Patient Non-compliance: What is the Cost?
Do you take your medicine? It’s a very important question. When patients don’t take their prescribed medication the costs are enormous – not just to the patient but to the health system.
A 2011 study by Capgemini shows a 40% drop in refills for prescriptions after the first six months, resulting in more than $300 billion of unnecessary costs to the healthcare industry each year. Studies conducted by the World Health Organization, the NIH and others support this result.
This is not a new problem, but with healthcare consuming almost one in five dollars in this economy, real solutions to patient non-adherence are necessary. One promising approach is making a game of medication.
How does gaming work? Three key elements work to engage the user:
- The challenge to adopt healthy behaviors
- A win condition where events and accomplishments combine to enable success
- Rewards and feedback that reinforce positive feelings
Turning Diabetes Treatment into a Game
Let’s look at an example. Treatment of Type 2 Diabetes consumes over 25% of the world’s healthcare expenditure. Roughly 50% of patients fail to meet their blood sugar goals. The main reasons are failure to take their medicines and failure to change their behavior around diet and exercise. Glucose level monitoring and tracking is painful and boring. Diets don’t “feel good”, and wellness by itself is not a sufficient motive for many patients.
Proteus Biomedical from San José, CA is testing a new approach which uses technology to automate most of this process and gamification to create incentives for compliance. Patients take a pill with a unique computer chip made from food ingredients. This pill senses the patient’s vital signs and transmits this data to a patch worn on the skin. Once the patient gets within 30 feet of their mobile phone data streams are captured and automatically and securely shared with the network of caregivers chosen by the patient. This might be family, friends or their physician – the people most influential in their care.
Proven Medications Plus Technology
This system, “Equa” enables tracking and display of summary and longitudinal data on the cell phone so that patients understand the relationship between behavior and health outcomes. It uses the data collected and tracked on the phone to educate and motivate the patient. It’s a three-step cycle to frame what is known, prompt an action and reinforce the belief.
The games are Power Challenge Personal (PCP) and MedMatch. PCP uses a system of tracking heart rate, fitness and sleep goals within a group of “contestants”. There are points earned, a leader board and prizes such as gift certificates to a sporting goods store for best in class accomplishments. MedMatch uses altruism for adherence. Healthy behaviors result in charitable donation. Every 20,000 steps walked results in donating a pair of shoes to children in need. Every six hours of sleep a night results in donating a blanket to a homeless shelter. Every medication pill taken on time results in donating a pill.
Are these approaches sustainable over the long term? Just ask anyone who has played and tired of a video game after a time. Social elements which share outcomes data with family and friends is key to maintaining interest. And hopefully the benefits of feeling better will keep patients engaged. But keeping games fresh and engaging will be a challenge.
This will be an interesting space to watch, and perhaps play in over the next several years.
What is your opinion? Is gamification a viable long term strategy to improve patient compliance and health outcomes? Or is it a fad? Click on comments link above to share your view.
- Adding Gamification Concepts to Sitecore(sitecore.net)
- Gamification and UX Design (cygnismedia.com)
- One of the best definitions of “Gamification” that I have seen (markjowen.wordpress.com)
- Signs of the (Pharma) Times. (sixuntilme.com)
- Four Ways Personalized Medicine will Change Doctor-Patient Relationship (tedkolota.com)
Currently patients with family history of various cancers are genetically screened for them. In the future, genome sequencing may become part of the screening that babies undergo after they’re born. This raises a number of ethical issues:
- who owns your genetic information?
- who has access to it?
- where is it stored?
After a recent blog post, “Personalized Medicine in 3 – 5 Years?” I received questions from readers on how results of genetic testing might affect their insurance coverage. They expressed concern that if insurance companies know their genetic weaknesses, they will raise rates or deny coverage.
The good news is that in the US, it is illegal for health insurance companies use genetic information to set rates or deny coverage. It is also illegal for employers to use genetic information in their employment, promotion or compensation practices. The law passed in 2008 and took effect in 2009. The name of the law is the Genetic Information Nondiscrimination Act or GINA.
Under GINA, health insurers can not ask any questions about genetic testing as part of the application process, at renewal or as part of any health screening or wellness program, if there is a penalty or benefit associated with those questions.
Importantly, this includes any discussion of family history. If your health insurer or your employer questions you about whether your father smoked, had a heart attack or if your mother had breast cancer, they violate GINA.
GINA applies only to health insurers and employers. It does not apply to long-term care coverage or life insurance. This is because of something insurers call “adverse selection“.
