Neupert On Health

Reform Health Care by Re-empowering Consumers

The Six Billion Pound Challenge -- How a Focus on Driving Outcomes can Improve Health Faster and Better than Legislation

I commend the administration for shining the light on the need to improve health in America!  While I want to be optimistic about change, I’m skeptical about how much real improvement we will really see under the guise of healthcare reform.  Like I’ve noted before, the national conversation we are having -- which bill will pass, a public option or not, an abortion amendment or not, which party is winning -- is just the wrong conversation.  Imagine if we were to take all the TV time, print space, blogs, and so on, consumed by the political debate and use it to advance an audacious goal like improving the state of our health!  Imagine what we could accomplish with a big sustainable campaign across schools, employers, state governments and the media -- just imagine!

Today’s reality is that more than 75 percent of America’s healthcare costs stem from six chronic diseases. About 133 million Americans -- nearly one in two adults -- live with at least one chronic illness -- and the numbers are forecasted to grow unless we do something differently.  Realistically, the only way to maintain some fiscal responsibility under any reform scheme is to address the controllable elements of chronic diseases.

What if we were to focus on a couple of conditions like obesity and diabetes?  Two-thirds of American adults are obese or overweight, leading to chronic diseases like diabetes, heart disease and other conditions.  Currently, obesity alone costs the health system $147 billion a year! What’s more, obesity is one of the biggest risk factors for developing the six chronic diseases that drive the majority of direct and indirect costs to our system, including diabetes ($218 billion), cardiovascular disease and stroke ($437.5 billion).  Not to mention childhood obesity with equally alarming statistics (one in six children are obese), the most alarming of which is that children who are obese have a 70% chance of being obese as adults.  Yet, obesity is completely within our control to manage/prevent. 

According to CDC, the average American adult (age 20 and 74) is 5’6 ¾”, weighs 177.65 pounds and has a BMI of 28 (Note: an adult who has a BMI between 25 and 29.9 is considered overweight and an adult who has a BMI of 30 or higher is considered obese).  To achieve a BMI of 24, America needs to lose 29 pounds per person.  With the U.S. adult population at 205,639,360, that means 5,963,541,440 pounds…almost six billion pounds. 

If we were to collectively lose this weight, we would have a direct impact on obesity and as a result, diabetes and other conditions.  Healthier diet and exercise are things we can immediately start doing -- without legislation.  Not to sound trite, but losing weight can be the “quick fix” for our health problems and rising costs.  Obese individuals incur an 42% more in medical expenditures -- about $4,800 for per person per year -- compared with normal weight individuals, who incur an average of about $3,400 in such expenses.  And little things matter -- for example, walking half an hour a day, five days a week cuts the incidence of diabetes by 40%.  Think of the impact we could have on costs and the economy!

I know losing weight is hard work, but letting the growing waistlines of America continue unchecked will only doom us to continue the cycle of out-of-control healthcare spending.  While I’m not sure I agree with Japan’s approach to legalizing waistlines, it does seem to have an impact.  If we can send a man to the moon, create 200 different versions of yellow sticky notes and other wonders of the modern world, we can figure out how to lose a few billion pounds!

And it should all start with a public education campaign.  Even though this is fundamentally marketing, it does belong in the domain of government action.  It doesn’t take much to create a great ad campaign, viral marketing and so on.  Look at the popularity of shows like the Biggest Loser -- now there’s a whole line of products and services.  There have been a lot of one-off “celebrities” championing the cause of weight loss -- Mike Huckabee, Valerie Bertinelli, and others.  But these have been isolated.  Imagine if the government organized a group of great marketing companies -- Nike, Apple, Proctor and Gamble -- and got them together to create a campaign about obesity and health -- and involve popular sports heros or celebrities -- in a sustained way over a period of time.  I’d bet there’d be some impact.  Another great example of something that could easily and inexpensively be rolled out to schools nationally is the preventative childhood obesity program driven by the Columbus Research Foundation.  These folks thought deeply about how to influence middle school students, and developed a program focused on education around diet/nutrition and exercise -- including a virtual cross-country competitive walk (students used pedometers connected to the Internet via HealthVault to track their progress).  Ten middle schools were involved with nearly 1000 participants.   

