Focusing clinical collaboration on prevention
“It’s not enough to pull drowning victims out of the river. You have to walk upstream to find out who’s throwing them in.”
Physician and educator David Kilgore invoked that piece of wisdom from Episcopal bishop V. Gene Robinson to describe the current state of medicine in the United States — and the steps needed to drag the nation’s outmoded, costly and inefficient healthcare system into the 21st century. For doctors and other health providers, Kilgore noted in a panel discussion at the New York Times’ “Health for Tomorrow” conference, “walking upstream” means changing the focus of care from treating serious health complications after they occur to preventing them in the first place whenever possible.
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“We’re still stuck in the model from the first transformation of medicine, which did a great job with infectious disease, acute illness and injuries. But it’s not an effective model for chronic disease,” said Kilgore, clinical professor of family medicine at the University of California School of Medicine. “The river is full of drowning people, and we’re going to need a lot more than drugs or devices to usher in the second transformation of medicine.”
That transformation, he said, “has to … focus on prevention, health and wellness.”
“We have more than two decades of research that clearly shows what keeps us healthy and what prevents chronic disease,” Kilgore said in a group presentation on the future of the doctor-patient relationship. “It’s the four foundational pillars of health: healthy diet and nutrition; exercise and activity; [attention to] mind/body [living conditions], including social support; and healthful sleep.”
Those factors, along with “toxin avoidance,” Kilgore said, are critical to long-term wellness. “These are powerful interventions that keep us alive longer, that help us have less disability and suffering for a lower-cost, greater-quality of life and less side effects. So the challenge for us as a profession and a society is how to move that second transformation … into [community outpatient settings like] clinics, so that the primary care physician, instead of rushing from room to room … is replaced by a new kind of healthcare team that surrounds and is part of that physician’s practice.”
That collaborative team of professionals, including nurses, pharmacists, clinic staff and nutritionists, Kilgore said, “then helps patients develop healthy lifestyle skills, self-management skills and self-efficacy.”
Driving the acute need for fundamental transformation in healthcare delivery, he added, is the fact that “in just the last 20 years, there’s just been an explosion of chronic disease. The incidence of diabetes has more than tripled. Sixty-eight percent of U.S. adults are now overweight or obese.”
“It’s a tsunami of diabetes and chronic disease,” Kilgore said. “And it’s completely changed what it means to be a family physician on the front lines. It very much seems like a ‘sick care’ system.”
Indeed, Kilgore said, “out of the $2.7 trillion [U.S. healthcare] budget, just 5% is spent on prevention and public health. We need to think about moving the whole enterprise upstream, targeting people even before they have that chronic disease. That means bringing tools for health and wellness to the workplace … to schools, to community centers. It’s really incumbent on us to make sure patients have the tools they need for a healthy lifestyle.”
Other panelists agreed. “Despite lifestyle behaviors being primary contributors to most chronic diseases — which according to the CDC, are consuming at least 70% of our healthcare dollars — we don’t have a practice model that leads to achievable or sustainable behavior change,” said Karen Lawson, a physician who directs health coaching at the Center for Spirituality and Healing.
“I think there’s a missing provider … who partners in a relationship-centered, client-driven process to facilitate and empower patients to achieve the health beliefs and behavior changes that they want,” Lawson said. “We call that person a health coach … who applies their knowledge and skills to assist clients to mobilize their own internal strengths, to access their best external resources and to make the changes they want to make to optimize their well-being.”
As care shifts to community wellness, costs will ease, hospital leader predicts
Pharmacists aren’t the only professionals grappling with the uncertainties of health reform, shifting patient-care delivery models and changing reimbursement standards. Doctors also are trying to redefine their health mission, patient relationships and practice priorities, said Toby Cosgrove, M.D., the top executive at Cleveland Clinic, one of the nation’s premier healthcare organizations.
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A decade from now, the U.S. healthcare system “is going to be very different,” said Cosgrove, president and CEO of Cleveland Clinic.
“I think … we’re dealing with probably the biggest social change going on in the United States since the New Deal,” Cosgrove said in a presentation on the future of health care at the “Health for Tomorrow” summit. “It affects 100% of the people and 18% of the GDP. And it’s changing a business that’s gone from B-to-B to B-to-C. So there’s going to be enormous change, and as a profession and an industry, we’re having slow adoption of this, and difficulty moving through it.”
Hampering the medical profession’s embrace of change, Cosgrove said, is the disruption that comes with it. “When we got into medical school, our career was pretty much fixed. Now, it’s very different. We don’t know what we’re going to get paid, what we’re going to get paid for or where we’re going to practice,” he said. “And we don’t know what kind of medicine we’re going to be practicing.”
“We’re going through a very interesting period,” Cosgrove said. “It’s a tough transition.”