An example of adverse selection – someone learns they are likely to die at an early age, then buys large amounts of life insurance to assure surviving family members’ security. The insurer, unaware of the high risk plan member, cannot adjust its pricing to the risk profile. This hurts the rest of the policyholders in that insurance pool whose rates will rise to fund higher claim payments.
When Your Insurer Can See Your Results
Be careful; there are circumstances when a health insurer can ask that an individual undergo genetic testing and share in the results.
Sometimes the choice of proper treatment depends on a patient’s genetic makeup. In that case, to decide whether the treatment is medically necessary and whether the insurer will pay for the treatment, genetic testing is needed.
If the patient refuses to take the test before taking the treatment, the insurer can refuse to pay the claim. However, the insurance company can only see the information needed to decide the proper treatment and payment.
The best advice is to discuss these issues in detail before being tested. Understand your options for sharing and storing this information. Talk with your doctor, the testing company and finally, discuss with your family.
If your insurer is requiring the test for medical appropriateness, understand what information they will see and get a written statement from the insurer that the request is permitted under GINA and that it will not affect your rates or coverage.
For more detailed information go to this link at The Genetics and Public Policy Center, Johns Hopkins University.
What’s your opinion? Should genetic information be shared with insurance companies? Should your employer have access to this information? Post a comment and share.
photo credit: Cave of Knowledge
- Can You Be Fired for Your Genes? (ideas.time.com)
- GINA Under the Microscope: Genetic Testing in Employment (laborlawposter.com)
- At a Personal Genetic Crossroads (pbs.org)
- Ten Unanswered Questions on Genetic Information (pbs.org)
- (Once Again) It Ain’t Necessarily So (patentdocs.org)
- TECHNOLOGY: First Bedside Genetic Test Could Prevent Heart Complications. “For some cardiac patien… (pjmedia.com)
- Four Ways Personalized Medicine will Change Doctor-Patient Relationship (tedkolota.com)
- What Is Your Genetic Profile? (drkennethorbeck.com)
- Genetic Discrimination Cases On The Rise | News in Psychology … (psychone.net)
The Hospital Stay Experience
Comedian Mel Brooks as The 2,000 year old man tells us what is was like as a patient in stone age hospitals. ”Hospitals ran on the same principles as today - the principles of people walking past you while you’re screaming and not caring. That same wonderful indifference to the sick and the dying. We invented that.”
Mel’s routine came to mind recently while talking with a physician friend who is a senior leader at a regional academic medical center. He said, “We deliver quality health outcomes, what we’re focused on is improving the patient experience.”
Many of us remember our hospital stays as mixed at best. Patient as prisoner, stoic caregivers, bland food, poor communication. Yet for many years patient satisfaction scores routinely topped 90%. Satisfaction surveys were usually filled-out at discharge, before the patient paid the bill. Patients, happy over their improved health, gave high scores on the survey.
Times have changed. Pressures to lower costs and improve outcomes intensify competition among hospitals. More employers offer tiered insurance plans which can cost less per month but charge the patient more to use hospitals with higher than average costs. Higher priced academic hospitals have to justify those prices to consumers. They want patients delighted with their hospital stay.
What Does “Patient Experience Mean?
The Gallup Management Journal reports hospitals are widely divided about what the “patient experience” means. For about a quarter of hospitals surveyed, it means excellent customer service – the hotel model. About one-third believe it means “patient-centered care”, which is more of a health outcomes model. The rest of the hospital executives in the survey gave answers somewhere between those two models.
The Centers for Medicare and Medicaid (CMS) created a nation-wide standardized patient satisfaction survey which represents the mid-point between the hotel and the outcome models. It’s called the CAHPS Hospital Survey. It measures how well doctors and nurses communicate with patients, cleanliness, pain management, quietness and discharge procedures on a 10 point scale. Consumers can see how hospitals compare to national averages in quarterly report published by CMS/CAHPS.
Hospitals which embrace patient-centered care don’t think the CAHPS survey goes far enough. They want patients to not only be delighted with the quality of service, but with their health as well. These hospitals work to redefine how care is delivered. It’s not easy. Current models of healthcare delivery often exclude patients and their families from an active role in treatment; they are episodic, not continuous. They focus on a specific problem, not the person as a whole.
With the help of consulting companies like Planetree, many hospitals are moving to the patient-centered care model. This requires them to rethink how they deliver many aspects of care, similar to Business Process Re-engineering (BPR). As with any fundamental change, hospital culture must change fundamentally. This is the difficult part and may take years to become real.
Happier and/or Healthier?
