Doctors and Technology: Working Together to Improve Value

A recent article and accompanying editorial from the Annals of Internal Medicine covered the topic of value and cost in healthcare. It was an interesting read because unlike most of the policy/pundits’ takes on the issue, it revolved around the physician’s role in addressing the challenge of high costs. As clinicians are at the point of care, the article specifically focused on the decision to order screenings and diagnostic tests.

There is a distinction between cost and value in medicine. High costs are not necessarily ‘bad,’ so long as they provide appropriate amount of benefit for the amount spent (think of it as a high ROI). This is the definition of value. In the article, the authors identified 37 procedures selected by a physician workgroup which “clinicians often use in a manner that does not reflect high-value, cost conscious care and does not adhere to currently available clinical guidelines.” In a phrase, evidence-based medicine (or depending on the political cycle, the death panel.)

Assume for a second that X is the number of tests ordered by a physician today, and Y are the number of those tests that are unnecessary. Where we ought to be heading then, is to maximize the value of “Y.” There are two parts to this: Physician behavior change, and system improvements.

• Physician Behavior Change: The article outlines three driving principles surrounding improving judgment related to ordering imaging or other diagnostic tests: Don’t test if the result won’t change patients’ outcomes. Don’t test if there’s low probability of a disease, because you raise the risk of a false-positive diagnosis. Don’t consider just the cost of the immediate procedure, but also the downstream associated costs. To some extent, these three principles all hinge on the availability of dependable, rigorously tested guidelines that physicians actually trust.
• System Improvements: But even if we ask doctors to get it right every single time, it won’t be enough to optimize the X-Y value equation. The editorial had an important point that doctors may sometimes order exams just because it’s easier than tracking down the old test. It’s important to see this as an area ripe for a health IT intervention. For example, a Humana study with the Wisconsin Health Information Exchange showed that ED Patients whose data was referenced on the HIE cost $29 less on average than their control counterparts. The savings came nearly entirely from reduced imaging and diagnostic costs.

Healthcare is one of the most complicated fields there is, and part of that is because of the miasma of stakeholders: Doctors, Nurses, patients, family members, administrators, vendors, payers, policymakers, just to name categories. With a huge problem like ballooning healthcare costs, it will truly take a village to work together. Overuse of imaging is a clear opportunity area: One CBO study has estimated that up to 5% of our nation’s GDP is wasted on redundant testing in healthcare. Identifying a specific problem like this, and then figuring out how to dovetail advancements in medical efficiency and evidence-based medicine with the promise of new but proven technology will be the path forward to lowering avoidable costs in our healthcare system without compromising the quality of care and level of patient safety.

Can We Really Buy Savings in Healthcare?

High Tech = High Costs

As everyone knows, health care costs are going up, and our health care system has been scrambling for quite some time to discover new ways to manage care so as to cut down spending growth. One approach to this is called “Disease Management” (DM) – in a nutshell, it’s focusing intensive efforts on the sickest of patients driving the majority of the costs (the old Pareto principle), while using things like self-management and evidence-based medicine guidelines to keep the unhealthy-but-not-ill patients running on autopilot. There’s been a lot of pooh-poohing about whether these programs actually save money – and for the most part studies haven’t come to any meaningful consensus. I bring all of this up because I read a nice post about whether DM’s value should be tied to saving money, or if in the context of the broader health care industry, better outcomes are enough to justify their existence:

 “Few health care interventions have been shown to save money, yet no rational person would suggest, for example, an office visit with a physician is “not successful” or bypass surgery is “not successful.” A more responsible measure of success might be whether the intervention creates value – in other words, whether you get your money’s worth. It’s the same yardstick we hold up to most other transactions, from a grocery store purchase to a new home. In that light, the evidence is clear that the right disease management intervention for the right population at the right time improves clinical outcomes (and, despite what disease management’s pallbearers would have you believe, can save money).”

While we cannot escape spending money to care for sick  people, it is disingenuous of these “specialized” companies (DM Vendors) to tout their offerings as cost-controlling when they’re not. Particularly when the prices they charge/program implementation costs are partially responsible for sabotaging the ROI. As a recent memo by the Congressional Budget Office points out (emphasis added):

“The evaluations show that most programs have not reduced Medicare spending: In nearly every program involving disease management and care coordination, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program, when the fees paid to the participating organizations were considered.”

This seems obvious – vendors, whether they’re hawking care coordination platforms for diabetic patients, electronic medical records, or other complex offerings, are just looking for that contract. Blaming them for high costs in healthcare however, would be like blaming a tiger for eating a kid who fell into it’s cage: That’s just the way the world works. Beyond profit-oriented stakeholders though, I took a step back to think about the true value equation of technology after reading about Blue Cross Blue Shield of Rhode Island, who recently retracted a claim that their EHR implementation saved them 17-33%. (Turns out their ROI calculation wasn’t risk adjusted. SMH). The ability of technology to introduce ‘efficiencies’ and ‘save costs’ is a given these days, but there’s so little data out there actually proving this to be true that it’s scary.

It’s due to a whole host of drivers, not the least of which is a national $30+B investment by the Federal government. There’s more than that at play however. I read one of the most scathing and depressingly accurate cross-section of the Health IT industry, written by a Drexel professor. It devolves into flat out ranting at times, and like most purely academic perspectives conveniently omits a path towards achieving congruence between different stakeholders’ interests, but at least it’s comprehensive and accurate.

