health / disease management companies & physicians: new ... · long history of population...
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Health / Disease Management Companies
& Physicians: New Allies & Alliances
Gordon Norman, MD, MBA
EVP, Chief Innovation Officer
Alere, Inc.
DMOF: New Challenges Breed New Models & Allies
Who is Alere?
• Alere, Inc. (formerly Inverness Medical Innovations) is a
global leader in point-of-care rapid diagnostic testing and
in personal health support solutions
• A $2 billion company with 11,000 employees globally,
including >2,200 healthcare professionals, with clients in
all 50 U.S. states and worldwide
• We are devoted to:
– Providing the most complete range of Connected devices and
services that actively integrate data collection
– Empowering individuals to make better choices
– Enabling payers, providers and individuals to make Smarthealthcare decisions
3
What Does Alere Health Do?
• Alere Health, the health management division of Alere,
comprises a family of innovative health companies that
connects diagnostic and monitoring devices with health
coaching and clinical outreach using health information
technology to empower care providers and their patients to
make smarter healthcare decisions
• We improve individuals’ health across entire spectrum of
health needs from preconception to end of life by extending
clinician reach into the community, workplace, and home
• Our solutions have been shown to reduce urgent medical
interactions and hospital visits; avoid unnecessary
healthcare spending; and improve workforce productivity
4
Long History of Population Health Mgmt
5
Alere Health
• A1991 Boston Consulting Group report, The Changing Environment for U.S.
Pharmaceuticals, coined ―Disease Management‖ as a value-added strategy for pharma
• Term is/was a misnomer — what is managed is not the disease, but the patient, through
integrated system of interventions, measurements and refinements of health care
delivery designed to optimize clinical and economic outcomes within a defined population
• ―Population Health Management‖ has replaced ―DM‖ as generic descriptor to cover wider
continuum of health addressed by the industry after 2 decades of evolution
Concept of Continuum of Health
6
DISEASE MANAGEMENTHEALTH IMPROVEMENT
POPULATION HEALTH MANAGEMENT
Population-based Case-based
Ditto…
7
Ditto Again…
8
• Catastrophic Care Management– Complex cases
• Special Population Care– Frail member, End of Life Care,
Centralized Transplant Mgt
• Disease Management– CHF, CAD/stroke, COPD, ESRD,
Diabetes, Depression, Cancer,Asthma, Neonatal, Orthopedics
• Acute Care Coordination– Onsite & telephonic concurrent
review, hospitalists, dischargeplanning, post-acute coordination
• Preventive Health Management– HRA, immunization programs,
cancer screening, smokingcessation, member education
Catastrophic
SpecialPopulations
Chronically Ill
Acutely Ill
Well
Me
mb
er
Co
nti
nu
um
Preconception
OB Risk Asst/Ed
OB Case Mgmt/Home
Perinatal screening
NICU
Wellness
Portal/HPA
Coaching
Online
Screening
Tobacco
Mind & Body
Oncology
Complex Care
Catastrophic
Intensive Care
End of Life
Collaborative Care
SolutionsSM
Patient-Centered Care
Care Gaps
Diagnostic
Screening
Care Gaps
Diagnostic
Screening
Diagnostic
Screening
Care Gaps
Care Gaps
Diagnostic
Screening
WellnessPersonal
Health Support
Supporting the Full Health Continuum
Disease Management
Asthma
Diabetes
Heart Failure
CAD
COPD
Chronic Pain
Women & Children’sCase Management
Provider, ACO, PCMH Support
Hospital Readmission Reduction
Collaborative Care Platform for Providers, Patients
Remote Biometric Monitoring
P4P / PQRI Tracking and Reporting 9
Lessons from EpidemiologyDifferent challenges require different approaches
10
Sick Individuals vs. Sick Populations
Q1: “Why Did This Patient Get
This Condition At This Time?”
• Emphasis on risk of the individual
relative to peers as underlying cause
of each case of disease
• Assumes a heterogeneity of risk
exposure among individuals within a
population
• Genetic factors often a significant role
• Examples:
– Why do some individuals within a
population have hypertension?
– Why do some smokers get lung cancer
while others do not?
Q2: “Why Does This Population
Have This Condition Prevalence?”
• Emphasis on absolute risk across a
population to explain the prevalence
of a disease
• Looks for risk factors that may be
common to many in the population
• Genetic heterogeneity doesn’t explain
differences between populations
• Examples:
– Why do some populations have high
prevalence of hypertension?
– Is smoking rate for the population related
to lung cancer prevalence?
11Rose, Geoffrey. Sick individuals and sick populations. International Journal of Epidemiology. 1985, 14: 32-38
Different Causal Perspectives
• Determinants of population prevalence are not necessarily the
same as the causes of individual cases within a population
• Genetic variability is greater within than between populations;
for environmental influences (diet, sanitation, lifestyle), the
opposite is often true
• The more widespread a cause, the less it explains distribution
of individual cases; the hardest cause to identify is the one that
is universally present, as it has no influence on distribution of
disease
• In our society and others, it is easy to identify diffuse factors
driving prevalence of many conditions at the population level
12
Example: Most Likely Cause of Death?
Patient A: Wally Wellness Patient B: Frank Framingham
A: ? A: ?
13
Example: Most Likely Cause of Death?
Patient A: Wally Wellness Patient B: Frank Framingham
A: Cardiovascular Disease A: Cardiovascular Disease
In U.S., odds for men dying from CVD are highest regardless of
individual risk factors due to excess risk for the entire population
14
Prevention & Treatment Follow
These two approaches to etiology
have counterparts in prevention
and treatment
– For first, strategy is to identify high-risk
susceptibles and offer individual
protection or intervention (screening,
case finding, 2˚ prevention)
– For second, strategy is to control
determinants of prevalence in the
population as a whole (1˚ prevention,
public health)
– Former approach doesn’t address ―root
causes‖, while latter tries to control or
influence them
Example: High-risk approach
– Does screening chronic smokers with
periodic CT scanning identify early
cancer in time to impact outcomes?
– How can diagnostics, biomarkers,
genomics help with early ID of diseased
patients?
Example: Population approach
– How much to increase cigarette tax to
reduce smoking by 50% to lower lung
cancer prevalence?
– Can population behavior change be
applied in a scalable, cost-saving
manner via wellness programs?
15
Important “Prevention Paradox” #1
• A large number of people at low risk may give rise to more cases of
disease (and aggregate cost) than the small number at high risk
• Interventions to broad populations may have large aggregate impact, but
individual risk reduction is very small, especially in the short term, creating
little motivation for individuals to change
• When success is defined by probabilistic event avoidance, individual
motivation for change is even harder
• This is the history of public health – of immunization, wearing of seat belts,
and the attempt to change various lifestyle behaviors for population health
improvement
• More powerful motivators for health education may be the social rewards
of enhanced self-esteem and social approval
• Wellness programs have found that financial incentives can be useful
(i.e., bias for wealth>health optimization for most)
16
Paradox Example: Surgical Outcomes
• High volumes of certain surgeries (txplts, CABG, PCTA) shown to correlate with improved quality and lower cost for institutions and/or surgical teams
• Some business coalitions propose regionalizing common, volume-sensitive surgeries to high volume centers only
• Aggregate benefit to population may be substantial, but absolute risk of adverse outcome to any individual is low to begin with, so potential risk reduction is small and uncertain
• However, unintended consequences are predictable– Regional providers would be ―strangers‖ to these patients; would all relevant
information for care be readily available?
– Travel to regional centers is inconvenient for all and risky: would auto accidents offset gains from improved outcomes?
– While higher volumes would improve already good centers, declining volumes could reduce quality in lower volume sites, or even jeopardize availability of emergent services and institutional viability
17
“Prevention Paradox” #2
• Health interventions are generally expected to improve health, not lower health care expenditures
• While sensible preventive measures may save lives, morbidity, and suffering, most are not cost-saving (reduction in total cost)
• Many preventive measures are considered cost-effective(cost-raising but outcome is worth the cost); others are not
• The need to provide preventiveservices to large populations, only some of whom were at risk for expensive outcomes,is the crux of this paradox
• There are some exceptions: childhood immunizations, flushots for chronically ill, etc.
18
Distribution of Cost-Effectiveness Ratios for Preventive
Measures and Treatments for Existing Conditions
Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? N Engl J Med 2008;358:661
Approaches to Health Improvement
High-risk
Traditional medical care
Screening programs
CDC reportable diseases
Case management
Centers of Excellence
High acuity DM, CM
Genomic medicine
Evidence-based guidelines
Clinical pathways
Population
Public health measures
Health education
Tobacco cessation
Managed care / HMOs
Consumer-directed plans
Value-based benefit design
Wellness programs
Health as ―human capital‖
Social marketing
19
Opportunities to Improve HealthRaising The Mean, Narrowing The Variation
Risk factor ID, risk mitigation
Predictive modeling
High acuity DM, CM programs
Preventive screening
Biomarker R&D
Remote patient monitoring
Culture of Health
VBBD w/ incentives
Wellness programs
Social networks
Medical homes, ACOs
Connected home health
Role modeling
Health ambassadors
Cultural icons
Social network mavens
Coaches, cheerleaders
Buddy system
Good Health
PrevalenceHealth Improvement Goals
Poor Health Average Health
20
How Is U.S. Healthcare Doing So Far?
• Moderately good at identifying high risk; inconsistent job mitigating risk
• Population approaches have checkered record – modest reduction in
some root causes; dismal performance in others (obesity rate >30% of
pop in 9 states)
• Fragmented efforts, siloed approaches; lots of specialization, little
integration, high frustration
• Reliance on individuals to decode and navigate complex care system,
find and utilize resources
• Goals and incentives often imperfectly aligned
• Societal interests not perfectly represented by structural configuration of
health financing or delivery
– Health plan turnover creates bias for short-term HM/DM horizon
– FFS reimbursement insulates delivery system from care outcomes
– Broad coverage for self-determined health = moral hazard
21
What Should U.S. Be Doing?
• The high risk approach to improving health may fail to identify or
mitigate underlying causes of prevalence
• It may be interim expedient, needed to protect susceptible individuals,
but only for as long as the underlying cause of prevalence is unknown
or uncontrollable
• If causes are known and can be removed, then individual susceptibility
no longer matters (or matters much less)
• The major drivers of today’s chronic disease epidemic (diabetes, CAD,
CHF) fall into the latter category
• Population health improvement strategies, alliances, and tactics seem
appropriate to address these
• Some conditions may continue to require both approaches
• It’s not a question of which approach we should be using, but how we
can leverage the strengths of each most effectively
22
Personal Health EcosystemsA new model for improving health in the 21st century
23
What’s a Health Ecosystem?
Biologic Ecosystem
A complex set of relationships of living
organisms functioning as a unit and
interacting with their physical environment to
form a stable system.
Health Ecosystem
The interplay of many factors, including the
environment, personal attributes and
relationships, cultural influences, technology,
and health resources that affect individual
health status.
24
• Specific to the individual
• More complex than
generally appreciated
• Myriad influences ranging
from global to local factors
• Some interactions evident;
others not easily discerned
• Social relationships are
important (e.g., Nicolas
Christakis’ recent work)
• Personal health behavior is
affected by all dimensions
• Traditional ―health care‖
targets very few of these
potential levers of influence
• Appreciating health
ecosystems helps us work
within them more effectively
25
Understanding Health Ecosystems
Determinants of Personal Health
Behavior
Change
Schroeder S. N Engl J Med 2007;357:1221-1228
26
Navigating the Health Ecosystem
27
End Results of Current System
• Persistent medical cost inflation at 2-3X general inflation
• Impending Part A Trust Fund insolvency (2017-2029?)
