Personalized health records promote horizontal integration within ACOs

ACOs, or Accountable Care Organizations, continue to be a hot discussion topic in health care reform. In the current issue of JAMA, Duke’s own Barak Richman and Kevin Schulman provide a unique business perspective on the implementation of ACOs. One of the issues they raise is the potential for the establishment of ACOs to result in health care system monopolies. They warn that health care systems might align under the promise of market dominance and not necessarily with the intention of improving health care quality or efficiency. In order to prevent a misaligning of goals, they urge that evaluation of ACOs should maintain focus on health care quality and efficiency.

Another recommendation they suggest is for health care systems to align under a horizontal vs. vertical or “bricks and mortar” approach. Whereas vertical networks focus on established hospitals and other infrastructure, horizontal networks would connect more fluid, geographically diverse care specialists. To me it seems like this idea mirrors themes in social and professional networking. Horizontal networks may take less time, investment, and have the potential to spread much more quickly than conventional geographically constrained networks. However, in my opinion a key challenge to the horizontal vs. vertical approach is how seemingly unconnected groups will be able to share information and provide coordinated care. I think that a potential solution would be the establishment of personalized health care records. Electronic personalized health care records would follow the patients, contain all their health care information, including their personalized health plan, and provide a virtual medical home that could provide a universal medium for exchanging health care information among horizontally connected providers. Without a universal medium to maintain coordination of care and ensure that information is efficiency conveyed, it may be difficult to envision how horizontal networks could provide cohesive care. In an ongoing era of rapid technology development, a personalized health care record would provide a potential means of increased portability and exploration of new options for new health care delivery models.

Medicare Jumpstarts Wellness and Prevention Efforts

As of January 1st of this year, Medicare must now provide free annual wellness visits and personalized prevention plans to their beneficiaries as stipulated by PPACA. An article by Francine Russo in this month’s Time Magazine discusses what these wellness visits and personalized prevention plans might look like in practice and some of the barriers providers might face in implementing these new measures. The wellness visits and prevention plans described in the article focus exclusively on lifestyle interventions aimed at improving diet, increasing exercise and limiting smoking – a far cry from utilizing an array of risk predictions tools to quantify all of a patient’s individual health and disease risks over time – but an important and critical movement in the right direction. The article points out the difficulty physicians might have in finding the time to fit a comprehensive personalized prevention plan that is thorough enough to be effective, yet compact enough to squeeze into their already packed visits with patients. These types of behavioral modifications are notoriously difficult to initiate and maintain over time. With this new tenet of health care reform going into effect, physicians will now be reimbursed by Medicare for taking the time to work with patients to try and address these lifestyle issues. Such a large undertaking will require the coordination of care between physicians, patients, and nutritionists, lifestyle coaches, etc. in order to be effective. These changes in reimbursement may be just what was needed to kick-start the wellness and prevention movement.

All the tests in the world don’t mean much without a plan

I recently spoke to a representative from the Indian Health Service about “personalized medicine” in federal initiatives. Of particular note, I mentioned during the course of our conversation that the Patient Protection and Affordable Care Act includes two stipulations for personalized health planning. Under the new law, Medicare will pay for one personalized health planning visit annually. Additionally, personalized health planning was a key initiative for demonstration projects through community health centers. Interestingly, despite the IHS’ focus on personalized approaches to care, this individual knew nothing about personalized health planning within the law. So I decided to see what the federal government actually says about personalized health care. Here’s what I found.

The government has great hopes for personalized approaches to care. In fact, “personalized health care will improve the safety, quality, and effectiveness of healthcare for every patient in the US.” The government also has a very limited definition of personalized health care, which is “using ‘genomics’, or the identification of genes and how they relate to drug treatment” as the means to “enable medicine to be tailored to each person’s needs.” But how could this be? What about Sec. 4206 of PL 111-148, “Demonstration Project Concerning Individualized Wellness Plans.” Or Sec. 4103, “Medicare Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan?”

The omission may in part be due to the fact that personalized health planning hasn’t caught on as a concept yet, despite its arguable potential to change the way health care is delivered – and perhaps more importantly, to improve health outcomes, as we’ve seen with coronary heart disease and type 2 diabetes here at Duke.  Instead, many people are wide eyed by the concept of fancy tests and SNPs and the prospect that if we decode a patient’s genetics we will have found the silver bullet and not only cure patients of disease, but prevent disease altogether.

Except we won’t.  At least not in the foreseeable future for the health problems that are currently costing us the most money.  Because science tells us that our genes are only one part of the story. Our environment is another – in many cases more important – contributor to our health. In fact, our environment can actually change the way in which our genes are expressed. We’ve see this phenomenon in nature. We’ve seen it in people.  And in both cases, we’ve found that there’s no way to predict exactly how the environment will change the phenotype.

But there is something we can do successfully for patients at risk for chronic disease. We can track those environmental factors known to affect gene expression – like nutrition and stress and environmental exposures to name a few. It’s called personalized health planning, a strategic approach to care that identifies all a patient’s risk factors for disease (genetic, environmental, behavioral, psychosocial) and very importantly tracks those factors that the patient  can do something about – either themselves or with the help of modern medicine.  Three quarters of national health care expenditures are for chronic diseases due to health behaviors, namely smoking and obesity. If we really want to improve the health of the nation while reducing health care costs, expensive genetic tests cannot be synonymous with, or the primary road to, personalized health care. We can run all the tests available in modern medicine. (Some might argue we already do.) But if we don’t help patients to plan for their good health in the context of their known risks from all those tests, we’ve failed them.    

Debating Health Care Reform: more talk, little action

Recently, the Duke University chapter of the Benjamin Rush society held a debate on health care reform.

Moderated by Dr. Christopher J. Conover, the topic was, “How does America achieve affordable, accessible, quality healthcare?” Debate participants included Sally Pipes, Dr. Hal Scherz, Dr. Peter Kussin, and Dr. Gustavo Montana.

The audience was polled just prior to the debate as to whether health care reform would be best addressed by (1) government regulation (2) self-regulation by the private sector or (3) unsure. The same question was asked at the conclusion of the debate. