The Personalized Healthcare Ecosystem of the Future: Welcome to the Year 2030

Against your better judgment, you've just checked your contact lens-enabled news feed. You're annoyed, because President Meghan McCain has just used the Trump Doctrine to "fire" Medicare's lead administrator over the botched roll-out of the Agency's block-chain claims payment system.  The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh. 

 

It's the year 2030, and personalized "eDxTx" (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of "Medicare for All" (a.k.a "TrumpCare") has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit.  Geico's ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.

Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor's team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long.  The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer. 

As you sit down and use the heads up display in your lens to ponder the short-list of candidates to replace the fired administrator (a well-placed leak suggests it reportedly includes Elizabeth Holmes), the patch modulates your drug dosing to account for the change in body position.

You're hungry and looking forward to your specially tailored evening meal that is being drone-delivered to your patio in.... your contact lens again... 28 minutes. 

This is one of the five days out of the week that you adhere to a configured meal of calories, carbs, proteins, fats, nutraceuticals, probiotics and prebiotics that's adjusted to meet your taste preferences. It will also achieve an optimal body fat percentage, and reduce your risk of cancer and a host of other chronic conditions. The other two days use competitive gamification that is linked to your online preferences to reward you with a real burger for meeting your nutrition goals.  Not for everyone, but your behavioral reward profile suggested that that would help motivate you to stick to the diet. Who knew?

You ponder getting a burger tonight, but fight the temptation by triggering a mindfulness app through your lens.  The lights in your living space also dim and a riff made up of an pleasing artificial jazz-indie chord progression offers a well-placed distraction.

Diet and risk reduction are not the only an ingredients you use to achieve your goal of living 105 years, but also participating in next month's Goggle Spartan Race.  Come to think of it, time to tailor a set of 3D printed sneakers. You look forward to you and your personal life-drone (your spouse suggests it's more evidence of your narcissism; you've named it "Donald" to confirm her suspicions and annoy her) competing in a mix of virtual and real obstacles in a course of that includes real rope climbing and a virtual 3-D avatar obstacle course. The drone and wearables will network, monitor and heads-up display your neuro and cardiovascular dashboard for optimal performance. It will also use the same technology that they used in hospitals to anticipate any medical emergencies that could happen to you.

Naturally, your drone will use artificial intelligence to image, edit and securely post the race video for friends and family to view.

That's what you did last year, when the video also showed you twisting your ankle.  You had to go to a treatment center and be evaluated the old fashioned way, where a doctor treated you.  Some things never change, but avoiding those opaque bills and paying your deductible using virtual currency was so convenient.

As your pour yourself your recommended 1.2 ounces of bourbon (personalized by the distillery with a proprietary combination of esters and lactones to create your preferred finish), you reflect on how healthcare has changed since the days of in-home monitoring and physician teleconferencing. It worked well while it lasted, but was soon eclipsed by the cloud-based technology that combined physician intelligence ("physint") with Watson (artificial intelligence) that "scaled" in an era of fully automated care. 

Sort of like the driverless car that will take you to next month's race.

Speaking of old fashioned cars, that eDxTx medical alert last year reminded you of that old fashioned "check engine" light.  It seems a biochemical marker profile was consistent with the presence of an early stage tumor.  Based on your past medical data, the calculated Bayesian risk that the tumor was real approached 1%.  Watchful waiting using Medicare's IPAB guideline recommendations was raised as an option by your doctor, but you decided to undergo the additional testing to rule it out.  Naturally, your insurance covered most of that cost.

You finish your bourbon after you get an alert that the pizza has arrived.  You silently wish President McCain good luck. Some things never change.

Image from Wikipedia

The Latest Health Wonk Review

Here we go again.  While money can't buy love, Steve Anderson over at Medicare Resources looks at money and healthcare reform, and a whole lot more!

Enjoy!

Bro-pulation Health

The Population Health Blog wishes a health insurer would be as clever as the marketeers behind the Geico "Flextacular" commercial while extolling the virtues of its population health program.  For example, wellness with less bro'tatoe chips and bro'nuts and more bro'colli, bro'bacco cessation, and bro'ing to the gym for some exercise.

Persons with diabetes could strive for a lower Bro1c, hypertensives could seek a lower bro' pressure while persons with heart failure can 'bro to the doctor if their weight goes up by more than four kil'brograms in a 24 bro-ur period. 

Make that bro-pulation health.

