” from birth.  Healthy babies have a better chance of a healthy lifetime.  Children who are obese when young are more likely to have problems as they grow older.  Employees who lack insurance or support in maintaining their health and avoiding risks will become sick and expensive Medicare beneficiaries, if they live long enough.

While it is clear that no single provider or even system of providers can serve most individuals throughout their health lifetimes, it is equally clear that the best model for care is a healthcare system that does so.  A lifetime personal health record, sharable and transferable from provider to provider within that system will be one essential element.  But the other is a system that is focused at least as much on the health of individuals as it is on their diseases and injuries.  And we certainly do not have such a system today.

While both the American Medical Association and the American Hospital Association give rhetorical obeisance to the health of patients and communities, hospitals and physicians are almost entirely dependent on the demand and payment for sickness care in order to survive.  Machinations by CMS and commercial insurers in revising payment schemes and amounts are a constant source of stress to all providers, save for a few hundred who manage to get by on payments by patients, alone.

But when we think and speak about healthcare reform, it would be far better if we thought in terms of a model built around a “healthy lifetime”, and on “individual health development”, both focused on achieving and maintaining as high a level of health in individuals and populations as is practical.  And health is very practical, to consumers, employers, insurers and governments, particularly when contrasted to “unhealth”.  Too many reform suggestions rely on one mechanism, such as consumer-directed health plans and free competition among them, rather than a thoroughly reformed model for health that a wide range of mechanisms might support, and reforms in existing mechanisms promote.

We have the technologies to make lifetime health records possible, and to enable all health- as well as sickness-care providers access to them, when appropriate and approved by individual record owners.  We have already, and are innovating significant new options for remote monitoring of people whose risk or disease conditions need constant attention.  We also have inexpensive communications technologies that can reach individuals almost wherever they may be to motivate, remind, coach, and otherwise communicate with them, wirelessly or wired, in person, by mail or online, to make health as important a priority as is unhealth.

It is not a health care crisis we face, so much as a health crisis, and we should be using the will and willingness to invest we showed in putting a man on the moon in the 1960s to design and implement a health system fifty years later.  Existing providers can choose to remain in the sickness care business, mix health with sickness care, or move entirely into health care – there will be room for all three options.  It is simply a matter of agreeing on the idea, then on a model that will unite all stakeholders well enough to try out different designs until we find the one that works best.

Lifetime health management based on a lifetime personal health record should be enough of a model specification to make a start toward this “moon”.  It is then a matter of gathering together the resources and will needed to translate the idea into reality.  There is really little question as to the necessity of doing so.  It only waits for those who have the will, the resources, and the ability to make the translation to get started on developing individual and population health as a key foundation for a better and healthier country, and perhaps a world.  If we put as much of all three assets into health development as we have for a century in sickness care development, we should have a good chance of succeeding.

Making Artificial Intelligence “Real”

by Scott MacStravic

I have copied, read, annotated and filed hundreds of analyses and evaluations of proactive health management (PHM) in the past ten years.  These have come from academic and research organizations, customers of PHM programs, the suppliers thereof, government studies, and virtually every possible source likely to conduct such analyses.  And the thing they almost all share is a myopic focus on a small portion of the dynamics of PHM effects, from the beginning to the end of the “causal chains” involved in achieving them.

Part of this myopia is simply practicality.  I still recall a story in the cartoon strip “Prince Valiant” where the hero visited a land where all its people could and did consider the entire set of consequences of everything they thought of doing – from now until forever, across the entire universe of things affected, and therefore could never do anything – caught inevitably in “the paralysis of analysis”.

Moreover, evaluating everything, or even just most of the important things that happen, during and as a result of PHM interventions, costs money.  If it comes to the point where evaluating the results and returns on investment (ROI) from such interventions threatens the possibility of achieving positive ROI, then it becomes a case where: “If ignorance is bliss, ‘tis folly to be wise”.

But we have made enormous strides in artificial intelligence (AI) in recent years.  I have visited and listened to the people at MedAI, in Orlando, Florida, for example, who keep winning international awards for their AI and predictive prowess, which includes predictive modeling that is used in analyzing healthcare expenditures for targeting PHM interventions.  The ability of AI to capture the interactions of hundreds of factors means that computer intelligence, at least, is perfectly capable of considering complex the complex systems that affect health and healthcare expenditures.

Ray Kurzweil, in his book The Singularity Is Near: When Humans Transcend Biology (Penguin 2006), notes that the rate of information technology growth is exponential vs. linear.  Our capacity to identify and understand systems is doubling every decade, and artificial intelligence will transcend the storage and analytical capacity of the human brain before the middle of the 21st century.

