Population Health

Want to improve public health? Start with housing.

A well-worn axiom says that “hope is not a plan.” Indeed, hope alone is such a hands-up abdication of planning that editor Thomas Mowle was inspired to use the phrase as the title of his 2007 book of essays on the war in Iraq, which says something.

Still, if we play with syntax and add a few words, we can say that every successful plan should offer a measure of hope—hope for success, an improved reality, greater opportunity.

With the twin American scourges of homelessness and addiction, hope starts with a plan that includes housing—a refuge, even if it’s just a 50-square-foot wooden box.

“Housing is one of the best-researched social determinants of health, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs,” writes Lauren Taylor in Health Affairs.

Perhaps, then, housing is a key component in the overall explanation for why health and life expectancy have been declining in America the last few years. When workers making minimum wage—more than 20 million people and roughly 30 percent of all hourly, non-self-employed workers over 18—can afford a modest one bedroom home in only twelve counties in the country, it’s near impossible to argue that the gap between wages and housing costs does not create profound desperation and instability.

That despair, in turn, worsens public health in myriad ways. People with no hope turn to drugs and alcohol, battle depression, eat poorly, work three jobs to exhaustion and injury, battle chronic pain with no viable options, sleep too little, etc. And in worst case scenarios, they end up on the street with few if any possible good outcomes.

Is it the housing as an end that creates better public health outcomes? Not really. No one who lacks adequate housing or has to move frequently is clamoring for a 7,000-square-foot home.

Instead, it’s the benefits housing provides that support a healthier, more sustainable life. As an essential social determinant of health, well-built and well-conceived housing is one corner of foundation supporting four interconnected quality of life pathways: stability, quality and safety, affordability, and community. If any of these pathways are lacking in the housing options available, housing potentially becomes a negative social determinant of health.

For example, consider the tiny homes many cities are now building to try and grapple with the problem of homelessness. Initially, it seems like any kind of lockable structure is an improvement on doorways, park benches and even shelters. But in some cities, tiny houses don’t come with heat, electricity and plumbing, effectively making clusters of houses a small step up from homeless encampments. As social determinants of health, they still register a negative, leaving America far from realizing the goal of housing as net positive for all citizens.

Of course, housing is only one social determinant of health, which collectively are generally lumped as social and environmental factors (20 percent), genetic fortune or misfortune (30 percent), and individual behavioral choices (40 percent).

The final 10 percent is healthcare, and maybe that percentage seems a little light, given how much attention we pay to the healthcare system. Still, think about the ability of healthcare to balance all other social determinants—diet, housings situation, employment status, mental status—when they’re decidedly or even predominantly negative.

It’s not hard to see why clinicians resent being held responsible for the fire after the house is engulfed in flame.

And what, if anything, can healthcare do about these social determinants over which they have no control? In short, look for solutions and shortcuts.

Comprehensive medical records, interoperable systems, healthcare data exchanges and the like can together enable hospitals and clinicians to circumvent the complications created by a transient life. But healthcare providers and organizations can also address social determinants of health more directly.

“The health care sector should continue to explore the extent to which home interventions, such as the well-studied community asthma initiatives, can make financial sense among other patient populations,” says Health Affairs writer Taylor. “Given the shift toward accountable care models and other value-based payments, the financial incentives for health care systems to take broader responsibility for social determinants of health (including housing) are likely to increase.”

And that’s the added factor that may motivate healthcare organizations as much as anything else. Housing makes communication with patients more reliable, which cuts down on the costs of care and lends stability that enables accountable care. Really, all social determinants on the positive side of the ledger decrease healthcare costs, but stable housing makes the others that much more likely.

The social determinants of health are also lurking in the national discussion of universal healthcare. At times, the nation and the industry seem caught up in discussions of payment models, insurance deductibles and technological advancements. Maybe we miss the fact that having affordable healthcare is better than not having it in the same way that having a 200 square-foot house with locks is better than living on the streets, even if we can agree that such basic standards are not enough.

Using social determinants, we could improve the health of many Americans without ever specifically addressing a medical record or length of stay. And until we do see patients as a complex amalgamation of influences, we can’t be surprised that specific therapies out of context have negligible impact on overall public health.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Insuring America and The Expanded Role of Medicaid

The expansion of Medicaid and insurance subsidies through the ACA meant 20.4 million more people had health insurance in 2016 than in 2010. According to the non-partisan Congressional Budget Office, somewhere just north of 20 million Americans would lose health insurance in the various repeal-and-replace scenarios that have been floated of late and rejected, for now. That number jumps to 30 million-plus if Obamacare is simply repealed.