“Never before has such a complex, costly, interdependent and culturally sensitive science and profession come under so much pressure by outsiders to adopt a technology based on major assumptions and perhaps blind faith regarding cost/benefit ratio, advancements in medical practice, and other “silver bullet” factors that are largely unproven and may or may not be true.”

I’m definitely an enthusiastic proponent of Health IT (the above professor would probably peg me somewhere between a Pollyanna and a Pundit)  – but this was a little bit of a reality check that the buzzwords you hear thrown around in this industry – words like “quality” and “value” are not simply things you can purchase. They take hard work, commitment, and strong leadership. And money.

Doctors and Patience: Thoughts on mHealth

An App a day?

Mobile Health, or mHealth, refers to an emerging set of tools and solutions that help people manage their own health through use of the web, smartphones or other tech devices. Things like fitness trackers, doctor reference tools, apps to find, schedule and pay for care, and plenty of other ideas all fall into this space. Forecasts and figures for mHealth are portentous. Most pundits point to investment in this area by health insurers as a magical turning point, and while it’s easy to be a skeptic, all signs are pointing forward that this is starting to happen. For example, United Healthcare, America’s biggest insurer, recently shelled out some money to buy up Fitbit, a market leader in user-friendly biometric trackers, and some other mobile health groups. I spoke with an old colleague two weeks ago who informed me that HealthPartners’ revolutionary Virtuwell platform has preliminarily been approved for Medicare payment. This is huge, both for HealthPartners and the future of reimbursement  – The fact that our own clunky, anachronistic CMS has decided to reimburse for clicking through an online questionnaire is tantamount to jumping into hyperdrive.

If you’re wondering what the big deal is, you’re not alone. Lots of people tend to dismiss these ideas as gimmicky. This pooh-poohing of the promise of technology in healthcare is two-fold: One, we all know that things like an e-pedometer or sleep tracker or run-tracker or other biometric devices are like the Christmas gifts you play with for a few weeks and then forget about. The idea that their potential will take root and drive behavior change seems overblown. Moreover, the people who will use them are probably gym rats and other quantified-self nuts who aren’t really that unhealthy, or at least not representative of an “average” patient. This relates to the second, more pessimistic dismissal: When you’re talking about the transformation of actual healthcare – for example, managing a chronic condition, if people could have taken care of themselves they would have done so already, and throwing technology at the problem is not going to make it go away.

As far as the first one, I am somewhat of a realist, and I know that giving a fat guy a phone app does not a fitter person make. But I do think that it can’t hurt much and it’s worth a try (and given the slew of investments in 2011, it does seem like we’re giving it a shot…) Increasingly, mHealth developers are thinking of mobile health apps not as one-off toys, but as components of the way that doctors will work with their patients. A friend has launched a company called “PrescribableApps” for example, centered on this exact premise for mental health. So, hopefully some of it sticks and the patients of tomorrow will use technology the same way we do today with our banking, fantasy football or calendars.

The second objection I have a bigger problem with.  To say that the patients who can’t manage their health now won’t be able to manage their health digitally is doing those individuals a disservice.  For example, people tend to gloss over how difficult it actually is to manage diabetes. Type 2 patients have gotten a bad rap as being lazy, old, fat and apathetic: Not fair at all.  Can you imagine managing your blood pressure, glucose, cholesterol and triglyceride levels, while taking several pills several times a day? And doing that every single day, just to maintain your baseline level of healthiness? While I’m not a doctor, I still feel a sense of responsibility in being a part of healthcare – the whole point of this field is to help people; dismissing them as inept and incapable of getting better is at best a cop-out, and at worst, mean-spirited. One of the fast growing areas of research is what actually works when it comes to patient self-management – let’s use those findings to move forward. As we become more and more plugged in and use our phones for everything, why dismiss it when it comes to healthcare?

To be sure, there are plenty of good folks out there, doing great things. Moreover the industry trends of quality improvement, value based payment, patient-centeredness and focus on chronic disease management make spillover into the mobile space inevitable. As mHealth tools are poised to jump from the world of consumers to the world of patients though, the biggest variable in their success probably isn’t whether insurance companies will pay for their use. I think it will be up to the physician community. mHealth is fundamentally about breaking down the barriers that come between a patient and the management of her health. Certainly we can agree that some of those barriers are a result of an ossified medical system where the experts tell you what to do, when to do it and how much to pay them – and if it doesn’t get better than you’re the one who’s probably screwing something up. Re-framing healthcare in a more patient-centered framework (please watch this video, then shake your head with me at Dr. Berwick’s departure from CMS) is one of the driving forces behind mHealth and Health IT. Obviously, getting doctors behind this will be a huge boost.

Where do doctors stand now? All signs are pointing in the right direction. 2012 will be a year of social media adoption among providers – the buzz is growing every day. A friend in medical school posted this topic on facebook over the weekend as the subject of one of his papers. Another recent acquaintance just launched a new project examining the physician leaders in social media. Though, as it stands today connecting the dots between social media and mHealth is done with a dashed-line, the premise seems plausible to me:  As doctors become comfortable interacting with their patients outside of the exam room, then they’ll become more amenable to the idea that they can work with them outside of the exam room as well.

Like most technology trends then, the question of mHealth’s role in improving healthcare in our country has moved past “if” to “when.” Looking around at what’s going on in business, media, technology, policy and medicine, the answer seems to be moving from “soon” to “now.”