The family doctor: a remedy for healthcare costs?

The primary care doctor is gaining new respect in Washington.

Battles may be breaking out over the various healthcare bills emerging from Congress, but reformers agree that general practitioners should be given a central role in uniting the fragmented U.S. medical system.

This according to an article in BusinessWeek.

This vision has a name: the "patient-centered medical home." The "home" is the office of a primary care doctor where patients would go for most of their medical needs. This medical home may sound like the "gatekeeper" model of the 1990s, a managed-care creation that was all about holding down costs. But advocates say the new concept is designed to help patients, not insurers. It's more like doctoring 1950s-style, when a Marcus Welby figure handled all the family's medical needs. This time it's juiced up with digital technology.

It also represents a way to streamline a disorganized and wasteful system that chews up a crippling 18% of the U.S. gross domestic product. That burden is felt particularly by private industry, which covers 60% of the nation's insured. Since most businesses try to ferret out waste and disorganization in their own operations, the medical home is a concept they can embrace in good conscience.

The current practice of medicine in the U.S. is a long way from this model.

• Only 27% of physician practices come close to qualifying as a medical home;
• Medicare and other insurers pay doctors on a fee-for-service basis that rewards quantity of care over quality; and
• There are no reimbursements for discussing diabetes management with a patient or talking over a case with a specialist.

It is tough for many doctors to focus on coordinated care when there is no mechanism to pay them for their time. A nationwide switch to medical homes is also constrained by an extreme shortage of primary care physicians, again because of the economics. Medicare reimburses primary care at a lower rate than any other specialty, so only 17% of medical graduates choose to enter the field.

The efficiencies came from relying on a team approach, where nurses take on a lot of the record keeping once left to the doctor.

Click here to read the full BusinessWeek article and watch an interview with the author.

Is there an innovation that could make it feasible to have many more "patient-centered medical homes?”

Could companies and/or other organizations even sponsor them?

I welcome your comments.

AAMC president Darrell Kirch on the impact of a physician shortage

Last year on July 3, I wrote about a vision of health care delivery about “the "patient-centered medical home."

The "home" is the office of a primary care doctor where patients would go for most of their medical needs. This medical home may sound like the gatekeeper model of the 1990s, a managed-care creation that was all about holding down costs. But advocates say the new concept is designed to help patients, not insurers. It's more like doctoring 1950s-style, but now juiced up with digital technology.

Click here to read “The family doctor: a remedy for healthcare costs?”

But of course the challenge of making this vision real is a shortage of doctors.

Darrell G. Kirch, president of the Association of American Medical Colleges, recently wrote that the physician shortage is, in part, a result of expectations in the 1990s that managed care and primary care would greatly drive down the need for physicians, particularly specialists. However, these expectations fell short against the rising needs of an aging, growing population that has high expectations of its health-care system.

Kirch says today, the overall number of physicians in the U.S. is lower than the average per capita number of doctors in other nations such as Sweden, Denmark, Spain and France, and we now "import" some 25% of our physicians from other countries. While expansions of U.S. medical schools can close this part of the gap, the overall per capita supply of doctors in the country will decline without an expansion in the number of residency training positions. This expansion will not occur unless Medicare resumes paying for its share of training costs.

Because it takes so long to train a new physician, Kirch says, Congress must lift the freeze on support for medical training now, as part of health-care reform. While the cost to add new physicians is significant, it is less than 1% of current Medicare expenditures and an essential investment if people are to have timely access to a physician's care, not just the promise of insurance coverage.

Even those who expect the U.S. health-care system to be transformed in the next decade know that wishful thinking cannot provide the care they and their families will need. Congress is right to expand insurance to as many Americans as possible. But it also has a responsibility to ensure that the nation is cared for by more than an insurance card and an answering machine.

3 steps to building your health advocacy skills

“Inspiration and ideas come from a wide variety of sources,” says Suzanne Ross of the Aerie Company.  I appreciate Suzanne’s ability to integrate new thoughts and make the strategy + communications + leadership link to elevate performance.

Recently, Suzanne’s newsletter featured an article on Health Literacy, and I asked her if I could share it with friends of Stinson Brand Innovation.

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As health care reform brings millions more people into the system over the next several years, there has never been such an urgent and dramatic need to advocate for yourself, your family and the people you love at the doctor’s office and in the hospital.

The successful champions will be those with a solid health literacy foundation – often described as an individual’s ability to read, understand and use healthcare information to make decisions and follow instructions for treatment. While it seems pretty straightforward, the complexities of chronic conditions, varied therapeutic approaches and an enormous array of drug options, let alone insurance and financial issues, require today’s patients and consumers to be prepared for even more responsibility and accountability for their health.