One of the health-significant examples in his book is the identification of the human fat storage gene, already identified.  He predicts that AI will provide the basis for the creation of drugs that will control the operation of this gene within five to ten years.  This will enable us to eliminate the overweight/obesity epidemic that is already sweeping most of the world.  In turn, this will dramatically reduce the rates of diabetes and related conditions caused by weight problems, for which linear predictions have already been made that foresee the swamping of the sickcare system because of weight problems.

The challenge in PHM is to identify the chain of cause and effects in operation therein – from PHM intervention to human behavior change to physiological change to reduced sickcare costs, worker absences and presenteeism, to improved productivity and performance.  Armed with data on each factor in this complex system, we will be able to understand and predict the meaningful effects of PHM interventions on individuals and populations.

In turn, this will enable us to not merely evaluate past PHM interventions, but to predict which existing interventions, and simulate new interventions, in order to pick the most effective and promising.  We will have the ability to achieve evidence-based health, in the same way as we have developed evidence-based medicine (EBM) in the past fifty years, but in a far shorter time, thanks to the “law of accelerated returns” that Kurzweil describes.

The widely mixed and invariably myopic evaluations of PHM interventions up to now have typically focused on far too few years, far too few factors, and far to few dimensions of value to capture even what is already happening.  As Kurzweil noted, quoting the philosopher Schopenhauer: “Everyone takes the limits of his own vision for the limits of the world.”  With AI, we will no longer be so limited, but be able to take PHM to its full potential, instead of being stuck in narrow and equivocal evaluations of its current achievements.

Healthy Lifetime Partnerships — The Ultimate Healthcare Reform

by Scott MacStravic

While practically everyone, particularly the aspirants to the American Presidency in 2008, seems to have a solution in mind for the “healthcare crisis”, one thing seems clear.  Any real solution will have to include a cost-effective strategy and program to dramatically increase the proportion of Americans who live healthy lifestyles, for as much of their lifetimes as possible.  The epidemic of unhealthy living that has been growing for decades has created a ticking time bomb of people who already have or are on the path to having chronic conditions that increase their, and the country’s need, demand, and expenditures for healthcare far past the affordable level.

Pursuing “healthy lifetimes” should be something that could at least be made appealing to most people, and the benefits of such made appealing to most organizations.  There is already growing in this country what hopefully will turn out to be the “critical mass” of stakeholders needed to not merely motivate but integrate sufficient effort to make the changes needed.  It would certainly have been better if we had started on a national, integrated effort much earlier, but it is, we can at least hope, not too late.

From the vast amount of research that has been done on the subject, it also seems clear that managing chronic diseases that already exist, in the senior population in particular, is truly the “last resort” in terms of cost-effectiveness.  Research reports continue to be published indicating that Medicare demonstration projects are not working.  Managing chronic diseases in the senior population seems to cost far too much money, and save far too little.

The net effect of this combination is a continuing series of disappointments.  While participants in these projects gain improved quality of care, and often of health and life, as well, the federal government and taxpayers gain little if anything.  It is difficult to say if it is the challenge of old dogs and new tricks, of limited opportunities once chronic diseases are well established, of disease management suppliers who haven’t figured out cost-effective approaches, or some other intractable difficulty.

In any case, what a number of analysts, including myself, are beginning to advocate is a far more proactive approach to the problem, namely reducing the incidence and prevalence of chronic conditions (and acute disease as well) across the entire population.  Instead of being guided by the Willy Sutton principle (rob banks because that’s where the money is), work with the entire population, as early as possible in their “health development”, to minimize the number who become sick, and maximize the number who stay well.

It is perhaps understandable that insurers and governments have waited until people get sick before trying to do something about it.  There are far fewer people to deal with that way.  Often the proportion of a population who are at high risk or high cost already is less than 10%, often more like 3-5% when younger populations are concerned.  This seems more efficient than having to worry about everybody.  And when the proportion already adhering to healthy lifestyles is considered, that usually amounts to an equally tiny proportion of the population, meaning that practically everyone needs some attention.

The American medical care system suffers from one major cost fixation that may make sense in sickcare, but is both unreasonable and horribly inefficient in healthcare.  This is that there is one high standard of quality that should be delivered to all patients regardless of their ability to pay.  We do make some exceptions in the form of “VIP” levels of care for the wealthy, “executive health” programs for the important, etc., but otherwise demand that all have access to a high and expensive level of sick care.