Real reform in healthcare isn’t solely the responsibility of government.  It’s about individual responsibility and how we, as consumers, embrace our part of the current situation.  I hope that reform will include changes to the payment system to enable and reinforce changes in behavior and stimulate innovation, but we don’t need to rely only on legislation to make things better.   We can all individually start making better choices. 

I understand that neither 'health reform' nor legislation are easy.  As many have noted, whatever legislation passes will not include a 'silver bullet solution' to either goal 'bending the cost curve' or improving the value we get for our healthcare spend.  Simple things can make a difference.  By taking more responsibility for our own actions, we can impact the healthcare costs of our nation. 

New delivery models will solve the cost crisis

This week's question for the Washington Post Health Care Rx blog was:

Has Congress done enough to constrain long-term, health care spending growth? What cost containment strategies would you advocate pursuing?

My response, New delivery models will solve the cost crisis, below:

I was again reminded at last week's Partner's Connected Health Conference about how much potential there is for innovation in health - for industry transformation. The session titles speak for themselves:

• Wireless Tech and Patient Self-Management: Opportunities, Applications, and Barriers
• Get Your House Smart: Aging in Place, At Home, Aided by Technology
• The Emerging Use of Videogames for Health: Innovations, Impacts, and Issues
• Mobile Health: Leapfrog technology for the developing world?
• And the list goes on...

What this showed me is that there are many innovations starting to happen with promising implications for tomorrow's health care system. To get there, we need less focus on the costs of today's system, and more on enabling a new delivery model for the future. We, as consumers, manage the rest of our lives from our phones or our PCs - our finances, our travel, our shopping. When we want to make any purchase or investment, we have all kinds of services we can leverage to get informed and act. Every industry that touches our lives has been transformed - complex, expensive products and services once only available to few are now accessible and affordable to the masses and provided by those (people or even software) with far less training.

In health, if we continue to 'do it' the way we always have, costs will continue to skyrocket. Not to mention that our current delivery model simply won't be able to keep up with the advances in medicine - think about a world of personalized medicine (we're on the cusp of some amazing things). Today's delivery model just isn't set up to handle the amount of personalized data, decisions and so on.

We can see pointers to the future -- virtual care from American Well, new delivery channels such as Minute Clinic, patient self-serve at Kaiser-Permanente, personal health management platforms like HealthVault and Google Health. We're seeing an influx of investment into health start-ups focused on making treatments or healthcare information more cost-effective and accessible to patients. But we haven't yet seen widespread change or adoption.

Why? Congress has carved into stone our current system, but this traditional 'fee-for-service' model just isn't flexible and won't enable the kind of innovation required.

We need Congress to create a new framework that drives value, rewards experimentation and enables innovation. This is what will transform health and ultimately drive costs down.

Learning from Singapore and Switzerland

Personal Accountability

So this week’s question from the Washington Post RX Blog was:

The Senate Finance Committee passed a bill containing its version of the health-care overhaul. Are you satisfied with this bill? What does it miss?

My response is below.

There's a long road ahead for health-care reform -- five bills to be merged and countless hours of debate still to come. A lot could change over the course of the next few months, and the content of the final reform bill is likely to vary from any of these individual bills. The question we need to keep asking ourselves is whether reform will drive the kind of wholesale transformation needed for the industry and consumers -- the kind we've seen in banking, travel and other service industries. Ten years ago, we wouldn't have imagined that people would do so many things themselves. Technology and business model innovation enabled new types of services -- putting consumers in charge, dramatically changing engagement and economics. Imagine the possibilities for new services in health.

Taking this into account, what's needed is a new 'health delivery' framework that drives value, rewards experimentation, puts consumers in charge, and enables innovation--essentially changing the attitudes, beliefs, and behaviors of everyone involved in health delivery. We all have to be prepared to work together in different ways.

We have an opportunity now to move the traditional healthcare business model in a new direction:

• Shifting the value of healthcare from treating people when they are sick to finding ways to keep them well (allowing physicians to focus on and be accountable for outcomes vs. volume)

• Transferring the management of routine diagnosis and treatment from highly-skilled professionals to newer, more efficient/convenient, and cost-effective delivery methods like minute clinic, self-serve, nurse practitioners -- so doctors can focus on using their skills in the most effective way possible (allowing physicians, health systems, and 'new entrants' to be accountable for value and innovation)

• Encouraging consumers to make better lifestyle choices. We need to help them engage in their health differently, be wiser purchasers, and understand the trade-offs involved.

