I attended the Connected Health Symposium last week in Boston and got a healthy dose of the past, present and future in health care connectivity, connectedness and connections. As always, I enjoyed connecting in person with a whole host of folks I know online — including those who know my twitter handle, @healthblawg, better than my name.
The conference was kicked off by Stuart Altman, who regaled us with tales of his days with the Nixon Administration, and made a couple of key points:
- The health care spending crisis is cased by rising prices, not rising utilization
- Any federal health insurance reform will cause cost-shifting to the privately insured, the states, the young
- Therefore the key to successful reform lies in reforming the payment system as well as the delivery system; otherwise we're "trying to grow flowers in a toxic environment."
- Value-based purchasing (P4P), gainsharing, global payments are reasonable options for payment reform
- Incentives for providers to use home-based systems will help heal the system at large, and promote connected health, which in turn promotes quality and efficiency
(But n.b.: while remote monitoring and home care will improve quality and reduce cost overall, it is not necessarily cost-effective for every patient.)
The conference closed the next afternoon with the official launch of the Journal of Participatory Medicine, presented to the group by members of the editorial board, re-emphasizing the need expressed in the intervening two days of sessions for clinicians to include patients in all aspects of managing their own care. (On this theme, see the JOPM kickoff on-line conference from earlier in the week, including e-Patient Dave's webcast How Great EHRs Empower Participatory Medicine; free registration required).
In between these two sessions, we heard from a wide range of speakers, panelist and vendors. I offer here an idiosyncratic sampling of some of the many overlapping sessions. (Please see the archived tweetstream from the conference, a couple of audio recordings of panel discussions on EHRs and PHRs, and please post links to other blog posts about the conference in comments below.)
Ed Markey, via videolink from DC, preached to the converted that the health care system needs CPR – connectivity, privacy and research (as the Center for Connected Health's Director, Joe Kvedar, tweeted, Markey has a terrific speechwriter). Markey has been delivering, having had a hand in building the national broadband network from his seat on the telecom committee, and in beefing up HIT privacy and security in the HITECH Act.
Jim Mongan, CEO of Partners, made the poignant comment that liberty, on the one hand, and justice for all, on the other hand, may be at odds with each other, and the unsurprising comment (from his perch atop a large IDS) that large IDS's are the way to go.
"It's the Network." Verizon's Rajeem Kapoor pitched his company's big entry into health care connectivity, noting that of 100,000 preventable errors per year in the US, 20% are due to the lack of immediate access to patient data.
A recurring theme: health care plans are designed by negotiation between payors and providers … they need to include patients.
Tom Lee, also from Partners, said that payors and providers are engaged in co-evolution, and that they need to work together or else chaos will result. Lee also said: Global payment isn't about bending the cost curve, it's about enhancing value — a different perspective than Altman's, but not unexpected from a large delivery system representative. The "alternative contract" offered by Blue Cross Blue Shield of Massachusetts is a global payment contract with risk adjustments, quality bonuses, and other bells and whistles, per Andrew Dreyfus (from BCBSMA) designed to fairly compensate and avoid perverse incentives for providers. The global payment system to be rolled out in Massachusetts over the next five years (maybe) is intended to separate insurance risk (not to be passed onto providers as it was in capitation's bad old days) and performance risk, or quality risk, which lies appropriately with the providers.
Since the current health care system is straddling the past and future, fee for service reimbursement in an age where a more holistic approach to care is recognized as preferred, Partners is paying physicians participating in a medical-home-like program a management fee to replace some of the lost FFS income. A panel on patient incentives yielded the observations that silos within health insurance companies lead to irrational decisions: a cost to one division could yield a many-times-larger savings to another division, but the first has no incentive to incur that cost.
In a panel discussion called The Futurists, Jay Sanders of WellDoc said we need to bring the exam room to where the patient is, and to personalize medicine (i.e., normal for me is not normal for you). Roy Schoenberg of American Well described his company's next step, plans to allow PCPs to bring specialists into the in-person patient visit; he also cited a Gartner prediction: By 2013, 25% of all health care encounters that can happen virtually, will. We also heard about implantable wireless sensors that will be able to transmit a stream of data and household robots from Microsoft.