What all proposed ACA-repeal legislation has in common is deep cuts to Medicaid. Indeed, the group most affected by any of the bills is poor Americans who receive Medicaid support.

“Federal Medicaid spending would be reduced by 26 percent by 2026, largely because of the phase out of federal Medicaid expansion funding, but also because of the imposition of per capita caps or block grants,” writes Health Affairs blogger Tim Jost in analysis of one legislative proposal, the Better Care Reconciliation Act released by the Senate budget committee on July 20. “The CBO projections of loss of coverage remain substantially unchanged from the earlier analysis … The number of the uninsured would increase by 19 million by 2020 and 22 million by 2026.”

In some instances, replacement legislation in Congress divides state and national politicians of the same party. Half of the states that took expanded Medicaid dollars have Republican governors. Total enrollees in ACA insurance marketplaces are highest in Republican controlled legislative districts.

“We are now able to provide health insurance to 700,000 people,” said Ohio Governor John Kasich, who maneuvered around his state legislature in 2013 to expand Medicaid. “Let’s just say they just got rid of it, didn’t replace it with anything. What happens to the 700,000 people? What happens to drug treatment? What happens to mental health counseling? What happens to these people who have very high cholesterol and are victims from a heart attack? What happens to them?”

As chief executives of state governments, Kasich and other governors are directly responsible for state management, a direct responsibility that members of Congress do not share. Ohio is in the eye of the opiate addiction storm—the most devastating substance abuse epidemic in American history—and badly needs the expanded Medicaid dollars.

The fundamental issue with Obamacare repeal is the expansion of so-called entitlements, the social safety net and federal spending. Once a social program is established and benefits are extended, it is extremely difficult to pull them back. If social security is the third rail of politics, expanded Medicaid may soon become rail 3A.

Why is there even a discussion of Medicaid contraction when there is clearly so much need? Because, for many, such handouts do not reflect how a nation built on a culture of independence and self-sufficiency should function. Because the perception of some is that programs like Medicaid create dependence and limit freedom.

"When the Democrats built Obamacare, they built a Berlin Wall to keep the American people inside,” wrote Utah Senator Mike Lee, a leading opponent of the ACA. “The Consumer Freedom Amendment I'm offering will tear that wall down and allow the American people to connect with willing insurers to buy the policy that is right for them."

But Lee’s proposal, while submitted with honorable intent, still leaves a massive gap between the availability and affordability of health insurance. It may give some Americans freedom of choice, but it does not alleviate the Berlin Wall of poverty and poor health, to use Lee’s analogy. It holds the line ideologically while doing little to address the underlying problem.

And it defines ‘freedom of choice’ only in terms of what citizens are not coerced into buying. Many Americans do not feel free to search the labor market for a new job because they risk losing health insurance. Many hospitals are not free to deny service to those without health insurance.

The uninsured who must ultimately go to the ER for treatment are often not free to pay for both medical care and food. Insurance consumers are not free to pay a lower premium bill because they don’t like that prices have been driven up by the uninsured. As every other industrialized nation has proven, costs per citizen are significantly lower when everyone is part of the same risk pool.

Some would have us believe that the 3 percent of citizens paying more for insurance thanks to Obamacare are the only ones impacted. Certainly, their hardship deserves attention. But don’t the millions who can’t get insurance without the ACA deserve notice as well? And what of the Americans who ultimately pay for those that choose not to have insurance and get hurt? Costs accrue, regardless, and someone will pay for them.

That problem is a healthcare system that routinely leaves those most vulnerable at risk. Medicaid expansion was one solution to that problem. It is an imperfect solution, to be sure, with legitimate liabilities, but at least it is a starting point for ensuring all Americans are covered.

“Sickness is costly, it shrinks the workforce and makes it less produc­tive,” write Walter McClure, Alain Enthoven, and Tim McDonald in the Health Affairs Blog. “Good health, like education, expands the workforce and makes it more productive … Good public investment programs infeas­ible in the private sector, such as universal public education, return far more to national prosperity than they cost in taxes. If both sides of the aisle will work together to do it right, universal health coverage is just such an opportunity.”

