CYNDY NAYER

Accountable care demands that the system sync with the preferences and choices of the consumer purchasing the services.  In order to get to real health value, consumer-patients must make the health care decisions that improve personal health and do not derail personal bank accounts.  It was hard to piece these together for the last 15 years.  Now, with high deductible plans, more transparency for costs, and on-time digital connectivity, there is less difficulty.

Information technology can deliver the needed information to the patient and the physician to improve not only the likelihood of improved care but also the time-to-achieve the outcomes.  Most patients want and need to be involved in their care.  There is evidence that giving patients access to their information results in higher levels of engagement and adherence to recommendations.  In fact, the latest evidence shows that patients have been signing up for access to their health system portals at a rate of 1% per month for over 30 months.

Workers and individuals are in need of health insurance literacy, so that they comprehend their out-of-pocket expenses, including co-pays, deductibles, and premiums.  Without this, they are liable to make costly mistakes in the health care choices they make, such as where they fill their prescriptions and where they get their care (one example is urgent care v emergency department).  They also need to understand the costs of care when they are not following the recommended treatments.

To add complexity, doctors rarely know the out-of-pocket costs to their patients for treatments, and they rarely discuss home or work issues that can add to the costs of care and poorer outcomes.

The opportunities for IT to increase the behavior changes needed in the health systems, providers and patients are intuitively accepted.  The value-based changes require context for engagement and system development.

Providing Context in the Consumer-Centric Health System

Wharton published an essay on the costs of care and quality outcomes recently in which they called out a deficiency from a previous post, in which the authors argue that providing evidence of better care and/or outcomes is the goal,  but there are no business models that show that physicians will change their behaviors quicker when provided with the evidence.  In the words of the Wharton essay:

The American health care system would surely work better if all physicians responded to new evidence on what kinds of care work better as soon as that evidence is definitive. That sturdy truism is at the valid core of the essay, “What Really Stands in the Way of Cutting Health Care Costs” by Ngan MacDonald and Walter Linde-Zwirble that appeared on Knowledge@Wharton (July 31). [Health Care: When the More Effective Choice Costs More]

The more effective choice is, by definition, the value-based choice, and value-based is not always the less expensive choice when measured solely in dollars.  When something costs more or is unexpected in the budget (such as out-of-network care, or care that is needed before a deductible is met), it must be weighed in the priorities of needs.  A big part of the systemic dissatisfaction is that most health care decisions have been valued in the needs of the system rather than the needs of the patient, including how they may impact financial, emotional, home (social) security.

In a truly accountable care organization, the recommendations would factor in costs of time lost at work, stalling family priorities or emotional stability, or charging expenses that cannot be covered in the person’s budget.  Such is often not the case in US health care systems.

We have written business plans for reimbursement changes, complex and potentially expensive treatments, and more.  Wharton calls out a revised Maslow hierarchy to focus on the contextual priorities that are needed in today’s society.  (Knowledge@Wharton, August 2014) note: hat tip to @LeonardKish, VivaPhi.com for his tenacity with Maslow’s hierarchy

This revised contextually-based hierarchy answers the need for rapid decisions that support total health value as prioritized by the consumer.  When context is provided and safe, secure environments surround the consumer, behavior change can occur.

Context and Accountability Drive the Consumer-Centric Decisions

In today’s health insurance marketplace, where more consumers bear increasing costs that are not matched with increasing salaries, they cannot rely on “evidence-based medicine” without linking the costs and behaviors to the rest of their necessities in life.

If the goal is to reduce costs or improve outcomes, or both, patients must be more deeply involved in these decisions than previously.  They will search for evidence and context that is relevant to each of them.

This consumer centricity improves the conversation and the appropriate delivery of health care.  IT delivers context that is relevant to the patient and promotes behaviors in the so that they will ask the doctors for the latest evidence AND ask social media peers for evidence and experience data.  The informed consumer will share this evidence with the doctor and, if still not convinced, ask questions about payment, reimbursement, and more.

This new consumer competence will create a more intimate and trusting experience with the doctor, one in which transparency in care and money can accelerate aligned goals.

The patient/consumer has become a real customer because there are real implications in payment decisions.

When the choice to adhere to recommendations is combined with the information on the additional cost burdens, the patient changes into the informed consumer and can ask the hard questions, and the system must respond or risk losing its customer.  It must flex toward the patient and accept her in the decision process.  If the system does not respond to the patient’s satisfaction, the patient-consumer can walk away, just as consumers do in other marketplaces.

IT Reaches Beyond Operating Systems

Integrated clinical data is part of the clinical decision tree.  But headlines and online advocacy groups are driving a new IT ecosystem for consumers and their decisions.  Social media has been loud on the subjects of some new studies in emerging health tech recently, providing real-world stories and context for consumers-patients to consider. As examples, these are some of the headlines that recently appeared in Facebook, Twitter, Google+, and other media outlets:

Digital Mammography Does Not Produce Clinically Better Outcomes.   This came from a study of 137,000 women in the first cohort, and 133,000 in the second cohort 7 years later.  During this time, digital mammography increased from 2% to 29%.  There was no statistically significant change in detection rates of early-stage tumors.  [Journal of the National Cancer Institute 2014]

The costs for the digital screenings during this same time increased from $76 to $112.  While the Medicare costs increased from $666 million to $962 million, no other social impacts were considered, such as time away from family (or, if this were a working population, time away from work and resultant costs).  Further, when a women is screened and told to come back six months later for a second screen because of a “suspicious shadow,” the stress impact may more derail more than out of pocket or system costs. IT (in the form of the digital mammogram) may actually help the patient reduce stress and return to work or family priorities.