This is not a fixation that makes sense in healthcare, nor is it affordable.  The challenge in healthcare is to create and execute population health strategies that can be customized to individuals, based on their risk/reward potential and personal idiosyncrasies, so that cost-effective and successful healthy lifestyles can be achieved and maintained by as many as possible.

This means beginning the effort as early as possible in the lifecycles of each of us, as early as pre-pregnancy, for example.  Minimizing the number of babies born before fully developed, or with congenital problems is one of the first places to begin.  Promoting healthy child development, particularly avoiding the recent epidemic of overweight/obese children is another, since weight problems early on tend to persist and create high risks of diabetes as well as psychological and social problems.

While the federal and state governments take on some responsibility for healthy pregnancies and child development through Medicaid, the rest of the population is pretty much left to their own devices, with medical care focused almost entirely (roughly 95% in terms of expenditures) on “sickness procedures” rather than on promoting and maintaining healthy lifestyles from the beginning of life.  And waiting until people become “government wards” at the age of 65 is easily the most inefficient possible approach.

The recent introduction of legislation that would give employers tax incentives to promote the health of their employees is one example of how governments could join with private business in promoting healthy lifestyles earlier.  Rather than waiting to inherit an entire population of mostly sick people, the federal government should, ideally, by promoting research that identifies the most cost-effective approaches to promoting healthy lifestyle in young and employee populations, in order to inherent healthier seniors.

Fortunately, America has a history of public/private partnerships for the most serious challenges in the most serious situations, such as the one that created a winning military capability in WWII.  With everyone sharing in the same challenge, including sickcare providers who should be convertible to healthcare providers with the right incentives, as automobile manufacturers were converted to making tanks in WWII, a healthy lifestyles partnership among all the stakeholders in our “system” should be pursued across a lifetime health paradigm.

This is not an argument for creating a “war on sickness”, despite the popularity of having “wars” on everything that we find objectionable.  It should be quite the opposite, with a focus on the benefits of health, to individuals and the national economy, for example, rather than on the “terrors” of sickness.  But it should clearly aim for the kind of national unity around a single focus that has served us well in past wars, when they truly had to be fought.

It may well benefit from government regulations or incentives, such as outlawing trans fats, taxing unhealthy foods to enable “budget neutral subsidies of healthy foods, for example.  The full range of public and private approaches to creating an epidemic of health should be considered and pilot tested on a pragmatic level, rather than preferred and promulgated on an ideological basis. Shares in the costs of a national effort could easily be proposed based on the value derived by each set of stakeholders, for example, since all should ultimately benefit if the effort is designed well.

It may be, as many conservative/free market advocates suggest, that healthcare reform based on competing suppliers of healthcare, rather than any national, government funded and operated system of healthcare, would be the best and most likely to be adopted solution.  But regardless of whether liberal or conservative models are proposed, they should be based far more on “cradle to the grave” healthy lifestyles promotion, far more than an equal-length guarantee of somebody having to pay for unhealthy ones.

The Path Not Taken: Physicians

by Scott MacStravic

While hospitals have occasionally and partly meandered into the proactive health management (PHM), physicians have been equally tentative in their efforts.  For one thing, specialists are almost totally committed to sickness care, and the procedure-based payment systems used by third-party payors.  Of course, specialists that deal with patients with chronic diseases, such as endocrinologists with diabetic patients, and cardiologists with heart disease patients, can take on proactive disease management functions for those specific conditions, but are rarely qualified for or comfortable with managing co-morbidities common to diseases in their specialty domain, such as depression, for example.

Primary physicians, including family practitioners, general internists, pediatricians, geriatricians, and even obstetrician/gynecologists who serve as primary physician for women in many cases, are the most likely to engage in PHM.  Unfortunately, taking on PHM challenges and managing patients’ health problems and risks proactively falls mainly in the category of “cognitive services” which are notoriously uncovered or poorly compensated by third-party payers.

When the Family Physicians of Western Colorado, a group in Grand Junction, CO adopted the Chronic Care Model for its diabetic patients, it was able to keep its PHM costs down to $114 per patient per year.  And it was getting $120 per patient per year for the program from its major payor, along with a grant to cover the additional record keeping required.  Unfortunately, it applied the program to all its diabetic patients, and less than half were members of the HMO that was the only one paying for it, so it ended up losing over $25,000 a year thereby.  It chose to continue the program, anyway, given the significant benefits it delivers to patients, but losing money is not popular among physicians. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management 12:10 Nov/Dec 2005 50-56]

Medicare/Medicaid , insurers and employers are gradually investing in PHM for their beneficiaries, members and employees.  But CMS and commercial insurers look primarily at reductions in sickness care use by chronic disease patients, and only those that occur in the same year as their PHM investments as desired outcomes from PHM.  These short-term savings come mainly from only a small portion of patients, and represent losses of sickness care revenue to the same physicians, so are not usually seen as particularly attractive by those physicians.