American healthcare has crossed the Rubicon and must find ways to extend insurance coverage, not retract it. The costs of the uninsured seep into the healthcare system anyway, as do the costs to society of addiction and mental illness when intervention comes far too late.

We should not cling to the ACA because it was passed by Democrats, nor should we oppose other ideas because they come from Republicans. I am not saying that free-market solutions are off the table and we must look to big government to save us.

But we must pursue ideas that expand healthcare availability. Healthcare costs threaten to bankrupt the country and lack of care is destroying lives in record numbers. For now, Medicaid expansion is one way to extend coverage and improve lives—to invest in the health and productivity of our people. It should not be viewed as the end game, but until we can improve on it in a way that makes insurance more broadly available, we cannot eliminate it either. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Population Health

Do we have to define population health to make it useful?

Maybe the initial challenge of population health is deciding exactly what that phrase means.

Well before it became a catchphrase in health IT, population health was the province of academics who devised predictably academic definitions like “… the aggregate health outcome of health-adjusted life expectancy (quantity and quality) of a group of individuals, in an economic framework that balances the relative marginal returns from the multiple determinants of health.”

Originally created by and revisited in a Health Affairs blog post by Population Health Sciences Professor David Kindig, this definition may help with understanding, but it makes specific application outside of academics kind of problematic. Today, there are many more minds working on population health matters, which has created what Kindig admits is “a conflicting understanding of the term today.”

Which version of the “conflicting understanding” a person subscribes to seems largely determined by prevailing questions. Are we trying to track the health of people in a geographic area? Is the primary concern the health of a particular ethnic group? Is economics the challenge in growing a client base enough to scale the costs of population health? Are we trying to track spreading disease?

Because the end goal determines where boundaries are drawn around subjects, the answer is ‘Yes’ to these and almost all population health objective questions.

The Affordable Care Act (ACA) and Accountable Care Organizations (ACOs) have made it more expensive to readmit patients soon after treatment, so the bottom line comes into play regardless of which question is being asked. But the spread of technology like electronic health records (EHRs) and other applications also makes it possible to use data in a variety of ways, perhaps many of which we have yet to discover and define.

“A critical component of population health policy has to be how the most health return can be produced from the next dollar invested, such as expanding insurance coverage or reducing smoking rates or increasing early childhood education,” Kindig writes.

More bang for the buck—everyone wants it.

“To do population health, insurers must have a critical mass of members in each of several high-cost diseases: diabetes, heart disease, cancer, behavioral health,” says Indianapolis Business Journal reporter JK Wall. “Otherwise, it will be too expensive to hire the clinical staff to develop the necessary clinical protocols, to staff the high-touch patient intervention programs and to develop the data analytics and customer engagement technology seen as vital for doing effective population health on a large scale.”

Wall adds that much of the insurers’ population health strategy is driven by two facts: The ACA squeezes per-patient profit margins, and maintenance of many diseases is expensive.

If you are a physician or hospital administrator, you will be concerned with chronic disease in a defined population from a causes-and-treatments, as well as a financial perspective. To that end, hospitals are frequently using remote patient monitoring and analytics as embedded components in the care process, writes reporter Jessica Davis in Healthcare IT News.

But even while much data is being gathered, there is a gap between the data we can compile and knowing what to do with it.

"Analytics provides a huge opportunity, but we lack the data science and medical algorithms," says Gregg Malkary, managing director of Spyglass Consulting Group. "We don't really know how to translate certain data because medical science is immature."

A high-profile example of what Malkary describes is the failure of Google Flu Trends (GFT), the company’s effort at tracking search data and alerting public health officials of flu outbreaks before the Centers for Disease Control could know about them.

“When Google quietly euthanized the program … it turned the poster child of big data into the poster child of the foibles of big data,” write political science professors David Lazer and Ryan Kennedy in Wired.  “But GFT’s failure doesn’t erase the value of big data … The value of the data held by entities like Google is almost limitless, if used correctly.”

Google’s adventure becomes a lesson for those that come after, adding to acquired knowledge and contributing to later success. In many ways, that same ethic is at the heart of the optimism surrounding all these piles of data we are starting to acquire. Right now, the rhetoric is ahead of the reality, but the gap between the two is closing rapidly enough that there is reason to believe the use of big data in population health will become common.