Salk or Sabin?  Using Both Polio Vaccines is Best, Study Reports.  This news, from JAMA, clearly says both are better.  Obviously, this causes a price increase for the vaccinations.  But in the life of a person, being safe from polio is certainly the better way.

An informed parent would consult with experts and/or social media and then ask the doctor why both are not being provided.  IT can readily support the question of “what’s the best protocol for my child?”  and be readily available on the parent’s phone for the transfer of information to the physician.  This can speed up the time for physicians to use new evidence for better outcomes.

Nearly 90,000 Emergency Department Visits Annually are Linked to Psychiatric Drug Events.  From JAMA by way of Modern Healthcare, the study shows that a large percentage of these visits come from overdosing, excessive sleepiness and head injuries.  IT and consumer-informed questions could avert some if not all of these incidences.  Caregivers can use the IT that currently exists to see drug interactions, multiple prescriptions from more than one provider, and other warning signs, then ask questions before the prescription is filled or when behaviors change in the patient.   IT can enable rapid questions and dose changes from the physician.

Milliman Shows CT Scans for Lung Cancer Save Lives and Are Cost Effective.  This Milliman study showed that, for high-risk patients, the CT scan is quite effective and efficient in diagnosing early stage cancer.  This is important because the USPSTF does not recommend CT scans for lung cancer diagnosis in healthy populations.  An informed consumer can find the right information using IT data and personalizing it through several apps that would qualify him or her into the high-risk group.

By recognizing the high-risk definitions, the informed consumer can find the right information to share with the doctor and request the appropriate, efficacious screen to protect his clinical and financial health.  Again, the new evidence can help both the consumer and the physician to integrate new evidence and protocols rapidly.

The real prize is when IT-proficient consumers can transfer their abilities for online entertainment to better care for themselves and their families.

Apple Could Be the IT Accelerant to Consumer-Centric Behavior Change

The conversations and criticisms of Apple’s new watch are everywhere in social media.  Those who believe that sharing heartbeats is about love taps have missed the huge opportunity that is being presented by Apple: each of us will be able, in the near future, to send the heartbeat to the cardiologist at Mayo or even the local paramedics from the watch that is usually on our arm.

Evidence of this thinking is revealed by the number of early collaborators on the apps for the Apple watch: Panera (“clean” food), Mayo (health management), Merck (information on condition management and adherence), Fitbit,  Bank of America, J.P. MorganChase, and more.  Health benefit plans, with their HSAs and deductibles, fit nicely into this health-wealth-performance mix.

Accessing health care data and insurance data will be simpler because of the integrated framework between the consumer, Apple Pay and the Apple Watch. Comparing costs for the visit or treatment, and comparing costs and locations for a better, cheaper or safer alternative, will be standard in the consumer-owned health value realm.  Rapid access to all the personal data (by linking to the apps on the watch) will ensure that a consumer can share health history, or more, with the new provider, anywhere in the world.

This 3-way play means that the consumer can now curate what health information is personally important, rank ordering his or her health value investments.

In fact, the consumer will be able to pay the copay with a wave of a hand through the integration of the watch and Apple Pay.  And, hopefully, in the best of dreams-come-true, she won’t have to fill out new forms with every provider.  Digital data will download directly into the interoperable provider EHR (with consumer permission).

Using the Apple Watch and Apple Pay as digital examples, IT becomes the cost-efficient and time-efficient accelerator for personal health ownership and investment. While the industrial revolution transformed the earlier centuries, the 21^st century is the Digital Age.

To consider an example, the curating consumer may have a Mayo app, a Fitbit app, the Modern Healthcare site as a Safari bookmark, and the JAMA app on the wearable tech.  The person can pull information to have an informed discussion with the doctor.

Then, because she also has a Chase app and a health plan app, she can also check on benefit coverage, deductibles, and possible out-of-pocket costs for the screens or vaccinations at exactly the time they are prescribed.  There would be fewer billing surprises with less juggling of unexpected expenses.

Consumer Centricity Will Bring Accountable Care to a New Level

Sometime over the next 2 years, the health care system will reside on our phones, watches and wearables.  Personal preference will choose the relevant data for the health care experience to include and focus on the consumers’ health care priorities.

Quality will go up, because consumers will demand higher safety and better care.  Efficiencies will go up for the system and the patient, because patients will “go social” when faced with care that did not deliver expected outcomes.  Satisfaction reports will include meeting cost and value expectations.

Communities will prosper because consumers will better manage expenses for health, paying for what they need within their income boundaries.  They will improve their research skills and choose the right care at the right cost, which will in turn save money for other products, building business while lowering unreimbursed hospital costs and controlling taxes.

Consumer centricity will drive healthier consumers and create communities of health value. Consumer centricity is built on the value-based principles and customized for each consumer. Most importantly, consumer centricity will drive a health investment economy in which members of a community will value the interrelatedness of health, work, safety, environmental and social efforts.

Cyndy Nayer is