Moreover, third-party payors seem to prefer specialized disease management (DM) providers when looking to outsource their limited PHM investments.  Including the physicians that already have a relationship with and serve particular patients in payor-sponsored DM programs would require enlisting a lot of different physicians, each of whom has only one or a few patients that would be involved in a specific payor’s program.  And physicians would have to cope with fitting into many payors’ DM programs, rather than just one in order to get all their patients with a given disease involved.

For these reasons, the physicians most involved in PHM tend to be those who are paid directly by their patients to do so.  “Patient-paid” practices include “concierge”, “boutique”, and similarly labeled physicians that are able to include a significant PHM element as part of their annual retainer services, or in some cases, practices that offer PHM “packages” dealing with specific conditions and risks.

One example is the MDVIP organization of practices, now numbering about 150 physicians and offered in 16 states.  These all include a major focus on maintaining and improving patients’ health under their $1500-1800 annual retainers.  This PHM focus is a major element of the organization’s appeal to physicians, and to patients alike.  It tends to dramatically reduce sickness care costs among its patients, though third-party payors have not rushed to help any patients served by these practices with paying the retainer. (www.mdvip.com)

Another far less common approach involves physicians that charge on a fee-for-service basis directly to patients, with specialized DM or PHM services, while not usually serving as these patients’ primary physician.  The Tempus Clinic in Los Gatos, California is one example, charging annual retainers for specific “preventive diagnostic” services, and ongoing coaching, often including membership in its own fitness center as well.(www.tempusclinic.com) Another is the Beyond Care practice in Branford, Connecticut, offering disease- and risk-specific packages of services that run from three to six months. (www.beyondcare.net)

The CareSouth Carolina organization of rural physician practices, headquartered in Hartsville, SC is another kind of example, offering DM for diabetes patients, including those with a co-diagnosis of depression, though not getting paid by insurers for it.  It was able to show annual management costs for such patients that were over $1200 less per patient per year than the average of other primary physicians in the state. [R. Chaufournier & K. Reims “Hidden Opportunities for Cost Savings in Disease Management” Healthcare Savings Chronicle  (Coalition America, Inc.) Mar 10, 2005 (www.imakenews.com)]

Primary physicians have two major advantages as providers of PHM services to their patients.  First, they are already familiar with such patients and their complete medical/risk status, and are a trusted source of advice, with their recommendations one of the chief motivators for patient adherence to medical care regimens and lifestyle changes.  Second, they are about the most powerful ally in getting patients to enroll in formal DM or other PHM programs when offered by third-parties, while otherwise, participation among such patients is either quite low, normally (10-20%), or requires payors to add to PHM costs by paying participant incentives to achieve higher participation.

When a PHM firms operating onsite medical clinics for employees conducted research on the effect of physician counseling on patient participation, it found that enrollment in DM programs increased from 25% up to 75% when a trusted clinician in such clinic became involved in recruiting prospects.  “Workplace Disease Management Program Participation Boosted Three-Fold by Patient Contact with Trusted On-site Clinician” i-Trax/CHD Meridian Feb 22, 2007 (www.i-trax.com)  Tripling participation not only increases the numbers of patients from whom PHM savings can be expected, but divides the costs of PHM programs by three times as many participants, since costs are often either flat fees or per employee, rather than per participant.

It is likely that payors will increasingly catch on to the benefits of having PHM program participants’ personal physicians involved as partners in such programs.  Already some employers are agreeing to pay physicians annual fees such as $300 per year for each of their patients who are managed as part of a PHM program.  And primary physicians are looking for ways to incorporate PHM activities in their practices, as sickness care payments to them are being cut continuously by third-party payors.

There should be a major growth in physician involvement in PHM activities in the future, as patients, payors and physicians alike recognize the mutual value to be gained thereby.  It should turn out to be far easier for primary physicians to become involved in PHM initiatives, as leaders and managers of such initiatives, since as providers they would usually add too much expense to be affordable.  Specialists may not have as easy a path, though some will undoubtedly find a way to make this path worth taking.