But do we still need an accepted definition to work from?

Actually, according to Kindig, we need two.

While population health is often viewed as a mostly clinical measure, Kindig feels the terms population health management or population medicine better describe this physiological aspect of group wellness.

“The traditional population health definition can then be reserved for geographic populations, which are the concern of public health officials, community organizations, and business leaders,” he says, and which factor in contributors like education, employment and other non-clinical issues.

Geography on one side and whatever the determinant is—ethnicity, education, diet—on the other. It may not get us down the path to universal understanding, but it does provide the kind of flexibility that will probably come in handy as we look for new ways to analyze mounds of data in search of healthier populations.  

Richard Sullivan is chief operations officer for Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Population Health

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

The viability of rural healthcare relies on evolution

Choice can be a double-edged sword—we all want more of it, but with too many choices paralysis can set in. Choosing a physician or hospital, for example, in an urban or suburban area without some kind of recommendation can truly be a daunting task.

But it beats having few or no choices. Increasingly, that’s the situation rural Americans find themselves in as the number of hospitals decreases and specialists stay in the cities.

While this may have been the trend in rural healthcare over the past 10 or 15 years, the current advance of technology in healthcare and the introduction of new care models offers rural hospitals much-needed opportunity. Heartland hospitals have the ability now to revamp and re-envision care in the essential areas where America produces energy and food.

What strategies and adaptions available now can ensure affordable and efficient rural care for the foreseeable future?

Strategy 1 - Forge relationships. As with all hospitals, Winona Health (99 beds, Minnesota) had more than a few patients using the ER for chronic but manageable health conditions. To get ahead of and maybe prevent ER visits, Winona Health established relationships with organizations that included a nearby senior center, the state health department and Winona State University to provide support for the chronically ill. This led to the formation of the Community Care Network in 2012, through which Winona Health trained Winona State University students as health coaches.

By providing basic emotional support and performing a few tasks like grocery shopping, the Community Care Network reduced ER visits by 91 percent and hospital readmissions by 94 percent in the first 90 days of the program.

Are there organizations in your community that can contribute to managing the health of those who need support and preventing health emergencies in the ER?

Strategy 2 – Innovate around care. Even where there are sufficient providers in a rural area, there are seldom enough specialists, which means patients sometimes have to travel long distances for specialized care. The University of New Mexico’s Project ECHO works to address this need through educational innovation by connecting specialists with physicians in rural areas, giving them the understanding they require to meet particular patient needs.

For more than 20 years, Stanford University has organized the Chronic Disease Self-Management Program (CDSMP). The program trains patients with chronic illnesses to manage their own emotions and behaviors—eating well, taking medications appropriately, communicating with friends and family, getting enough rest. Results demonstrate that the CDSMP improves the lives and satisfaction of chronically ill patients, and it saves money on reduced hospitalizations and readmissions.

Are there cost-saving care innovations your organization is not yet utilizing? How can you implement proven programs to keep costs down and bring patients deeper into the provision of care?

Strategy 3 – Focus on what you do well. Most doctors willing to live in rural areas are not specialists.

“Specialty has a powerful effect on physician location choice …” according to a study on physicians and rural America published in the Western Journal of Medicine.  “Family physicians distribute themselves in proportion to the population in both rural and urban locations and are the largest single source of physicians in rural areas. All other specialties are much more likely to settle in urban areas.”

Specialized care is not and probably never will be the strong suit of rural physicians. But this perceived weakness gives rural hospitals the opportunity to focus on natural strengths.

“A rural environment lends itself to population health and wellness,” says Jennifer Lundblad, CEO of Stratis Health, a Bloomington, Minnesota, nonprofit that promotes innovation and collaboration. “Providers probably know the patient and their family, they may go to church with them, they see them at the grocery store. If rural communities can figure out how to harness those assets, they will be well-positioned for the future.”

Of course, rural health providers remain the most important interface with patients, making them primarily responsible for creating access to specialists by forging relationships and innovating around care (above), and by maximizing the use of technology (below).

Are the wellness and population health efforts in your organization robust enough to create lead time when your patients have to utilize your relationships with specialists?

Strategy 4 - Use technology. Much has been written about the potential of telehealth to alter the rural healthcare landscape.

