The last post reviewed the stranglehold of greed that blocks progress to a more patient-centered healthcare system. This article on the failure of the Teledoc/Livongo deal provides evidence that business leaders in medicine often don’t understand the facts, science, and evidence of chronic disease management and quality well enough to construct a program that will improve health and reduce costs. Before you use a disease management program, you should see proof that it achieves those goals. That is part of your fiduciary responsibility as a business leader.
It is completely fascinating to me that the Teledoc/Livongo discussion is all about the business and financial considerations and I did not find a word describing the actual patient intervention, outcomes, etc. Now that you have read that, read this. "Of the 10 highest paid among all corporate executives in the US in 2020, 3 were from Oak Street Health, and salary and benefits included, reportedly, $568 million for the chief executive officer (CEO)." That quote is directly from this article by Don Berwick in JAMA. Based on that information alone, I would predict that Oak Street will not improve health and save money for the people who pay the bill.
But let's go back to Livongo. I copied their offering on diabetes directly from their website. Here it is.
Sign up and receive
An advanced smart scale ($95 value) and app
Unlimited one-on-one expert coaching
Guidance on creating healthy habits that last
All-in-one weight, activity and food tracking
That's it. As far as I can see, you get a scale, glucose testing supplies, and coaching. I see nothing about medication protocols and nurse practitioners being able to change medications in real time. According to the evidence, it cannot work. I would examine their clinical and financial outcomes with an Al Lewis level of skepticism.
Here is the evidence:
"Many approaches have been tried to improve diabetes care but, with one exception, have been mostly ineffective. These include simply reminding patients about appointments; providing laboratory information on the patient to the physician, even when specific treatment recommendations for the individual patient were included; case management when the case manager could not make independent treatment decisions; education of physicians; and multifaceted quality improvement interventions in the practice setting...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."
That works. That is not what Livongo and Teledoc are doing.
I spend an hour every week with a registered nurse who leads the diabetic coaching effort for another telehealth company. Measurement and coaching alone simply cannot work to achieve the best outcomes in diabetes. It is essential. The longitudinal trusting relationship is critical, but it is insufficient. I am also in frequent communication with the coaches in another diabetic coaching company. Diabetics die of cardiovascular disease. It is possible to prolong healthy life in a patient with type 2 diabetes by eight years with diabetic coaching, best practice diet and exercise, behavioral health support, and controlling the blood pressure, cholesterol, and glucose to aggressive goals concurrently using specific medications that lower the risk factor while protecting cells and organ system. Patients with complications like vascular disease and chronic kidney disease should also be on an aspirin. If the Livongo/Teledoc company does not remodel its interventions to conform to this evidence, it will never be what it could be, I don't care what kind of business gyrations occur. You cannot solve a health challenge with an administrative solution. Improving clinical and financial outcomes in cardiovascular and related diseases like diabetes requires a comprehensive solution. If you lose one leg on the stool, the stool falls over.
This was predictably true, and unsurprisingly shocking!
I call this "administrative medicine" is another ugly actor in the "Late Stage Sickness Seeking Profiteering" of the American Legacy Kabuki Dance Theater Sponsored by the "Honorable Paymsters" of the American Medical Industrial Complex! It costs us $8 trillion annually. What do we get from the money? We get the third leading cause of deaths of Americans following heart disease and cancer! Had enough yet, people???