New System: Our current healthcare treatment system has changed very little since the days of the rotary telephone. We keep doing the same thing and expect a different result. Primary care special operation teams focused on a related set of priority chronic conditions will make all the difference. Cardiovascular diseases and related conditions like diabetes or hypertension make up almost half of these priority conditions. Our model is evidence-based in every function including system design. That includes improving diabetes and blood pressure control. “The one approach that has proven to be effective is using specially trained nurses or pharmacists, under appropriate supervision, with authority to make medication changes without consulting the physician as long as the changes fell within approved treatment algorithms.” Your practice or institution can serve as the hub with the supporting protocols, education, CME credits, payment model, analytics, and population health tools. The spokes can be federally qualified health centers, critical access hospital providers, pharmacists under collaborative practice agreements, or single independent nurse practitioners focused on chronic diseases.
New Science: New genetic, epigenetic, signaling and optimal medical therapy science means that we can understand the related topics of chronic disease and aging in much greater depth and manage these conditions with much greater precision. We can extend healthy life and treat chronic diseases more effectively now. Chronic diseases and accelerated aging are related at the level of epigenetics and molecular biology. Most chronic diseases are not caused by abnormal genes. Accelerated aging and chronic disease development are related to abnormal regulation of normal genes (epigenetics). Genes that are essential to fetal and childhood development become much less active in healthy, young, fit, adults only to be reactivated later by cigarette smoking, processed food, abdominal fat and aging itself. These abnormally activated genes switch on the master metabolic genetic switch mTOR (mechanistic target of rapamycin) or they switch off the master metabolic switch AMPK. In the fetus and child, these switches coordinate food supply with growth and energy production. In middle-aged and older adults switching on mTOR makes the heart bigger, the arteries thicker, and cancer more likely. Metformin, empagliflozin, caloric restriction, intermittent fasting, and exercise switch off mTOR and switch on AMPK directly. Lisinopril, losartan, statins, spironolactone, and eplerenone switch off mTOR and switch on AMPK by reducing oxidant production. That is why these interventions reduce heart attacks and strokes more than they lower the target risk factor.
When you combine these interventions in optimal medical therapy (OMT) protocols for chronic medical conditions like heart artery disease or diabetes, you achieve much better clinical and financial outcomes than in usual care, the care that most patients receive in the United States. In heart artery disease, mortality may be reduced by up to 90% and per patient per year costs by $21,900. All-cause mortality is reduced to a similar level. We have 21 years of follow-up in a similar study in patients with high-risk type 2 diabetes that proves patients on OMT lived 8 years longer at lower cost than patients in usual care. Half the usual care patients were dead by age 68. Patients with diabetes on OMT had one fourth as many heart attacks, one fifth as many strokes, and one sixth as many progressed to diabetes. There was a 70% reduction in heart failure hospitalizations. These two initiatives are still active in Colorado and Denmark. It is time to replicate and scale what they have done so that OMT is available in our smallest towns, largest cities, and most disadvantaged populations.
New Payment: Our fee for service healthcare payment system is the biggest barrier to OMT adoption. We pay primary care organizations to produce widgets. In primary care, the main widget is an office visit. Payment for an office visit only requires documentation that you covered certain topics during the visit. The computer your doctor is busy with during your visit documents that he covered the topics. Your problem, your medicines, your medical history, his examination, and her recommendations. That’s it. There is no requirement that your provider develop a relationship with you or solve your problem. So, big health systems require that doctors run from room to room documenting office visits on computers. There is a quota for widget production for primary care providers in big health systems. (relative value units or RVUs) If they don’t make the quota, they get dinged. If they exceed the quota, they get a bonus. Solving your problem is nowhere in the equation. They are on a hamster wheel. The average panel size for a family practitioner in the US is 2300 patients. Estimates of the time required for a provider to deliver all recommended acute, chronic, and preventive care to that many patients is 22 hours a day! Primary care providers are no happier about their practice patterns than you are. This is a systems and leadership problem. Your primary care provider is doing the best she can in a broken system. Fee for service payment is all about institutions. Patients and primary care lose in this system. It will never produce better health at lower cost!
So, what payment model would work? We should pay providers to help you live a longer, healthier life for less money if you have a chronic disease. You have learned on this site that diabetes with chronic kidney disease is very expensive. One third of these patients have chronic kidney disease (CKD). Patients with no CKD cost just over $7000 per patient per year. Patients with stage 3 CKD cost $24,000 a year, and cost rise quickly from there so that stage five patients generate costs that exceed $100,000 per patient per year. Most of these patients are dead before they ever reach dialysis—half by age 68. Pay a provider organization $22,000 per patient per year for the total cost of the patient. Shift the risk to them and save money while dramatically slowing progression to more expensive stages of CKD. The panel size for a provider doing this work should be about 400. That provides almost 9 million dollars to provide all the care needed by those 400 patients. The provider can provide the time to call that patient, to sit and develop a relationship with that patient, and to closely monitor that patient. If the patient can’t get to the clinic, the group can pay for an uber ride. The care costs the employer less money, the patients are healthier longer, and primary care is financially secure again. (the payment number may not be right but the idea is correct) Keep your employees healthier longer so that they can stay on the job and be more effective. Determine the current cost of care for a population of patients with chronic cardiovascular and related conditions and pay primary care a bit less to provide all the care they require including specialty visits, tests, and hospitalizations. Everyone in the system wins.
New Education: This platform can train your chronic care team members for $7 per member per month. It helps teams understand the new science, new systems, and new payment models required to consistently produce OMT for patients with cardiovascular and related diseases. It is a living resource that is regularly updated to close the gap between new information and clinical practice. Scroll back to Jan 1, 2021, to find the segments 1-47 that make up the core education material to support your team. Each segment takes 15-20 minutes to complete and there are extensive links to sources. You and your providers can learn as much as you care to. That is just 16 hours of work to prepare to provide OMT. The platform shows how much your students or providers are engaged with the content. No stars represent no engagement. Five stars is total engagement. There is a test to see how well individuals did with learning the material. The education engagement can be tied to performance in producing OMT, reducing complications, and lowering costs. That is the ideal for focused CME that your institution can sponsor.
New Ecosystem: The most rapid improvements in clinical and financial outcomes come from addressing the highest-risk, highest-cost patients with multiple chronic conditions in minority and rural communities. I have developed relationships with other organizations that can assist us with capabilities that you may not have. Each of these organizations is already ahead of the pack with their OMT support capabilities. Congruity Health is an analytics and population health company. They can identify patients in each of the high-risk categories. They can perform robust clinical and financial analytics at baseline and report improvements quarterly. They can identify triggers for your team to close gaps in care. They facilitate providing the right care to the right patient at the right time in the right setting and it is automated to the extent possible to reduce expense. Convergence telehealth extends the impact of your providers on the ground. Vestra Health is a small worksite clinic company and TrueLifeCare is nurse coaching operation aimed at diabetes. I am currently working with each of these companies to improve their OMT efforts.
Success requires precisely replicating the systems, processes, and procedures used in the heart artery disease and diabetes OMT studies mentioned above. That is the most urgent and highest impact translational research project for the US in the near term. We must show that we can scale and spread these systems and I am confident that we can do it. Medical educators must prepare their students to treat chronic conditions more effectively. They have a critical role. We should be starting the pilots right away. Get in touch if you are ready. whbester@gmail.com 423-782-0372
Very well said. If only the powers of being would go along. It all goes back to the almighty dollar not the patient. Our major health system is a prime example of keeping the hamster on the wheel.
We sure did!