The Path Not Taken: Hospitals

by Scott MacStravic

Since I was born and raised in the Boston area, I was naturally exposed to a lot of the poetry of Robert Frost, including his poem about choosing “the path less traveled by”, and how that “made all the difference”.  Hospitals have a choice today of paths, where which they choose could certainly make, if not all, at least a major difference in their future – the option of moving toward proactively managing health and disease, as opposed to mainly or solely reactively treating illness and injury.

Hospitals have always been ‘dabbling’ in proactive health, including offering free immunizations to their employees and communities, along with health fairs and other educational or screening events.  Screening has had the added advantage of identifying people who should be seen by physicians, and often end up needing hospital care, so are at least partly marketing tactics, in addition to delivering “community benefit”.

The option of choosing the proactive alternative more intensively is not merely one of adding service lines to current activities.  Proactive health management (PHM), by definition and intention, will reduce the incidence and prevalence of illness and injury in the populations served by hospitals, and thereby reduce the need, demand, and expenditures for sickness care, and thereby the revenue to which hospitals will have access.

Proactive “wellness” care has often been promoted as a tactic to gain PR value and the interest of employers in hospitals’ markets, and thereby to potentially make up for reductions in the overall sickness care market by winning a greater share of the reduced market.  Since wellness care can generate its own revenue (it has been twice described as a $1 trillion market in its own right), the combination of gaining a greater share of a declining two-plus trillion dollar sickness care market and a significant share of the one-trillion dollar proactive health market could turn out to be a successful strategy.

But PHM can also place hospitals “on the side of the angels” with respect to the “health care cost crisis”, by enabling them to become part of the solution, rather than a major part of the problem.  Sickness care — for employers, insurers, and governments, as well as taxpayers and patients – is a “cost center”, whose benefit has always been difficult to put a value on.  By contrast, PHM is a “cost-saving” center for patients and payers, as well as a potentially “revenue-generating” center for both providers and employers.

As employers, often among the biggest employers in their communities, hospitals should logically be invested in PHM for their employees, since this can save substantially on labor costs.  Not only does PHM reduce sickness care costs, it also reduces worker absences, impaired productivity at work (“presenteeism”), errors and quality problems, and even employee turnover.  It can also improve employee morale and commitment, energy levels and enthusiasm, and thereby increase customer satisfaction, loyalty, and the generation of new business and revenue.

Because the total economic impact of PHM is difficult and expensive to measure, the pattern of past efforts – by employers in general, and hospitals in particular – has been one of measuring only one or a few of the many dimensions that probably have been affected.  In most cases, even a limited measurement effort has found significant returns on the PHM investment (ROI), so has been sufficient to justify repeated or continuous investment, and no additional measurement efforts were needed.

But deliberately choosing to ignore the rest of PHM’s value can lead to reducing or even ending investments that would have been continued if the full benefits were known.  And with the growing importance of employee performance, not merely productivity, given the increasing potential for pay-for-performance (P4P) bonuses and revenue, measuring performance provides both a strong reason for and basis for evaluating PHM’s impact on performance.

Instead of or in addition to measuring a wide range of selected measures of quality, output, errors, efficiencies, etc. as possible effects of PHM investments in employee health, hospitals can focus on workforce performance in the specific dimensions for which it is paid extra under P4P systems, and reported in published performance ratings that affect payers and consumers choices of hospitals to put in their provider networks and use for patient care.  By evaluating PHM in light of performance impact, and by achieving better performance as a result, hospitals can both increase their knowledge of the full effects of PHM and increase the resources available to invest in and measure its effects.

If hospitals choose to invest in PHM as a revenue-generating service line, in addition to doing so as a labor cost saving and performance improvement internal investment, they can use what they learn about the best ways to improve employee performance as the basis for their externally marketed PHM programs.  They can also use the results they have achieved in their own employee PHM efforts as evidence of their success and total economic impact when marketing to employers.

When they evaluate their success in external PHM efforts, hospitals will naturally want to include the net effect of such efforts on their sickness care revenue and overall profitability as well.  The net effect could be positive, if externally focused PHM reduces overall demand for sickness care and revenue derived therefrom.  It could also be positive, if the combination of external PHM revenue and any increased market share gained through successful partnerships with employers produces an overall positive effect.

In any case, the combination of internal and external PHM investments will represent a path not previously taken by most hospitals, and make a big difference one way or the other.  Many hospitals and integrated health systems — including Mayo Clinic and Fairview Health Services in Minnesota, Geisinger Clinic in Pennsylvania, Northwestern Memorial in Chicago, and Duke University in Durham, NC — have already invested in internal, external or both applications of PHM.  All are in the early stages of both application and measurement of results, but are certainly at least partially aware of how much difference this path can make.

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