In South Carolina, the state Department of Mental Health worked with the University of South Carolina School of Medicine and 18 hospitals, mostly rural, to provide telepsychiatry services. Most of the hospitals had no psychiatrist in the ER when mentally ill patients arrived, and the program provided that resource 16 hours a day, 7 days a week.

The telepsychiatry services have reduced both wait times in the ER and inpatient admissions, and it has lowered costs. Patients are going to their scheduled outpatient appointments more often, and levels of satisfaction are up for both patients and physicians.

Telehealth services, while not the only approach to technological innovation, are now seen as the most promising technical cure for what ails rural hospitals.

“There are two kinds of healthcare innovation: more-for-more and more-for-less,” write Nathan Washburn and Karen Brown in the Harvard Business Review. “The American healthcare system exemplifies the first kind, offering more and more value at higher and higher costs … Virtual consultations … are at the heart of a reconceptualization of rural hospitals (and eventually urban clinics and hospitals as well) because they provide access to higher-quality care at much lower costs.”

Of course, rural hospitals cannot provide effective population health and wellness services without effective, affordable, interoperable healthcare IT systems; the technology is a prerequisite. While rural health organizations currently lag behind their urban and suburban cousins in terms of adoption, government initiatives are helping to close the gap.  

Is your organization maximizing affordable technologies, including telehealth and electronic health records, that improve the bottom line without busting the budget?

Strategy 5 - Merge. Wafer-thin profit margins (if they exist at all) and threats of insolvency would cause any rural hospital executive to consider merging or being acquired. Predictably, activity in the hospital M and A sector has been brisk over the last several years as rural facilities sign on with larger, more financially stable urban and suburban health networks. 

So, is independence even realistic, let alone desirable, for rural facilities? The answer is yes, though with caveats.

“The trick to staying local and ‘going it alone’ is often through configuring creative but limited partnerships with larger systems,” writes Beth Nelson in Hospitals and Health Networks. Complete independence may be completely historical, but that doesn’t mean rural hospitals can’t maintain a semblance of self-determination.

Have you explored the alliances available to you that may enable your hospital to survive and provide for the needs of the surrounding community?

A piece of good news: At least one study shows that rural hospital closures have not had a measurable impact on local mortality. The not-so-good news: rural residents are generally less healthy than urbanites, so having no local hospital and healthcare organization eliminates the opportunity to improve care through various wellness and population health programs.

Just as they always have, rural hospital executives and clinical leaders are doing all they can with the resources available. The difference in our current technological age is that so many more cost-saving tools exist than just ten years ago. By employing strategy and technology, rural healthcare organizations finally have the tools to move beyond survival and become catalysts for healthier communities. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

On engaging patients and having the patience to make it work

When people in healthcare use the phrase ‘patient engagement,’ they mean involving patients more in their own care, perhaps urging them to be more responsible for their own health.

From a costs perspective, this makes sense. No one argues that the healthcare system is not rife with waste and duplication, and much of the treatment would be unnecessary if patients paid attention to their health well before dramatic efforts are the only remaining option. Also unarguable is the impact healthcare has on the American economy as it steadily gobbles up higher shares of national revenue. 

But simply identifying patient engagement as one solution to systemic healthcare challenges achieves little. Sure, Americans would have fewer health problems if they ate better, lost weight, took their medications regularly and got more sleep, but most everyone already agrees on that. Human behavioral change is difficult and gradual, and it happens through incremental approaches, not general pronouncements.

So what tactics can hospitals and providers use to shift some responsibility onto patients themselves?

  1. Teach patients to do what they can. In a fascinating example, a hospital in Sweden transitioned more than half of dialysis patients to a self-management program after a single patient asked for control of his own care. 

    “Shortly afterward, the patient was managing his own dialysis and experiencing fewer side effects of the treatment, such as nausea, edema and hypotension,” according to an American Hospital Association case study. “The patient and the nursing staff took this success to the next level and began training other dialysis patients interested in self-dialysis.”

    Similarly, Dallas’s Parkland Memorial Hospital began a program in 2009 that trained patients on long-term antibiotic therapy to administer the drugs to themselves at home. The benefits of the program today include shorter hospitals stays, lower readmissions and millions of dollars saved while still achieving comparable outcomes. 