At the end of the day, the ultimate success of health-care reform will depend as much on how we will work together and change our behaviors as on the legislation ultimately passed by Congress and signed by President Obama. I applaud the administration for shining the light on health care as it has never been done before.

Reflecting on the healthcare system while waiting at the hospital for a loved one

Often when we talk about healthcare reform, it can be a rather abstract discussion -- you watch some tv show with ‘experts’ reflecting on some 20 page bill or hashing through the merits of a public insurance option.  Last week, however, all the intellectual and abstract ideas were brought into something very personal for me and my family.  

My wife had a Hysterectomy, and I spent three days at Swedish hospital in Seattle caring for her.  With all the waiting time, it was hard not to reflect on the experience and think about it in the context of health reform.  I’m happy to say that my wife is now recovering on schedule, and she’s given me permission to share the story and my insights. 

Once she had decided surgery was her best option, we became even more avid information seekers; we shopped for the procedure with the best outcomes and then the surgeon with the most experience and best quality results for this procedure.  The best available counsel we found was for a Robot-Assisted Hysterectomy because there was less risk, less pain and faster recovery times vs. the alternatives.   We didn’t have to shop for ‘price’ (thanks to Microsoft’s benefit plan, but that is a different future post)…but even if that were the case, we probably would have chosen a more ‘expensive’ option if it meant less risk and more productive days -- getting back to normal life as quickly as possible. 

We all know that surgery can be pretty scary.   Throughout the experience, everyone from the doctor’s office to the staff at Swedish helped to make the experience a positive one, allaying any fears and making us feel comfortable and confident.  We often forget that healthcare is truly a people business.  In just three days – the number of different people we dealt with was amazing -- five docs, seven nurses plus the ancillary folks (lab techs, transport and other helpers).  They all took time to connect with our emotions while doing their jobs.  

Swedish is leveraging technology to improve their systems.  You see it throughout the organization, starting in the lobby, with signs advertising the hospital’s new EMR system.  During the course of our stay, when there was time I asked various staff members about their experience with the new EMR, and they were positive about the system because they had all the information in one place.  While a common complaint was that the data entry took them more time, they felt overall it made them more productive and effective.

This highlights that we need to remember that technology is a means to an end.  It is NOT the introduction of technology that will make a difference, but rather how leadership leverages the right technology to make a difference…in both quality results and economic outcomes. 

I also saw a real focus on patient safety, starting with the pre-op processes.  Each member of the care team carefully checked her arm band, her chart and asked several specific questions to be sure she was getting the right action.  For us, the repetition became frustrating, but if this process were to improve patient safety, then it would be  worth it.  Despite the technology investments, the core safety process was in the human factors.

After the surgery was completed, she spent two days recovering in the hospital.  This was a day longer than originally planned due to very low blood pressure and a declining hematocrit.  While I used the guest Wi-Fi for work and email, it was even more critical for answering key questions about her condition, the trade-offs, the next steps – which helped me to get some context and understanding to a) engage more thoughtfully with the care team about questions/choices and b) assure my wife about what was going on during the long time periods when neither doctor or nurse was around.  I think hospitals should consider leveraging their video and wireless infrastructure more effectively for patient specific education and connecting with their care teams.  This is potentially a big opportunity for improved patient compliance and care team coordination.

Because the low blood pressure persisted, I called her primary care physician to get her baseline BP.  If we had stored this information in HealthVault, I wouldn’t have had to make the call – I would have just been able to look it up.  Furthermore, I would have preferred to have gotten her discharge information automatically transferred to HealthVault.  We were given paper copies.  This should be easier.     

So, what’s the moral of this story? 

·         We can’t lose sight of innovation and there’s a risk that could happen if the government were to become the primary funder of health. 

·         Technology is a means to an end, but we have a long way to go to figure out how to use it smartly.

·         We can’t lose sight of how important the personal aspect of healthcare is.  The emotional support and human caring delivered by the care team was the critical component of our overall satisfaction. 