While there are many case studies which show effective implementations of patient-centered care models, the long-term effect of this change on health care quality and the overall health of the patient is unknown. Many question whether patient-centered care’s focus on delivering only what the patient needs and no more is just a cover for rationing care and lowering costs. If the patient is happier, but is not materially healthier, why go to all the trouble?
As one physician, commenting on an earlier blog in this series said,” The goal has always been to individualize the treatment to the patient but I fear economic pressures may influence this in another direction.”
Right or wrong, this is the road we are on.
How satisfied are you with your hospital’s quality of service? What do you think about patient-centered care? Please comment and share.
- Patient-Centered Care – We Aren’t Ready for It (healthecommunications.wordpress.com)
- Patient-Centered Care: Who Is Doing Your Surgery? (centerforhealthmediapolicy.com)
- In hospitals, a tradeoff between better clinical quality and a good patient experience (eurekalert.org)
Personalized Medicine Gains Traction
Since completion of the Human Genome Project in 2003, the promise of personalized medicine (PM) caused many to consider its effect on bio-science, pharma and healthcare delivery. Physicians contemplate a future in which patients enter their office equipped with symptoms and a list of the genetic variants they posses and questions about what they mean.
The problem hasn’t materialized because the cost of discovering and developing drugs customized to the needs of a sub-genetic group have been prohibitive. Today however, IT frameworks like Hadoop deploy massively powerful, inexpensive processing power. Now the huge genomic database becomes a more accessible resource to develop medications that are effective for targeted patient populations.
These new drugs offer improved cost-effectiveness over blockbuster drugs for conditions like high cholesterol or hypertension. Physicians will spend less time and money in trial and error to find which drugs work for which patients.
Disruption in Healthcare
In my last post, I raised the question, “Will Personalized Medicine have a disruptive influence on medical practice?” Those familiar with Christensen’s theory of disruptive innovation understand that market leaders focus resources on product development for advanced users who don’t care about cost. Often products contain features and benefits that don’t matter to most users. This leaves room for competitors to develop new technologies and business models to meet the needs of average consumers and “disrupt” the market leader’s business from the bottom up.
Healthcare is not like other businesses. The role of payers and policymakers as well as the interests of public health intervene and create barriers to natural market forces. These factors slow the rate of disruption. Yet there will be fundamental change in the way physicians and patients interact as PM gains traction.
Four ways PM will disrupt healthcare delivery
#1 Predictive, not reactive:
- Rather than waiting to treat symptoms of a disease that occur, physicians can predict which diseases a patient is susceptible to.
- The physician develops a personalized health plan to prevent or detect these diseases early.
- Patients will become a true partner in the delivery of healthcare, monitoring their progress and reporting results to their caregivers.
- Home testing may replace testing in the doctor’s office.
- Fewer office visits, less face time with the PCP is less expensive, but is it better medicine?
#2 More information on more treatment options:
- Physicians prepare to answer patients’ questions about new genetic tests and the treatments for their sub-group.
- Continuous access to up to date, peer-reviewed medical information will increase dramatically.
- As more options for care become available, will the patient’s trust in the sources of clinical information and outcomes begin to erode?
#3 New ethical and moral obligations:
- What is the physician’s role with patients on the moral and ethical questions surrounding access to genetic tests?
- If one family member wants genetic testing and another doesn’t and a serious disease potential becomes known, what is the physician’s obligation to inform?
#4 Physician’s role in decision to test:
- Should patients have their own testing done without supervision of a physician?
- Should tests be offered for genetic disorders for which no treatment is available?
- Who pays for development of testing and treatment for small sub-groups of patients?
What do you think? Will PM disrupt or enhance healthcare delivery?
- Genetic causes found in nearly 1 in 5 patients with dilated cardiomyopathy heart failure (eurekalert.org)
- DIYgenomics community computing health models (slideshare.net)
- Ex-Cleveland Clinic colleagues Topol, Nissen at odds on personalized medicine (medcitynews.com)
- Four Themes to Watch in Personalized Medicine (xconomy.com)
- Working with Healthcare Stakeholders towards Brain-Based Personalized Medicine (sharpbrains.com)
- The State of Personalized Medicine: The Role of Biomarkers (sharpbrains.com)
Healthcare Delivery Symposium
The optimism was overflowing at the Aspinwall Symposium at WPI yesterday. The healthcare transformation is on with distributed care, quality payment models, analytics and big data on display.