  2. Change the dialogue with patients. For decades, medicine has used the language of subject or actor and object—the doctor applies his wisdom and knowledge; the patient accepts the treatment. Arguably, this manner of speaking about the doctor/patient relationship has contributed to a level of patient passivity. 

    “Under that outdated model, patients were expected to comply with treatment plans, not contribute to the development of them,” writes Ginny Adams, a clinician and consultant. “Certainly, we as clinicians meant well, but our style of caring was sometimes distant and too directive.”

    The language of medicine often widens the gap between physician and patient. If doctors and nurses want patients to be more involved in their own care, they must take the time to explain in layman’s terms. If patients want to truly understand their situation, they must ask clinicians for more explanation and understandable language. 

  3. Engage technologically. Especially for younger generations, communication is now the product of more applications and devices than even the savviest consumer can keep track of. If healthcare organizations want to embed in the lives of patients, there needs to be some adapting to the predominant media of the day. 

    What does that mean, specifically? Should hospitals be on Instagram? Probably not, but that’s a decision for each provider and organization. It does mean patients should have access to a robust patient portal (see more on the benefits of long-term portal use here) that enables viewing of records, scheduling, communication with providers and paying bills. It might also be helpful if patients could see an explanation of their records; for most, blood on the brain is more understandable than subdural hematoma.

  4. Partner with the community. As healthcare shifts to a more consumer-oriented and patient-focused model, it’s hard to not see most healthcare organizations as population health entities. Sure, we’re talking about how patients can take on more of the responsibility for their own health, but that has to include making sure they have the information and knowledge necessary to do so.

    Wisconsin’s Bellin Health, for example, engaged with the local community through The Live Algoma Coalition, a partnership that includes local businesses and government, the school district and community agencies. With grant funding from the Institute for Healthcare Improvement, the Algoma Coalition will “help communities further their capability to improve the health of targeted populations and develop ways to share and spread community-driven approaches across the country.”

Beyond engaging in strategies to improve patient engagement, it might also help if we could alter our perspective of medicine and caregivers.

“We have a certain heroic expectation of how medicine works,” Atul Gawande, MD, writes in a recent New Yorker article. “We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.

“But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.”

In other words, because we too often view doctors as fire fighters, by the time many of us ask for help, the house has already burned to the ground.

Realizing the kind of patient engagement we’re talking about is no easy task, to be sure. While pursuing it, we also have to deal with ancillary concerns: making EHRs work effectively, expanding health insurance so citizens have access to care, integrating physical and behavioral health to reduce comorbidities. And that doesn’t even address the fact that changing attitudes and behaviors across a large, diverse society is more challenging than doing an about face in an ocean liner.

But the evidence for moving forward is clear. Engaged patients are healthier and more active. Health systems and practices that engage patients reduce costs. Communities with embedded healthcare organizations are more cohesive. In a society that measures success in hours and days, not months and years, it will be crucial to highlight the victories along the way and enable both patients and caregivers to celebrate improvements. Hopefully, a society that celebrates the individual might see the value in a self-empowered approach from the very start. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Population Health

America has a rural healthcare crisis. Technology can help.

As 2017 begins, around 81 percent of Americans live in urban areas, up from 79 percent in 2000. At the same time, urban and suburban areas where vacant land exists (so, not you, San Francisco) have been expanding, redefining what used to be rural. With this demographic shift comes a transition of resources and tax bases that leave rural areas and rural services, including healthcare, struggling to survive.

Indeed, we can learn a lot about the state of rural healthcare from several access-related statistics:

  • As of last year, more than 70 rural hospitals had closed since 2010 and 673 were vulnerable to closure, of which 68 percent were critical access.
  • The distance to hospitals in rural America is often much further than in urban areas, sometimes meaning the difference between life and death.
  • The number of doctors per 10,000 residents is 13.1 in rural areas and 31.2 in urban environments, simply making care harder to get. With regard to specialists per 100,000 residents, the average is 30 in rural areas and 263 in urban.
  • More than half the counties in the country have no practicing psychiatrist, psychologist or social worker to deal with mental health and addiction issues.

More generally, America’s rural population is older, makes less money, smokes more, is less healthy and uses Medicaid more frequently. All these factors dramatically complicate access issues and yield predictable results.

Opioid-related addiction and overdoses, for example, are disproportionately higher in rural areas than in urban. Improvements in the death rate for rural residents have evaporated. For rural white women, death rates have increased as much as 30 percent in recent years, a stunning reversal of previous trends.