In an interesting back-to-the-future answer to the question: What'
s the killer app? we heard this answer from Paul Williamson of Cambridge Consultants: Family-provided, wireless-enabled care. This vision of the future was echoed later in the day by Joe Kvedar, who posited as an ideal a world in which the patient coordinates self-managed care with a clinician as coach and an employer as enabler. A related recurring theme: The need to move to more of a team approach to care.
Some of the toys in the exhibit hall (some called it vaporware) seemed more geared to the futurists (e.g., Intel's offering, a wired home hub for communication among providers, case managers, family members and patients, now being put through its paces in a few demos), but some are ready to go now, sporting tags signifying their compliance with Continua connectivity standards (the Continua Alliance is a standards organization jump-started by Joe Ternullo, assistant director of the Center for Connected Health, who, along with director Joe Kvedar and the Center's staff, put on a terrific conference) — and some are positively old warhorses already in widespread use, like Honeywell's offering, with interfaces for automated home monitoring and communication of data directly into interoperable EHRs or standalone software.
The Myca/HelloHealth presentation highlighted the robustness of the Myca platform (employee health programs — Qualcomm was featured at length; are there others?), medical home programs for small physician practices with "fractional use" of physician extenders — a new twist on the Vermont and South Carolina medical home pilots), PHR integration already there or on the way, lab results integration coming soon (Quest); reiterated the slow rollout of HelloHealth (12 practices so far); and demonstrated (in part via BCBS Ventures' investment in the company) that Jay Parkinson & Co. may not be able to put as much space between themselves and third-party payors as they may like. (This issue is not limited to HelloHealth, of course; the retail clinic sector, also founded on the premise of dissociation from third-party payors, has had to retrench; and some of the speakers also pointed to insurance companies as players not to be overlooked, due to the Willie Sutton factor . . . that's where the money is.)
Linda Magno, head of demonstration projects at CMS highlighted experiences with some demos and shared the podium with a couple of physician demo sites. Key takeway from her presentation was that payors (beyond government payors) are just not willing to pay more for improved quality. (Putting the Medicare managed care program / fiasco in the best possible light, her comment is consistent with the dismantling of that program, which pays higher prices, theoretically in exchange for more comprehensive care, because it was costing more than traditional FFS Medicare.)
Mark Bard, of Manhattan Research, shared some of his data re: physician internet use (doubled on-line work hours in past five years, and 2/3 of docs use smartphones in their practices — using apps 15-20 times a day), and patient use of "Health 2.0" tools (doubled to 80 million in past two years). This demonstrates that moving health care to the cloud will not leave all providers and patients behind.
More than one speaker concluded that we need to subsidize healthy choices as well as tax unhealthy ones (e.g., tax the Big Mac and subsidize the salad).
John Halamka and John Glaser presented interesting personal counterpoint on the issue of changing behavior, Halamka saying he easily chose diet and exercise over putting "poison" (Lipitor) into his body, Glaser saying he went for the stent and still enjoys his hamburgers.
Nicholas Christakis (looking at obesity as a social network epidemic, using Framingham Heart Study data – see NY Times magazine treatment), offered a couple of terrific analogies: First, carbon makes coal, graphite and diamonds – the difference depends on the interconnections between carbon atoms. Second, the form of the network yields its function: are you finding the mastodon, or killing the mastodon? As Christakis was winding down, I tweeted: "Unanswered Q: How do we design health care interventions to leverage IRL social networks?" The immediate, slightly tongue-in-cheek, response from @cascadia (Sherry Reynolds), tweeting from the Pacific Northwest: "Ask women with actual friends."
Jason Hwang (co-author of The Innovator's Prescription, applying principles of disruptive innovation to health care) spoke about technology as enabling decentralization in health care as in other industries, through commoditization of historically valuable and expensive expertise, and the need to replace the hospital-centric model with new types of networks. This shift is already under way, of course.
Bottom line: Given the crushing cost of hospital-based health care services, the current and growing primary care physician shortage, and the expectation of high-quality health care services accessible to all, the Center for Connected Health is letting us all know that the road to the future is the information superhighway, paved with intelligent payment reforms — but that the nodes in the network will always be human beings.