This experience reinforced for me that a ‘healthy’ health ecosystem requires consumer choice -- it is a critical component to the effective functioning of markets and innovation.  We made the decision to ‘save time/hassle’ vs. saving dollars as we do in other aspects of our lives.  This really drove home for me that the debate about ‘rising health care costs’ doesn’t really account for improved patient outcomes in terms of fewer lost days of work/productive living.  I am all for comparative effectiveness of various options and knowing what things cost, but it needs to include patient values -- like less pain and getting back to normal faster -- or it may lead to bad unintended consequences.  I am more concerned than ever that increased government financing of health will ultimately lead to fewer consumer choices and will stifle future innovation with tangible economic benefits.

I haven’t received the multiple confusing bills and outrageous line items of detail from the hospital stay yet.  Nonetheless, when it comes to getting a quality outcome from an advanced surgical procedure, I prefer the current U.S. health system with all its flaws to the alternative future of less consumer choice and innovation.

Empowering Consumers

In the Health Reform Recipe, the Missing Ingredient Is the Consumer

So this week’s question from the Washington Post RX Blog was:

What's Your Take On Obama's Speech?  What did you think of President Barack Obama's Sept. 9 speech to a joint session of Congress? Was it effective? Did it "move the needle?"

My response is below.

I applaud the administration for shining a bright light on health reform. The government -- as buyer, regulator and leader -- must be a part of any solution. The political calculus has created a real sense of urgency to do something about this complex system which touches everyone and accounts for one sixth of our economy. The consequence however, through a lack of transparency and understanding, has reduced the public dialogue to be between "public insurance options" vs. "death panels." Framing the debate this way and consuming available public attention on "wedge" issues won't lead to a sustainable future system.

My attendance at an Institute of Medicine workshop this week in the midst of the buzz about the speech served as a stark reminder about the depth and breadth of the hard problems:

• Access (too many uninsured)
• Costs (growing faster than inflation)
• Demographics (aging populations driving up systemic costs)
• Quality (not enough -- as measured by comparative outcomes, disparity in care geographically)
• Worsening health (people dying because of a lack of focus on improving the care delivery process).

I was struck by the number of smart, passionate people representing the major stakeholders working together to drive change. Veterans of the process recognize that change is imperative but hard -- because the details matter. We are in this predicament because incentives, tax policies, government reimbursement schemes and increasing specialization and capability of medicine have led us here.

The president delivered an inspirational speech, laying out basic principles: everyone should have access, nobody with insurance will have to change it and cost growth must be slowed. Voters know there is no free lunch, and health is no different.

We can't achieve reform without educating the public. A sustainable system is not as simple as providing more access. Consumers are ultimately responsible for their health and their daily choices cost the system. We need to help them engage in their health differently, be wiser purchasers, and understand trade-offs. As long as they believe the price of care is their co-pay and continue to engage as they have, there won't be sustainable reform.

There are best practices at organizations like Geisinger that have re-invented care delivery and consumer engagement models. These leaders will tell you that success is about aligning incentives, understanding the details and making trade-offs.

The difficult work of figuring out the details and making hard choices is still ahead.

Three Simple Truths

So this week’s question from the Washington Post RX Blog was:

Recent polls show declining support for President Obama's handling of the health-care issue. What should he do to get the effort back on track?

My response is below.

Individuals and Personal Responsibility May Be the Tipping Point in Health Reform

Lessons from Medicare and Medicaid

So this week’s question from the Washington Post RX Blog was:

Do you think that a government-sponsored health insurance option is needed to help control rising costs and "keep insurers honest," as President Obama says?

My response is now live:  Lessons from Medicare and Medicaid.

My main points:

·         How will another government-managed option be better at building a health system that works for the 21st Century than the one we already have (Medicare and Medicaid)?

·         While these programs began with admiral goals and are politically popular, in reality, over the past 40 years, they have done little to control costs or drive innovation.

·         What's needed is a new framework to drive innovation, better value, improved outcomes and increased access.

Please feel free to comment with your own thoughts on the public option. 

Health Care Needs New Rules to Enable Innovation and Reward Experimentation

(cross-posted on Microsoft on the Issues)

Technology is playing a major role in helping bring healthcare into the 21^st century.  Many of us have seen it first hand in treatment from our doctors, from MRI scans to laser surgery.  

