week is Health Innovation Week, and thousands of health tech people
have descended on San Francisco to participate in the Health 2.0 conference, a “showcase of cutting-edge innovation that’s transforming
health and health care.” Many would say that if you want to see what healthcare could look like soon, Health 2.0 is the place to be.
So what might we expect in terms of impending changes to the care of geriatric patients? Today I’ll share some thoughts on the yesterday’s kickoff keynote speech, given by the healthcare futurist Joe Flower. (I watched the keynote via webstream on LearnItLive.)
Unsurprisingly, Joe described our current time as one of great instability, and predicted major changes coming up in healthcare, no matter what happens to the Affordable Care Act. Key drivers of change he cited included an aging population, the need to manage healthcare costs, increasing burdens of chronic disease (with a special shout-out to the obesity epidemic), and exciting technological innovations which he thinks will allow us to deliver better care for cheaper.
Based on these factors, Joe described the following shifts in healthcare. (It was unclear to me whether he is merely recommending these, or thinks they are quite likely to develop based on the big change drivers described). My comments and reactions are in purple.
- Explode the business model. This, if I understood him correctly, requires changing reimbursements and financial incentives that usually shape healthcare delivery. This would allow a shift from physical geography of care to virtual geography of care. He also envisions the end of cost-shifting: instead of following the average cost of hip replacement, we’ll be focusing on the cost of care for each individual patient, and trying to get it down.
- Couldn’t agree more re changing financial incentives. Geriatric patients in particular are disadvantaged by the current model which emphasizes volume of (short) face-to-face visits, and discourages care coordination. But many healthcare policy experts have been bemoaning the reimbursement system for years, and it’s still there, currently interfering with attempts to create good primary care medical homes. Does Joe know about a viable plan to get this changed on a meaningful scale soon?
- Keeping costs down for every individual patient? Patients are interested in this when they are using HSAs, it’s dicier with frail elders using Medicare. Interesting recent NYT op-ed titled “How to Die” notes the downsides of emphasizing cost in certain situations.
- Build on smart primary care. Prevention and primary care are apparently hot among the healthcare innovation crowd. Joe wants to see primary care get “smarter,” which I think means an emphasis on addressing problems further “upstream.” As an example, he cited the Vermont Blueprint for Health Chronic Care Initiative.
- Definitely a laudable goal and I am all for better and smarter primary care, especially for frail and vulnerable elders who stand to gain a lot. How you make it happen for lots of elders is another story, especially given the shortage of healthcare providers with geriatric expertise.
- The smart geriatric primary care models that jump to my mind are PACE (Program of All-Inclusive Care for the Elderly), followed by Guided Care and GRACE, but all of these are currently hampered by reimbursement issues, among others.
- Put a crew on it. A reference to Atul Gawande’s proposal that medicine needs to be based on pitcrews rather than lone cowboys. It also dovetails nicely with the current interest and emphasis on interdisciplinary teams to provide care. That being said, Joe’s examples seemed to be of building an “integrated practice unit” for a specific medical problem.
- How would these integrated practice units work for geriatric patients, who will have multiple chronic diseases and symptoms simultaneously? I worry that health tech innovation is going to focus on creating expert teams for specific diseases; will they mobilize to develop expert teams in caring for a frail older persons?
- To me, this sounds like an expansion of current disease management services. So far, I’ve found such services to be problematic, since they require yet more coordination and usually don’t provide good geriatric-specific disease advice. (Please don’t bug my elderly patient about checking blood sugar three times a day without talking to me first!)
- Last but not least: it takes a lot of work to create and maintain a well-functioning team. This needs more than lip-service; administrators need to give teams guidance and time for their teamwork; my personal experience is that this is often neglected.
- Swarm the customer. This seems to mean two things. One, you extensively monitor the well-being of patients. Two, the moment something seems to be going wrong, you swarm in and fix it. As Joe pointed out, a small portion of the patients create a large part of the costs, so the goal is to spot those patients with extra need early. Per Joe, the people with the most needs offer the possibility of the greatest savings.
- Intriguing to think about re geriatrics. Obviously we are constantly faced with situations in which early intervention leads to better health outcomes (which I feel better emphasizing, rather than less cost even though better outcomes often do cost less).
- But geriatric patients also have high needs. My guess is that if you start monitoring them extensively, you will bring a lot of previously less seen issues out of the woodwork, and that will cost money. Some of those should be addressed because they are likely to lead to better outcomes. Other things will be like elevated PSAs: they will attract attention and evaluation, of unclear overall benefit.
- This sounds like a good arena in which to involve geriatricians, who have expertise prioritizing health issues for this population, if you want to extensively monitor and pre-emptively intervene with frail elderly patients.
- Rebuild all processes. “Measure, improve, try, and measure again.” He emphasized getting close to the customer experience while doing this.
- As a graduate of the VA Quality Scholars program, I love the idea of PDSA, CQI, and using measurement to guide process improvement. Lots of processes related to geriatric care need this.
- As a former clinic director, I can tell you that this is damn hard work. It can and should be done, but resources will have to be allocated to support it, or you run the risk of souring your front-line providers on the idea.
In closing, Joe said the changes are going to force us to develop a leaner, smaller, and smarter system. I’m certainly all for change, but will it happen as soon as he thinks, and how will it play out for those of us caring for frail elderly patients?
My own guess is that reimbursement issues will be the number one obstacle, or driver, affecting change in the average elderly patient’s care. I haven’t heard that serious change is on the near horizon (the $20 average per member per month Medicare coordination fee now being tested sounds skimpy; this Health Affairs study on Medicare care coordination demos reported monthly per member fees of at least $70, often more ).
But these are changing times. I’d loved to be surprised by radical improvements to geriatric care sooner rather than later, here’s hoping they are closer to reality than I now realize.