Why this is happening is complex and not easily fixed—certainly lack of economic opportunity is a factor, as demonstrated in the recent election—but in many ways technology can make a discernable difference.

Opiate Addiction and Treatment

“While my city patients are well aware of the fact that most physicians consider opiates high risk for addiction, this fact may totally elude my rural patients,” writes Dr. Leonard Sowah in a recent KevinMD post. “I had a few experiences with individuals who were clearly addicted to opiates but would constantly state they were not addicts since they received opiates only from licensed prescribers.”

Certainly, increased awareness and better educational materials will help this situation, but the responsibility will ultimately fall to physicians. Without the Prescription Drug Monitoring Program (PDMP), this would be a near impossible task. The PDMP—a database of electronically prescribed medications and patients that functions in 49 states—makes it possible for doctors to see a patient’s prescription history and identify potential “doctor shopping” and addictive behaviors.

Behavioral Health Treatment

If the National Health Service Corps, which uses loan repayment as incentive for doctors to work in high-demand areas, isn’t doing the trick, what’s next on the list of ideas?

Right now, almost all bets are on telehealth, which has proven effective thus far in treating depression and PTSD. Congress made funding for telehealth a significant part of the recently passed 21st Century Cures Act and is requiring CMS to periodically report back on how telehealth is being used in Medicare and whether or not it is working.

Telehealth may also provide relief on the cost side of the equation for rural hospitals. According to a 2012 Institute of Medicine report, telehealth increases volume, improves care and cuts costs by keeping patients out of the ER and reducing readmissions. To make it really effective, all insurers need to embrace telehealth and all providers need to implement the technology.

Hospital Closures and Access to Care

Telehealth is also one solution to hospital closures, even if it’s not ideal or even effective for every scenario where a hospital would improve or save lives.

Electronic health records (EHRs) and participation in health information exchanges (HIEs) and accountable care organizations (ACOs) offer benefits in terms of streamlining patient care and improving efficiencies, as well as having ready access to best practices and specialists when referrals are necessary.

“The ACO Investment Model was designed to help rural communities move down a path receiving better payment for delivering better healthcare,” said CMS Acting Administrator Andy Slavitt. “In this rural-oriented model, we prepay shared savings to ACOs in rural areas – an oxymoron, but a clear acknowledgement that you need to invest when that’s not always easy and a sign of our willingness to invest along with you.”

No, the ACO Investment program is not a technology, but it is almost completely hamstrung if rural providers don’t adopt technology to make improvements.

Non-technological Factors

Of course, technology alone won’t fix the issues that plague rural healthcare. It’s not magic, after all. Economics and public policy will also come into play.

For example, the slim profit margins, if they exist at all, that rural hospitals create necessitate an affordable EHR system that doesn’t require a huge pile of cash up front to implement. Most hospitals have used Meaningful Use to help pay for those systems, but the unique financial challenges of rural healthcare might necessitate a Stage 3, even though CMS has signaled that the program is about done.

Using policy to assist rural providers is the focus of the recently formed CMS Rural Health Council, which operates with an all-encompassing agenda:

  • Improve access to care for all Americans in rural settings
  • Support the unique economics of providing healthcare in rural America
  • Make sure the health care innovation agenda appropriately fits rural health care markets

A solution that meets all three of those objectives will have to be creative, flexible and effective.

The ongoing changes to American healthcare occur in a time of social and political upheaval, and it will take some time to know whether or not past legislation and upcoming changes to those laws have had a positive impact. If not, the nation may have a difficult decision to make about rural care. If the economics don’t improve and technology can’t make a significant financial difference, what are the alternatives? Can acquisitions by larger hospitals keep facilities alive AND keep costs down?

It’s an important conversation, and solutions will be difficult to hammer out, but what hangs in the balance for the people that grow our food and harvest our energy is essential to the entire nation. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

When illnesses collude: How comorbidity threatens American healthcare

Comorbidity is not a word heard every day—not even in healthcare, where it applies. But researchers and physicians, assisted by IT-derived diagnostic data, have come to understand that comorbidity is essential to understanding and managing population health, especially among vulnerable populations challenged by mental illness and addiction.