• Chronic conditions proliferating for B’Boomers and adolescents alike
• 2/3 of U.S. are overweight or obese, no reversal in sight
• Health disparities not improving; some widening
• Lifestyle, diet, habits thwart best public health efforts
• Quality of care highly variable – ―geography is destiny‖
• Medical errors result in 98,000 deaths annually
• PCP, nursing shortages regionally, and worsening
• U.S. business competitiveness undermined by health costs and impacts on
productivity
• Today’s youth may be 1st American generation to have lower longevity than
their parents
• Widespread recognition that U.S. gets poor value for our healthcare spend
• Sustainable universal health coverage elusive w/o better health value for $
28
“Coin Toss Quality” for Medical Care
―Our results indicate that,
on average, Americans
receive about half of
recommended medical
care processes. Although
this point estimate of the
size of the quality problem
may continue to be
debated, the gap between
what we know works and
what is actually done is
substantial enough to
warrant attention.‖
MCGlynn EA et al. The Quality of Health Care Delivered to Adults in the United States NEJM 06-JUN-2003; 348(26): 2635-2645
GoalMean
29
Hardly the “Fairest” of Them All
Davis et al. Mirror, Mirror On the Wall. How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update, Commonwealth Fund 30
So It’s Broken… Now What?
31
“Health”
A state of complete physical, mental, and
social well-being and not merely the
absence of disease or infirmity (WHO,
1948)
A Very Important Distinction“Health”
The highest achievable state of relative
physical, mental, and social well-being
given uncontrollable or irreversible health
influences (2010)
“Health Care”
The prevention, treatment, and
management of illness and the
preservation of mental and physical well-
being through the services offered by the
medical and allied health professions
“Caring for Health”
What you do to improve your state of
health, w/ or w/o help of others
32
Caring For Health Is Different!
33
From Physician-Centric Models…
• Care delivered by clinicians
• Efficient for providers of care
• Patient convenience optional
• Acute care focus (―sick care‖)
• Care reactive, episodic
• Primary care devalued
• Specialty care, technology
• Care segmented by condition
• Hierarchical relationship with
clinician in charge of care
• Patients take passive role
• Clinician biased by assumed
values, preferences
• Clinician defines ―successful
care‖ in clinical terms only
Patients
Nurses
Hospital
Community
ResourcesPharmacy
Subacute
Facilities
M.D.Me DeityM.D.
Admit
Discharge Admit
Discharge
PrescribeRefer
34
To Patient-Centric Health Ecosystems
• Patient needs, values,
preferences dictate more
of what happens, when,
how to improve health
• Expanded care team
organized around PCPs
serve as core of personal
health ecosystem
• Integration through health
information exchange,
controlled by patients
• Care architecture supports
highly personalized care
• Enhanced self-care
augmented by additional
external resources as
needed
&
PCP
Convenience
Care
CoordinationEngagement
Decision
Support
Patient
Access
Retail Clinics
Worksite
Clinics
Disease Management
Personalized
Communications
Price / Quality
Information
PHR / EHR /
HRA Dataflow
Coaching &
Incentives
Remote
Monitoring
Wellness
Prevention
SCPDiagnostics
Health
Advocacy
Adapted from FBR Capital Markets, Patient-Centric Care: The Direction of 21st Century Healthcare, 12/2007 35
• What’s lacking today is
connectivity, context
across the components
• Pervasive health
information exchange
and integration is
required for improving
personal health
• We want all parties to
share data to have
integrated information
that’s contextualized for
health decision support
• Technology to make this
happen is no longer the
key barrier
Adapted from FBR Capital Markets, Patient-Centric Care: The Direction of 21st Century Healthcare, 12/2007
&
PCP
Convenience
Care
CoordinationEngagement
Decision
Support
Patient
Access
Retail Clinics
Worksite
Clinics
Disease Management
Personalized
Communications
Price / Quality
Information
PHR / EHR /
HRA Dataflow
Coaching &
Incentives
Remote
Monitoring
Wellness
Prevention
SCPDiagnostics
Health
Advocacy
PCP
Convenience
Care
CoordinationEngagement
Decision
Support
Patient
Access
Retail Clinics
Worksite
Clinics
Disease Management
Personalized
Communications
Price / Quality
Information
PHR / EHR /
HRA Dataflow
Coaching &
Incentives
Remote
Monitoring
Wellness
Prevention
SCPDiagnostics
Health
Advocacy
Remaining Gaps in The Ecosystem
36
It’s Not Easy Being Patient-Centric
Care reminders
Public report cards
Personal health record
Online health information Nutritionist
Fitness center
Wellness health coach
Care coordinator Worksite health program
Urgent care facility
Imaging center
Retail clinic
Ancillary care providers
Specialty care referrals
Primary care ―home‖ Electronic health record
37
It’s Not Easy Being Patient-Centric
Care reminders
Public report cards
Personal health record
Online health information Nutritionist
Fitness center
Wellness health coach
Care coordinator Worksite health program
Urgent care facility
Imaging center
Retail clinic
Ancillary care providers
Specialty care referrals
Primary care ―home‖ Electronic health record
38
It’s Not Easy Being Patient-Centric
Care reminders
Public report cards
Personal health record
Online health information Nutritionist
Fitness center
Wellness health coach
Care coordinator Worksite health program
Urgent care facility
Retail clinic
Ancillary care providers
Specialty care referrals
Primary care ―home‖ Electronic health record
Imaging center
39
Human Beings Are Complex Biosystems
40
Why Do We Behave As We Do?