But these clinical advancements represent only a small piece of what technology can do to transform health care.  The power of technology lies in the potential to transform the rest of the health care system, enabling new ways of working and communicating, new economics and new business models.  As consumers, we’ve experienced how technology impacts nearly every other area of our lives -- how we manage our financials, travel, communicate, shop and so on -- with more self-service, more control, more convenience and ultimately better value for what we spend.

Similar business innovation and consumer engagement has been slow to reach health care, where many physicians still opt for a pen-and-paper over a computer to maintain patient histories and chronicle treatments.  Patients continue to navigate frustrating and hard-to-understand medical and insurance organizations, physicians don’t always talk to one another about care and medical errors, waste and duplication drain the system of resources.

Today, we are finally seeing the first signs of systemic change in health care.  This change was clearly highlighted with the President’s recent visit to the Cleveland Clinic, which has leveraged technology to improve efficiency and health outcomes and give patients an active role in their health decisions.  But the Cleveland Clinic is just one example.  There are other health care institutions -- the Marshfield Clinic, Kaiser Permanente, the Mayo Clinic -- whose leaders have embraced technology to improve efficiency and quality while reducing costs.  And newer players are showcasing the possibilities brought by innovation, including virtual care from American Well and new delivery channels like Minute Clinic. 

But we haven’t yet seen widespread change.  The rules governing health care simply haven't allowed this to happen.  Congress created rules that have in fact stifled innovation (e.g. Medicare) by reinforcing volume over value -- reimbursing on a per-procedure basis rather than on the number of patients who remain healthy year over year.  Now Congress needs to look to the organizations that have used technology to create a new health care reality -- such as the Cleveland Clinic -- and develop a new framework that drives value, rewards experimentation and enables innovation.  Only then will we realize the policy goals of increasing access to health care while maintaining fiscal responsibility.

Reform efforts should focus on enabling the kind of transformation that Clay Christenson describes in his book "The Innovator's Prescription".  He describes how almost every other industry has been transformed -- complex, expensive products and services once only affordable to the wealthy have become accessible to the "masses" and provided by those with far less training.

As I described in my post this week on the Washington Post’s  Health Care Rx blog, real change requires:

• Figuring out what works (and what doesn't)
• Enabling supply-side innovation
• Letting consumers do some of the work that expensive health-care professionals shouldn't be doing anymore

With our ailing economy and worsening health, it’s imperative Congress act quickly and tear down the barriers that exist to enabling innovation.

A New Place for Health Care Policy Debate

About a month or so ago, the Washington Post launched their new Health Care Rx blog, and I was asked to participate as a panelist.  Every Monday, questions are sent out, and a variety of “experts” from across the health care industry respond.  It provides a great snapshot of the many different perspectives that exist.   

This week’s question:

The Blue Dog Coalition worries the health bill in the House does not address fundamental cost drivers in the system. Is it possible to rein in costs in the current system? How?

My response is now live:  It's Not About Costs, It's About Enabling Transformation

My main points -- real change requires:

• Figuring out what works (and what doesn't)
• Enabling supply-side innovation
• Letting consumers do some of the work that expensive health-care professionals shouldn't be doing anymore

To read the full post, click here. Please feel free to comment with your own thoughts on how to rein in costs in the current health care system.

And you can see my responses to previous questions:

Who Pays for Whose Heath Care?  [Posted July 14]

The political debate is often framed around covering the uninsured. At the heart of this is the supposition that health care is a moral obligation -- that everyone has a "right" to it. But it's difficult to separate the moral from the economic because there is no other "liberty" that requires payment.

 

Defusing the Health Care Bomb  [Posted June 16]

The "big red wire" that needs to be clipped first is the fee-for-service payment system driven by the government today through Medicare reimbursement decisions. Until that's addressed, the ticking bomb won't be stopped.

 

Diagnosing and Treating the Health Non-System  [Posted June 7]

We do not currently have a health system at all: it is a health non-system.