Speaking of 'bro's, like many readers the PHB was also astonished by bad-boy "Pharma 'Bro's" smirking insolence during the Feb. 4 Congressional hearing on how Turing Pharmaceuticals turned a generic into a $750 pill.  That being said, the adult witnesses at the hearing later pointed out that the initial retail price - once the supply chain does its work - has little correlation with the final negotiated rate.  For Medicaid patients, that turned out to be "a penny a pill." 

The PHB suspects that the staff advising the House Committee on Oversight and Investigations knew this, but went along with their bosses' interest in publicly humiliating Mr. Shkreli.  While his bad behavior may be symptomatic of a deeper personal contempt for the rules, what this also demonstrates is that the U.S. is one of a handful of countries where we are able to publicly laugh at those in power and walk freely out of the room.  Good for us.  

An Update on the Evidence of the Impact of the Patient Centered Medical Home on Cost and Quality: Of Soup and Weather Vanes

In its work with a variety of payer and provider customers, the Population Health Blog has advised that primary care medical home planning is more "soup" than "soufflé," and that outcomes are more a matter of direction than preciseness.  Naturally, the MBA-types that populate and advise the C-suites and Boards of our health institutions never liked hearing that, preferring instead to impose their notions of cookbook orderliness on what they disdain as inefficient.

Bunk.

Anyone who has had an underinsured patient in crisis in their clinic at 4 in the afternoon knows what the PHB is talking about.

Which is why the trained professionals who actually take care of primary care patients will find a lot to agree with in the Patient-Centered Primary Care Collaborative's report on the Patient Centered Medical Home's Impact on Cost and Quality. 

This is a summary of the 30 recent peer-reviewed, state, industry or federal publications examining medical homes' impact on cost, utilization or quality.  There are pages of tables that conveniently describe the initiatives, the payment methodology, their impact on cost/utilization (mostly good), and the impact on other outcomes (mostly good).  To the PCPCC's credit, the review is free of the trade association-style framing that can obscure neutral assessments of the data; it even includes an entire section dedicated to study limitations.  Good for them.

Two PHB Insights

   

Soup: While often portrayed as a caveat, one of the major insights of the report is that the PCMH is best thought of as a "model" of care defined by a set of "attributes" that include patient-centeredness, comprehensiveness, coordination of care, accessibility and quality/safety.  Do right by adapting those principles into a clinic and, to paraphrase Justice Stewart, you'll know it when you see it.  Turning to the "soup" analogy, if it's liquid, there's stock, the ingredients are softened and the flavors have been extracted into a broth, you've got something that will satisfy. 

Let a thousand medical home clinics bloom.

Direction: Another major point of the review is that outcomes vary considerably, and not just in terms of dollar impacts, but on various measures of utilization and outcomes.  The insight here is that the "directionality" of this model of care is "pointing" toward lower overall costs with better clinical outcomes.  Unfortunately for administrators and insurers everywhere, the answer to "how much" is that "it depends." 

Fortunately for patients, the wind is blowing in the right direction

There are some other interesting take-aways. 

As "alternative payment models" (reminding the PHB to also use acronym "APMs" whenever possible) expand, the funding for PCMHs is likely to grow. The Medicare Access and CHIP Reauthorization Act (another acronym "MACRA") has fans in the PCMH community. 

$4.90 per patient per month is an average payment for medical home services, with dollar add-ons possible from various measures of performance, shared savings, care coordination, pre-payment and risk adjustment (see above on how "it depends"). 

Multi-payer collaboration convening commercial and government payers is more likely to have an impact on PCMH outcomes than single payer programs. Based on experience, this reminds the PHB of a similarity between the PHB spouse and Medicare: compromise is always possible so long as you do it her way.

Next Steps

The PHB couldn't have said it better.  Advocates for the PCMH need to continue to share their design and outcomes in the public square so that everyone can better understand its strengths as well as weaknesses and to make this soup even better.  As the report concludes

"Investment (ROI) or “total cost of care” research is needed that assesses the costs associated with PCMH transformation (or “upstream” spending) that results in “downstream” savings, through reduced ER visits or hospitalizations. This would demonstrate the extent to which spending on primary care results in long term ROI to the overall health system."

"As in past years, there was a dearth of studies that evaluated cost or utilization measures together with patient experience or provider satisfaction and health outcomes, essential elements of the Triple Aim. As we evaluate cost outcomes associated with the model, we must increasingly evaluate the model as a whole to ensure that cost savings and better patient care go hand in hand."

Soup and vane images are from Wikipedia