Health Literacy awareness draws increased attention on the importance of access to accurate, understandable health information and promoting good health. It has been well documented that limited health literacy has a direct link to worse health outcomes and higher costs, something we can ill afford today.

Among many resources available to promote greater consumer understanding of health, particularly navigating the system, is “The Empowered Patient” by CNN senior medical correspondent Elizabeth Cohen. The book is an outgrowth a career reporting on healthcare, her Empowered Patient column for CNN.com and personal and family experience as patients. Cohen takes a be-prepared-like-a-Boy Scout approach offering advice, patient stories, resources and check lists on getting the right diagnosis and plan for the best medical care, dealing with your insurance company, how to maximize prescriptions, ultimately informing patients of their vital role in creating a smarter, safer health care system.

The basic principles for becoming a personal advocate ring true for the business environment as well, whether responding to a crisis or promoting a new point of view on issues critical to your company or industry. To help pave the way to define and resolve problems, focus on advocacy skills that enable you to:

1. Be prepared – do your research to support your position, keep organized records that outline all details and have a plan for success
2. Be clear – articulate a clear, specific definition of the problem that distinguishes major issues from incidental details and always be listening to ensure you understand any response you receive
3. Be engaged – adopt a lifelong learning mindset so you are receptive and can question new information and options while remaining polite and persistent

With better understanding comes better decision-making. When it comes to a healthy and productive workforce, health literacy cannot be the sole obligation of a single stakeholder. Employers, care management programs, insurance companies and individuals alike need to be the advocates for better health and outcomes.

You can contact Suzanne Ross at www.aeriecompany.com.

110 million interactions with a brand most consumers have never heard of – interview with Healthwise founder, Don Kemper

“For most health consumers, Healthwise is the biggest brand they’ve never heard of,” says e-Patient Connections newsletter.

“Even though Healthwise content is accessed over a 110 million times a year, it is accessed most often through online health publishers, health plans, hospitals and disease management companies. Even though this company is over 30 years old, they continue to find innovative new ways to support patient decision-making.”

Healthwise founder Don Kemper was recently interviewed by Kevin Kruse, head of Krū Research, a global think tank focused on empowered patients who are increasingly marshalling digital technologies and communicating with peers to actively manage their health.

Here with permission from Krū Research is the interview:

Kevin Kruse: Don, why did you start Healthwise. It was back in the 70s right?

Don Kemper: That’s right 1975.  During the time of the Vietnam war, I became an officer with the Commissioned Corps of the US public health service.  One day I went to a talk by Vern Wilson, Assistant Secretary for the US Department of Health and Human Services. He said, “The greatest untapped resource in healthcare was the patient.” That just took hold of me and I decided that that was something I wanted to work on.  I had a baby at home at the time and somebody gave me the book by Doctor Spock on raising children. I started promoting the idea that we needed a Dr. Spock type book for the whole family that would guide people in how to take care of themselves… this led to the creation of Healthwise in 1975 and then later the Healthwise Handbook.

Kruse: Has the Healthwise mission changed since then?

Kemper: Well the mission hasn’t changed but the media changes. The mission has always been to help people make better health decisions. We did that initially through both the Healthwise handbook and workshop.  So we had a focus on education early on, just wasn’t as scalable as it is now on the Web.

Kruse: Healthwise online content is syndicated by most of the major health portals - how did you become an innovator with web technologies?

Kemper: We have a wind sculpture outside our building that’s devoted to our relentless innovation.  The base of it is solidly in the ground as is our mission, which never changes, but that sculpture is always in motion and it means we are continually trying to find new ways to help people make better health decisions.

Kruse: Speaking of innovations, are you embracing social media?

Kemper: We certainly are very supportive of the whole 2.0 movement and the social networks around health.  We think there are three sources of information that people need. They need to have information from their doctors, information that has a good solid evidence base, and then they need to hear from other people who have been in similar situations. The piece that we focus on is the information that is really documented by medical research.  We are really trying to find the right ways to reach out to the 2.0 group, so that we can get those two sources of information collaborating on a more regular basis and I think that’s going to happen in many different ways.

Kruse: Tell me more about your “virtual conversations.”