Another milestone on the journey forward…

Over three years ago, we started on a journey -- to empower consumers with tools to help make better health decisions and drive better health outcomes.  We believed that the simplest, easiest way to start was to give consumers their data in a secure and private way, and allow them to share it from provider to provider, keep it in one place over time, and learn about it in order to make better daily health decisions.  That simple idea was the beginning of HealthVault. 

Back then, there were a lot of objections.  Consumers don’t want their data.  Consumers can’t understand their data.  Their data might actually do them harm…blah…blah…blah…

But fortunately, things have shifted.  Consumers have made it pretty clear that they want to be involved in their health – as evidenced by looking at social networking sites like PatientsLikeMe, the raw numbers of health Internet Searches, or research reports like The American Public on Health Care:  The Missing Perspective, released by the CEG, Accenture and IOM:

·       78% of American favor giving doctors the ability to share access to their medical records if done with their permission.

·       66% said that they see the value in including their own information anonymously in a large database to help researchers.

And I’m happy to say for a number of reasons that consumer products like HealthVault and GoogleHealth continue to gain market traction. 

Today marks another milestone – the first Industry-wide initiative to establish a “Declaration of Health Data rights” to support patients’ rights to access and share their own health information – https://healthdatarights.org will go live tonight, along with blog posts and endorsements from thought leaders and organizations across the country.

While we’re making change, and it's great to see so many organizations and thought leaders coming together, it’s important that we not stop here…that we continue to move forward—specifically by ensuring that consumer access to their data is included in the definition of “meaningful use.”  While I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system -- we will not be successful without further refinements.  Consumers cannot just be given access to data in static form, but must be provided with an electronic copy of their data so they can easily share it, use it, add to it -- creating a lifelong health data asset.  In the end, consumers are the ones accountable for their own health.

The willingness to succeed is only exceeded by the willingness to prepare

After many long months of discussion and debate, the first draft of Meaningful Use has come out.  I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system. 

It’s important that we keep this in mind -- that we’re not just trying to implement technology.  We’re trying to improve the performance of the health system.   And our willingness to succeed should only be exceeded by our willingness to prepare, and as part of that preparation, we must ensure that flexibility, scalability, and interoperability are inherent traits in the system.  Why?  Because, health is fundamentally data-driven.  Nobody -- physicians, consumers, hospitals, insurance companies, governments -- can make good decisions without good data.  

So driving data liquidity -- that is the ability for data to flow throughout the system -- has to be the critical focus.  For years, we’ve been building systems in a “top-down” way to reach information, but what we need to do is build from the information up.  One thing Carol Diamond said at a Health Affairs event that I attended with her really struck me -- the idea of bringing the question to the data -- leaving  the data where it is and bringing the question/problem/issue to it.  For a long time, what we did as an industry was use expensive research grants and complex tools to cull and compile data that was intended to answer one specific question, and by the time we’d sorted through the data enough to answer that question,  it was either out of date or ten other, more pressing questions had popped up in the meantime.  What we need is a system that unlocks all of the data that exists already in the health care sphere, and allows it to flow between silos so that when questions arise, we can bring those questions to the data for quick, evidence based answers -- rather than the other way around. 

Given this, as discussions/refinements continue around meaningful use, I believe it’s critical for the following to be a part of the final definition: 

·         We can’t just capture data, it must be available in “real-time” in order make the right decisions and improve outcomes -- whether we’re talking about patients or populations.

·         We have to enable data to become liquid -- specifically, doing this by separating data from applications.  This is one of the recommendations from a study by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes.  Let the excuse not be that the data is trapped in systems that we built, that we have to wait for standards. 

·         We’ve got to give consumers access to their data -- not just in static form -- but empower them with an electronic copy so they can easily share it, use it, add to it–creating a lifelong health data asset. 

·         We should accelerate the objective of having PHR access to EHR data to the 2011 Objectives and Measures.  There is no need to wait until 2015.  These technologies are available today and will bring real, sustainable benefits, not just for consumers, but for the overall health care system. 

·         We must ensure that we do not have an overly-prescriptive certification regime that focuses on certifying features and functions every-other-year.  This will produce the unintended consequence of stifling innovation.  Software vendors will be forced to develop towards a certified feature list rather than look for new and better ways to improve clinical processes and health outcomes,

The foundation of success is based upon data liquidity, and so it must be central to our thinking as we prepare for the future.