A patient with comorbidity has at least two chronic diseases at the same time that interact in such a way as to worsen the impact of each illness on the individual. Imagine irritable bowel syndrome or Crone’s and diabetes working in tandem, for example, and it’s not hard to see how comorbidity becomes a tag-team bludgeon.

Among the total population of the United States, 25 percent have multiple chronic conditions, according to the Centers for Disease Control and Prevention (CDC). Of course, those chronic conditions are not limited to the physical. Once we include mental illness and substance abuse in the definition of comorbidity, rates rise dramatically and are often more debilitating.

There is simply no denying that even the most common mental illness creates the risk of comorbidity with drug and alcohol abuse. According to the National Bureau of Economic Research, Americans with a current mental illness account for 38 percent of all alcohol, 44 percent of all cocaine and 40 percent of all cigarettes consumed in the country. Those who have ever had a mental illness consume 69 percent of all alcohol, 84 percent of cocaine and 68 percent of cigarettes.

In this environment, doctors and the healthcare system are not tasked with just treating a physical illness or three. They also have to treat a physical challenge that may have been neglected due to mental illness made worse by substance abuse. Or maybe they’re trying to wean a patient off heroin used to deal with chronic pain after the OxyContin subscriptions ran out.

It’s this complex self-medication dance that regularly doubles back on itself and dramatically ratchets up costs in terms of both healthcare dollars and lives. Opiate-related deaths just recently surpassed those from gun violence, and healthcare costs rose 3.4 percent last August, the highest one-month rise since 1984.

“On average individuals with chronic medical conditions incur health care costs two to three times higher when they have a comorbid substance use disorder compared with individuals without this comorbidity,” wrote Surgeon General Vivek Murthy in his recent report on addiction in America.

No, mental illness does not always lead to substance abuse and an often irreversible downward spiral. But addiction always makes both physical and mental illnesses far worse, even if we cannot determine causality or directionality.

A survey by the National Institute on Alcohol Abuse and Alcoholism, for example, identified comorbidity in a majority of respondents. A separate study by the NIAAA found that 56 percent of subjects with bipolar disorder also practiced some form of alcohol abuse and were more likely to have medical comorbidities like lung and breathing issues because smoking is so common.

How can we deal with mental illness to try and avoid substance abuse and medical comorbidity?

  • Catch it early. “… research indicates that 90 percent of people who develop a substance use disorder started their use before age eighteen,” writes Alexa Eggleston of the Conrad Hilton Foundation in a recent Health Affairs blog post. Eggleston speaks of substance abuse in general, but the risks are greater in the teenage years, when most mental disturbances manifest, making increased awareness even more necessary.
  • Initiate treatment. Addressing a mental issue is more straightforward before comorbidity becomes a factor. If mental illness and substance abuse comorbidity happens, treatment should focus on both issues at once, according to the National Institute on Drug Abuse.
  • Break down silos. The unfortunate tendency in healthcare going back decades has been to silo information and care. Treatment has tended to focus on independent specialists treating separate aspects of the patient condition without fully addressing how they impact one another. That must end. The placebo effect, for example, shows us that the brain and the body are not separate and that treating them as unrelated makes as much sense as changing the oil on a car with four flat tires.

To be sure, changes to the way we provide care—paying for value, Patient Centered Medical Homes, ACOs, HIEs, etc.—have gained great momentum that should continue. As mandated by the recently passed 21st Century Cures Act, interoperability among healthcare IT systems must become a reality so ER docs can see when a patient is bipolar and family practitioners know immediately that their new patient is on anti-psychotics.

Annually, the United States spends $35 billion from both public and private payors to treat substance misuse, but that’s a small fraction of the amount addiction extracts from American society in terms of services for the homeless, work absenteeism, broken families and other types of fallout. In total, substance abuse is estimated to cost the United States more than $400 billion each year, an amount that is 2/3 that of the Pentagon budget.

We are currently in the midst of one of the worst drug-addiction epidemics the nation has experienced. No, integration of patient record systems and patient care protocols will not prevent the destructive chain of events that leads to substance abuse, but becoming more alert to the frequency and severity of comorbidities may enable us to see warning signs sooner, share information and work more interactively with other caregivers, and more effectively improve patients’ overall health and quality of life. And this multi-pronged approach to quality of care will very likely minimize the costs to society in the process.

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Subscribe to Population Health