41
Changing Health Behaviors
Do you know WHAT to change and
WHY?
Do you WANT to change?
Do you know HOW to change?
Successful health behavior change
typically requires information,
motivation, and behavioral skills
The health ecosystem must provide all
three for a high probability of
sustained behavior change
42
Different Skill Sets For Different Roles
Skill SetMost Physicians
& Nurses
Most Health
Coaches
Provide information Good Fair to Good
Stimulate motivation Poor Good
Enhance behavioral skills Poor Good
• It’s a matter of different perceived roles, training, philosophy,
practice, rewards, reinforcement
• Doctors have not historically perceived their role to change
behaviors, but rather to render health advice & treat disease
• Coaches are expected to help individuals achieve health goals by
building motivation, skills, and providing support
• Each practicing at the ―top of their license‖ can be highly
complementary and synergistic, if connected and coordinated
around a unified care plan and shared data
43
What We Physicians Are NOT Usually
Taught in Medical Training
• Working in care teams
• Continuous quality improvement
• Epidemiologic health perspective
• Social psychology, adult learning
• Stages of change management
• Patient-centered interviewing
• Large dataset management with
advanced analytics
• Clinical process improvement
• Community resource integration
• Motivational interviewing
• Building self-efficacy, activation
• Sustaining behavior change
• Predictive modeling
• Disease registries
• Interoperable EHRs/PHRs
• Remote biometric monitoring
• Consumer-oriented education,
motivation techniques
• Behavioral incentives
• Scalable platforms for inbound,
outbound patient contact
• Low health literacy counseling
• Culturally-sensitive health
education approaches
• Overcoming resistance
to change, recidivism
44
Slow Adoption of Health Innovation
From time new knowledge discovered until >50% of physicians
act on that knowledge = 15-17 years
Everett Rogers, Diffusion of Innovations, 1995
% o
f p
op
ula
tio
n
time
Adoption Half-life = 17y
Knowledge Half-life = 10y
The further we go,
the behinder we get??
Balas, Boren. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 200045
Clinical Inertia Common in Patient Care
46O’Connor et al. Clinical Inertia and Outpatient Medical Errors, Advances in Patient Safety V2. 2005
• Clinical Inertia: lack of treatment intensification in a patient
not at evidence-based goals for care
Losing The Faith
47
What About Health Reform?
• PPACA health reform legislation has initiated a 10-20 year
change process of great complexity & uncertain outcomes
(notwithstanding major strategic shift after midterm elections)
• Many seasoned observers are skeptical that current reforms
are enough to turn the corner on cost, quality, and value
• Bottom-up regional health reform at the state and local level
offer nearer term options, and many such experiments are
underway which bear watching
• Employers and health plans can be innovative by establishing
proof of concept in locales where interests may be more
aligned, and status quo inertia can be overcome
• The magnitude and seriousness of the challenge demands
innovation and experimentation at all levels
48
Coverage w/o Access = Faux Reform• MA healthcare reform has exposed reality that expanding coverage
can overwhelm an already saturated primary care delivery system
• MA is not unique in facing primary care shortages
• Shortages are not limited to primary care, but these are most critical
2009 Massachusetts Medical Society Physician Workforce Study, www.massmed.org/workforce 49
U.S. Students Retreat from 1° Care
50
Just as Boomers Hit Medicare…In 1950, primary care to specialist ratio of active medical workforce was >2:1 – currently it is <1:2
In 2006, only 3,032 (15%) of 20,072 residency applicants matched into primary care residencies
By 2020, U.S. will have estimated shortage of 40,000-200,000 PCPs, with 78 million Boomers seeking more chronic care
51
Does a PCP Shortage Really Matter?