Even well before the onset of the Affordable Care Act and health reform, mounting cost concerns were driving big changes in U.S. healthcare delivery, he said. “Twenty years ago, there were a million hospital beds in the United States. Now there are 800,000, and it’s 65% occupancy,” Cosgrove said. “You’re going to see a consolidation, a closure of hospitals and a reduction in hospital beds as more and more things move out of the hospital.”
Where have those patients gone? For one thing, they’re shifting to outpatient care sites like clinics and pharmacies staffed by clinically oriented pharmacists who can deal with patients with chronic conditions. They’re also being transferred out of the hospital and into the community care setting and their own homes much more quickly following most surgeries, Cosgrove said. Nowadays, “people don’t get hospitalized for chronic disease until they reach desperate straits; that’s taken care of by outpatient [settings].”
What’s more, he added, many surgeries like knee reconstruction, mastectomies and thyroidectomies are now being done on almost an outpatient basis, involving just one- or two-night stays.
“That is going to decrease demand for hospitals,” he said.
Cosgrove was joined onstage by physician and New York Times senior writer Elisabeth Rosenthal, who posed a question that was never far from the surface at the daylong summit. Given that drop in demand, she asked Cosgrove, “as we close hospitals and move patients to an outpatient setting, why aren’t there more cost savings?”
One big reason, Cosgrove said, is cost shifting. As health systems lowered prices on procedures within their hospitals to compete more effectively for insurer reimbursements, they raised prices for outpatient care. “The costs just got moved from one place to another,” he said.
Cosgrove offered some solutions to this ever-rising cost spiral. “We recognize we have too costly a healthcare delivery system. There are only two ways we can take costs out of it. One is by having a more efficient delivery system. And the second is by having less disease … if we kept people healthy.”
To that end, Cleveland Clinic adopted a sweeping set of initiatives aimed at making its own 43,000 employees healthier. “We started by taking steps to try to prevent disease,” he said, by addressing “smoking, lack of exercise and obesity or food intake.”
The health system, which is Cleveland’s largest employer, began by adopting a no-smoking policy on its own campuses, and by offering free smoking-cessation programs and nicotine patches not only to its own employees, but also to all residents of Cuyahoga County. “Then we took a bold step; we said we’re not going to hire smokers anymore.”
In addition, Cleveland Clinic pushed the Ohio Board of Regents to ban smoking from all public universities in the state. The result was a reduction in smoking in Cuyahoga County over a five-year period, from 27% of residents to 15%. “And the incidence of smoking among employees of Cleveland Clinic is [now] 6%,” Cosgrove said.
The clinic also overhauled the menus in its own cafeterias, removing unhealthy offerings and even candy machines. It also began offering all employees free access to its on-campus fitness centers, as well as free pedometers and weight-reduction programs. “Over the last five years, we’ve [collectively] lost 450,000 lbs.,” Cosgrove said.
The clinic also began providing its employees with financial incentives to enter into disease management programs for such conditions as diabetes, hypertension, smoking, obesity and asthma.
“We saw a reduction in hospitalizations [for some of those conditions] of 20%,” Cosgrove said.
Another challenge to capping health costs and improving Americans’ health, however, is the lack of continuity in insurance coverage and care. As patients move around and frequently switch insurance plans, “no one [is] investing in [patients’] long-term disease state,” Rosenthal said.
Dealing effectively with that challenge, Cosgrove said, “is a societal issue” that “is going require educators, physicians, universities, government, food producers, food servers — all beginning to realize that it’s in their best interest to deal with this issue. It’s going to take a big national discussion.”
He predicted that the health system would undergo “the disintermediation of hospitals,” adding, “I think you’re going to see lab tests going to Walmart or Walgreens and radiology leaving the hospital. It’s going to be like a department store, and that will increase the efficiency and decrease the costs.” And price, he said, will drive many choices in sites of care.
Health care, in short, is evolving into “a consumer-driven organization … with transparency around costs” that’s driving a more competitive and efficient health system, Cosgrove said.
Defending health reform: Experts assess ACA
Despite a rocky start, the full rollout of health reform under the Affordable Care Act has already brought major benefits to the nation’s troubled health system and affordable coverage to millions of formerly uninsured or underinsured Americans, one of the Obama administration’s top health officials asserted recently.
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Marilyn Tavenner, administrator of the U.S. Centers for Medicare and Medicaid Services, strongly defended the controversial health reform law in a panel discussion at the New York Times “Health for Tomorrow” conference. She was joined onstage by John Bertko, chief actuary and director of research for Covered California, the Golden State’s health insurance exchange, and by Elisabeth Rosenthal, M.D., correspondent and senior writer for the New York Times.
“It’s been a tough year of implementation, but a great success,” Tavenner said in a presentation on the progress of the ACA rollout and the impact of health reform. “More than 8 million people are now covered in the health insurance exchanges, and a little more than half the United States has expanded Medicaid coverage [state by state].”
Bertko predicted a big jump in the number of new enrollees over the next two to three years, from 8 million to roughly 20 million, along with “a smaller number of people buying the same health plans … separately, without the exchanges.”