Most interesting were the panel presentations and discussions. Recently I wrote about the need to accelerate building our health information infrastructure nationwide. This enables a faster transition to digitized health records, I argued. The news for me at this conference is that an interoperable infrastructure in the traditional “plumbing” sense may become less important.
Distributed Care Models
David Dimon at EMC spoke about the growth of distributed care models which rely on an “exostructure”. Virtual data centers enable caregivers to connect with patients in a variety of settings outside the doctor’s office or hospital. Monitoring patients vital signs at home is certainly less expensive than at the hospital and may change some treatment protocols around length of stay.
Dale Wiggins, CTO of Phillips Patient Care and Clinical Informatics shared an example of how one distributed care model works. Phillips eICU is a virtual Intensive Care Unit. Its aim is to end the need for multiple, highly trained and highly paid Intensivists – the physicians who specialize in the care of ICU patients.
The center of the eICU is a cockpit where an Intensivist works, monitoring patients’ vital signs and video real-time over distance. This model extends the ability to dramatically improve outcomes, particularly among patients in more rural settings. The eICU is now deployed at UMass Memorial Hospital system.
The next logical step is to extend the ICU to the home, reducing readmission during the critical 30 day period after release from the hospital.
Analytics, Predictive Informatics and Big Data.
Robert Friedlander IBM Master Inventor spoke about the promise of breakthroughs in distributed data processing create massive computing power. Google’s open source MapReduce framework and its successor Hadoop have given researchers in biotech and pharma an unprecedented ability to query very large data sets quickly and with great flexibility.
Prior to Hadoop, a large data set like the human genome was impossible to analyze and query in-depth. Relational databases are efficient with tabular data. Medical research requires analysis of very large ”heterogeneous” data sets which don’t fit into tables.
Medical breakthroughs can happen by applying predictive analytics which involve many complex queries of these massive data sets. All this happens easily and relatively inexpensively through distributed massively parallel processing powered by Hadoop and MapReduce frameworks.
Bob predicted that these technologies may radically change the way healthcare is delivered and in the foreseeable future. “The promise of truly personalized medicine may become a reality in the next three to five years.”
Can the healthcare system handle that kind of disruption? Let me know your thoughts.
photo credit: healthcare.philips.com
- When ICU Beds Are Scarce, Doctors’ Goals Change (nlm.nih.gov)
- Too Few ICU Beds May Up Patient Deaths (nlm.nih.gov)
- Oracle Big Data Appliance – Zbyszek Swoczyna, Oracle (slideshare.net)
- R and Hadoop: Step-by-step tutorials (revolutionanalytics.com)
- Former Yahoo! Hadoop honcho uncloaks from stealth (go.theregister.com)
- The CAM-ICU, More Flexible Than You Think (jajsamos.wordpress.com)
- Next Hadoop confirms data as a platform (infoworld.com)
Is Hospital Advertising Effective?
Why do hospitals advertise? As someone who spent a career making and watching advertising, it seems like a waste of money.
Take a look at hospital ads on YouTube. If you edited the name of the hospital from the commercial, it would be impossible to tell the difference between them. All deliver top-notch healthcare, with world-class doctors and an attentive staff of happy people.
This should be no surprise; all hospitals share the same mission.Their physicians train to the same standards. There is little tangible differentiation at level of the institution in the hospital world. If there was, you would be hearing about it on the evening news and soon they would close their doors.
Yes, there are teaching hospitals and community hospitals and regional hospitals, but they compete with others of the same ilk on the same dimensions.
When to Advertise
In my view, there are only three legitimate reasons for hospitals to advertise:
- Change of ownership. The hospital is obligated to tell the communities it serves of any change in ownership. With it may come enhancements to facilities which improve the patient experience or a renewed commitment to serve the community. Corporate ads like this are often full of platitudes. During my agency career we used to say corporate advertising is where the rubber meets the sky. Try to stick with the facts.
- Marketing a center of excellence. These ads work because there is a tangible, differentiated benefit to the patient. Centers of excellence usually are excellent. And the halo they create enhances the overall image of the hospital.
- Improve the patient mix. Hospitals in blighted neighborhoods are often burdened with high costs of treating the uninsured, and shrinking subsidies for paying for that care. Often, these hospitals deliver superior outcomes treating chronic disease states because of the problems of their populations. Targeted, program specific spending in adjacent neighborhoods can revitalize a hospital’s profitability.
My advice to hospitals considering an ad campaign outside those purposes…scrap it and put your money to work engaging with the communities you serve. It’s more work, but it actually demonstrates the “commitment” that is too often spoken of in those commercials.
- Patient Experience: What does it mean? (customerthink.com)