• Quality and cost data
say otherwise: PCP
supply correlates with
lower cost, higher quality
• Ample studies replicate
these findings elsewhere
• Maybe primary care is
overrated…?
• Perhaps this is a timely
step toward a specialist-
driven system with better
health outcomes?
52
Will Reform Solve this Problem?
• PCMHs, ACOs are exciting developments that have great promise
but are highly dependent on revised payment from majority of
payers to realign incentives – we are not there yet
• There is a serious PCP shortage now that will grow worse before it
can correct in response to any proposed incentives, a la PCMH
• The best provider-based ―medical home‖ in the world is only a
partial solution since most ―caring for health‖ occurs in one’s own
home, at work, in the community
• PCMHs and ACOs may become key components of the health
ecosystem for many, yet will likely remain an incomplete solution
• We need delivery systems to connect with other health components
and partners to form a coherent, interoperable, personal ecosystem
that individuals can leverage for greater empowerment and control
53
Good For Health & Good For Business
• Every $1 of medical & Rx costs is matched by
$2.30 of health-related productivity costs
• Health-related presenteeism has larger impact
on lost productivity than absenteeism
• Top five health conditions driving total
medical/Rx and health-related productivity costs
are depression, obesity, arthritis, back/neck pain
and anxiety
• Evidence based medicine should go beyond
clinical outcomes or financial outcomes and
include functional outcomes
• Co-morbidities drive the largest effects on
productivity loss so integrated personal health
support approaches are critically important
JOEM, "Health and Productivity as a Business
Strategy: A Multi-Employer Study", 51:4, April,
2009. pp 411-428
54
Creating, Sustaining, & Advancing
A Workplace Culture of Health
• Leveraging technology, analytics
– Remote monitoring, home testing, PHRs,
secure messaging, social communities
– Using aggregated data for predictive
analyses, gaps in care, personalized
interventions
• Progressively raising the bar
– Increasing goals as targets achieved
• Integrating patient-centered models
– Providing strong health ecosystem support
for employees
– Supporting PCMH, ACO approaches
– Encouraging collaboration between health
management vendors and physicians via
connectivity, HIE, & interoperable
EHRs/PHRs
• Fundamental value recognition
– Employees as human capital
– Indirect vs. direct health-related costs
– Executive champions ―walking the talk‖
• Integration across ―health verticals‖
– Health benefits design, absence /disability
mgt, wellness programs, incentives, partners
• Ongoing value documentation
– Clinical indicators, health behaviors
– Direct and indirect health-related costs
– Value translated to financial terms (EPS)
• Balancing ―skin in the game‖ with
effective incentives & health support
– cost mitigation vs. cost shifting
– CDHP vs. VBID vs. Wellness
55
Value Consensus Strong
―In a critical meta-analysis of the
literature on costs and savings
associated with such programs, we
found that medical costs fall by
about $3.27 for every dollar spent
on wellness programs and that
absenteeism costs fall by about
$2.73 for every dollar spent.
This return on investment suggests
that the wider adoption of such
programs could prove beneficial for
budgets and productivity as well as
health outcomes.‖
Health Affairs 2010. 29:2
56
A Patient-Centric Health Ecosystem
• Aligns clinician, coach, self
caring for your health by being
person-centered
• Defragments health silos,
connects all the pieces
• Delivers
• Convenience
• Emphasis on proactive,
continuous, self-care
• Effective information,
encouragement, support
• Closely links
• Sites of care
• Expanded care teams
• Relevant health data
• Integrated care plans
• Personal health records
• Electronic health records
Coaching & Incentives
HealthAdvocacy
57
Media: Health As Random Events
58
Little Awareness of Risks & Benefits
59
We Make No Time For Health
60
For Many: All Work, No Play
61
For Others: You Are What You Watch
62
Relapses Are Frustrating, Challenging
63
Health Literacy Can Be Challenging
64
We Don’t Know the Cost of Anything Much Less the Value
65
Mass Medicalization & Moral Hazard
66
ConclusionNew Challenges Breed New Models, New Alliances
67
What Do We All Want From Our
21st Century Health Ecosystems?