Kemper: Many people learn best through personal interaction with other individuals and we also know that psychologists have developed a number of techniques like motivational interviewing. We can now model these interactive conversations by using software developed by Jellyvision, the makers of the computer game called “You Don’t Know Jack.”  So instead of having the very obnoxious Jack run the game show we use a very supportive voice and individual called Shelley that guides the person through this interactive conversation.  One type of conversation is around medical gaps mostly in chronic illness. For example the importance of the hemoglobin A1c test for monitoring and controlling your diabetes or the importance of aspirin to a person at risk for heart disease.  The other type of conversation is around wellness.  We don’t have a prescription exercise program, but we have the conversation that will help you make an exercise program work for you. It’s like having a twenty-minute conversation with a psychologist around what is it going to take for you to be successful in your fitness program.

Kruse: Shifting to some business questions, how many employees do you have now? And you’re setup as a non-profit?

Kemper: We are a not-for-profit with 120 employees.  One advantage of being non-profit is that nobody can come buy us, so that’s good. The not-for-profit approach allows us to play with everybody now because they aren’t concerned that their main competitor might buy us or take us over. We are now used by all ten of the ten largest health plans.

Kruse: What are your future plans for Healthwise?

Kemper: Our next big initiative that we are currently looking for funding and partners for is taking on the whole issue of late life care. We want to use interactive conversation technology to engage elders and their family care givers.  We have identified 26 critical moments in late life care ranging from the early days of just helping prevent falls to deciding when you stop driving, all the way to when do you need to move out of your home, when do you need to put in your advance directives, etc.  We think this will be a highly impactful program that will address what has got to be one of the biggest problems in American medicine; the program is called “Elder Talks.” I think it is going to be a one of our major legacies.  Also we have 154 patient decision aids, which is by far more than anybody else in the world. These guide the person through clinical treatment decisions like do I need the surgery, do I need this drug, do I need this test, etc.  We’ve had these for quite a while, but we are releasing a whole new generation of them.  The same topics but reformatted into a much more interactive and richer user experience.  Last year we had about 10 million uses of these decision aids, so that they are making a big difference.

To learn more about Krū Research, visit www.kruresearch.com

And connect with Healthwise at www.healthwise.org

Engaging “Opinion Leaders” that may be “Practice Influencers”

I've shared many examples of how N-of-8 can shift opinion to practice.

Another case was when I moderated a group of leading cardiologists to discuss eplerenone, the first agent designed to selectively block aldosterone for the treatment of high blood pressure.

The eight participants in this group included the chair of a major medical society, the client’s chief medical director, and six of world’s top hypertension specialists.  We were to discuss how aldosterone blockade reduces mortality and morbidity among patients with severe heart failure.  Simply put, eplerenone is used to treat high blood pressure by blocking aldosterone, which in turn lowers the amount of sodium and water the body retains. Lowering high blood pressure helps prevent strokes, heart attacks and kidney problems. Eplerenone is also used to treat congestive heart failure following a heart attack.

To say I felt intimidated would be an understatement.  As their facilitator, however, my job was not to go toe-to-toe on the science.  Instead, I was to help determine how emerging science could apply to practice.

The conversation turned to the difference between diastolic and systolic blood pressure.  And after several minutes, I asked the most innocent and naive question:  

“When you say systolic BP, 

what would that mean to 

the average family physician?”

Well, the question was apparently so elementary that my client almost had a cardiovascular event right there.  But then, one doctor responded, “You know, that’s a very provocative question and one that has created some controversy.”  This led to a lively, engaging, and fruitful debate – with more implications for practice than we expected.

Approximately 50 million, or one in four, adult Americans, have high blood pressure. Of those, 73 percent are not adequately controlled, and are at increased risk of heart attack, stroke, kidney failure, damage to the eyes, heart failure and atherosclerosis. Control of hypertension has remained inadequate despite the availability of several key classes of compounds.

"Hypertension is a complex disease with many factors contributing to the problem," said the advisors during our N-of-8.  "For patients and their health care providers who face unique challenges in achieving and maintaining control of their high blood pressure, eplerenone could represent an important new treatment option that goes beyond standard therapies in targeting the aldosterone pathway."

Preclinical and clinical studies had suggested that eplerenone works with relative selectivity to block aldosterone receptors, a key component within the RAAS (renin angiotensin aldosterone system).  This fact, the advisors said, plays a significant role in the body's regulation of the cardiovascular system.

In the discussion, they concluded that data showed the addition of eplerenone to optimize medical therapy could reduce morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure.

This all ultimately contributed to the company’s marketing strategy.  FDA initially approved eplerenone for the treatment of hypertension, but the brand team decided to wait another year for a second indication – the treatment of congestive heart failure (CHF) secondary to an acute myocardial infarction – a first for any drug in the class. 

Eplerenone was launched, and marketed by Pfizer, under the brand name Inspra.