“The goal now is to make those plans much more efficient,” he said.
According to Tavenner, the reimbursement and coverage changes mandated by the health reform law are beginning to yield larger health and cost-saving benefits as public and private health plans begin to shift the focus of coverage from standard fee-for-service payments to prevention and the avoidance of hospitalizations. “A lot of the ACA removes co-pays and deductibles around preventive care because part of our mission is to [encourage] folks to have early care in an outpatient setting,” said the CMS chief. “And that’s what we’re seeing. Early indications are it’s tracking as we thought.”
Whatever the pace of those changes in health delivery, they can’t come fast enough, asserted Karen Ignagni, president and CEO of the insurance industry trade group America’s Health Insurance Plans, or AHIP. “On the cost issue … we’re getting to the point where the chickens are coming home to roost, and to keep people in the healthcare system, you have to talk about the issue of affordability … and sustainability,” she said in a separate panel discussion at the conference on the impact of the Affordable Care Act and the economics of health reform.
Out-of-pocket costs, Ignagni said, are “the kitchen-table test of healthcare reform” that many lower- and middle-income families are grappling with as they try to balance higher insurance deductibles and lower monthly premiums in the plans available either through the health insurance exchanges or via employers or the private health plan marketplace.
“All research suggests there are families very focused on out-of-pocket healthcare costs … as they face a range of choices,” Ignagni said. “We need a better support system in terms of what works.”
Will Obamacare help improve that system? “It will certainly help prevent bankruptcies and help patients with pre-existing conditions, but it still involves considerable outlays for patients who can’t afford it,” Rosenthal said in a separate presentation. “We still have to figure out a way to get those initial price tags down.”
Rosenthal ticked off some dramatic comparisons to underscore the rise in healthcare costs in the United States. “In 2012, childhood vaccines averaged more than $1,700 to immunize a child against childhood diseases to the age of 18, versus about $70 in 1990,” she said. “The cost of our hospital stay is many, many times what it is in other countries. And we don’t get better results for that.”
According to research published by the New York Times, a day’s stay in a hospital averages more than $4,200 in the United States, and can range as high as $12,500, Rosenthal said. That compares with an average of less than $1,500 in Australia, $853 in France, $731 in the Netherlands, $476 in Spain and $429 in Argentina.
Bending the healthcare cost curve nationally won’t be easy. There’s no simple fix, said Mark Pauly, Bendheim professor of healthcare management at the Wharton School of the University of Pennsylvania, who joined Ignagni in the talk on healthcare economics.
Much of the dramatic rise in health spending over the past two decades, Pauly said, has been driven by factors like expensive new technology; an insurance system that historically has shielded patients from much of the cost impact of lab tests, MRIs and other health services; and the fact that “we pay healthcare people better than almost any other country.”
“In terms of controlling healthcare spending growth, we know how to do it, but it’s hard to know how to do it in ways that do more good than harm,” Pauly said.
“The bottom line is we could have lower healthcare spending growth if we’re willing to have lousy new technology, terrible job [growth] in the healthcare sector, more skin in the game [by patients] and a continuous political debate about healthcare reform,” Pauly said. “To get lower prices [for care], we’ll have to give up something.”
Americans covered under the Affordable Care Act still face an out-of-pocket maximum expenditure of $6,350 in potential annual health costs, according to several conference panelists. “We’re all facing greater co-pays, deductibles and out-of-network issues,” Rosenthal said. “Americans aren’t accustomed to these kinds of charges … [especially] in an era of stagnant wages. How do you educate people to learn the language of health insurance?”
That question is clearly on the minds of federal health officials. As reforms continue to roll through and transform different sectors of the nation’s healthcare system, Tavenner said, “there is going to be more and more personal responsibility” for patients, along with more choices that will have to be made. That will require a big and ongoing commitment to “consumer education,” she told participants.
It also will require new thinking from all health providers and stakeholders, and an insurance industry and health plan payment system that supports continuing innovation and new approaches to patient-centered, cost-effective and holistic care. “Our job is to help consumers balance access and affordability by recognizing that premium costs are something they are very focused on,” AHIP’s Ignagni said. “So we’re [supporting] things like disease management … and significantly increasing care coordination and disease management. We’re doing tailored networks. We’re doing a whole range of things to support consumer choices wherever they are on that spectrum of choice.”
Added Bernard Tyson, chairman and CEO of Kaiser Permanente, “the ACA has been both a positive and a negative. It’s been a tremendous challenge in that there’s still a lot of uncertainty that’s being worked through in this country.”
One big source of that uncertainty, Tyson said in a talk at the Health for Tomorrow conference titled “Transforming Health Care to Achieve Affordability,” is whether the vision of universal coverage for Americans is sustainable. “We have no idea at this point what the risk level is of this population because it’s too early to tell,” he said. “We’re going to work to figure all of that out.”