• Comprehensive health care
– High quality, convenient, affordable, care coordination, team-based, safe,
confidential, easy navigation, social community
– Allow me to share in important decisions and control my health ecosystem
• Empowerment to help me care for my health
– Make it easier for me to do the right thing for my health by offering me different
options for achieving my goals
– Give me knowledge, but don’t forget motivation, skills, incentives
• Personalized, supportive approach
– Accept who, where I am now, but help me to get healthier
– Communicate and interact with me in the manner I prefer
• Health information integration for holistic health decision support
– Across sites, sources of information, analysis, guidance
– Failsafe: tell me what I am forgetting or providers are overlooking
68
Going Beyond The Delivery System
• Strong workplace Culture of Health perspective
• Integrated continuum of care programs for pre-cradle to end-
of-life and all health states in between through a highly
personalized, convenient interface
• Communication flexibility and convenience that adapts to and
supports individual preferences
• Empowering technologies like remote monitoring, home
diagnostics, interoperable health information exchange for
EHRs, PHRs to assist physicians and individuals in making
appropriate, timely, and coordinated health decisions and
interventions
• Behavioral expertise, tools, and incentives to drive positive
change in participants’ choices, helping them achieve and
sustain their individual health goals
69
What’s It Going To Take?
Meaning:• Culture and design changes to
respect and adapt to patient
differences, values, preferences
for how care is delivered
• Expanded team-based care
where specific roles leverage
capabilities of different players, all
integrated for and controlled by
patients
• Delivery systems own outcomes
of care, not just processes
• Adopting or partnering with other
organizations for population
health capabilities, technologies
Buzzwords:• Patient-centric foundation
• PCMHs, Team-based care
• ACOs, Accountable Care
• Collaborative Care, Coordinated
Care, Virtual Team-based Care
70
What’s It Going To Take?
Meaning:• Care team reimbursement
contingent on measured and
reported outcomes of care
• Patient OOP cost materially
related to personal health
behaviors & decisions
• Better connectivity, interoperability
of health data, communications,
and health decision support under
control of individual patients
• Greater quality and safety
transparency, literacy, and
incentives for value
Buzzwords:• Payment reform, P4P, robust
quality measurement, reporting
• VBBD, P4P4P, HRAs, HSAs
• Connected EHRs, PHRs, HIEs
• CE + public reporting, education,
marketing + CQI
71
“The King’s men helped some, but the horses just made things worse!”
What Outcome Can We Expect?
72
A Patient-Centric Health Ecosystem
• Aligns clinician, coach, self
caring for your health by being
person-centered
• Defragments health silos,
connects all the pieces
• Delivers
• Convenience
• Emphasis on proactive,
continuous, self-care
• Effective information,
encouragement, support
• Closely links
• Sites of care
• Expanded care teams
• Relevant health data
• Integrated care plans
• Personal health records
• Electronic health records
Coaching & Incentives
HealthAdvocacy
73
What Ideal Collaboration Can Yield
74
– Predictive
– Personalized
– Preventive
– Participatory
– Equipped
– Enabled
– Empowered
– Engaged
• Traditional health care and ―caring for health‖ are compatible,
coordinated, comprehensive, and mutually reinforcing through
integrated efforts of clinical teams with health management partners
• All members of the health ecosystem contribute to an interoperable,
unified care plan controlled by the individual, enabling a new level of
personal health ownership and empowerment
• Outcomes of care are optimized through a satisfying, personalized
experience adapted to individual needs, values, preferences, at
lowest achievable cost to individuals, payers, and society
P4 Health Care for E4 Consumers in a C4 Ecosystem– Convenient
– Connected
– Coherent
– Cost-effective
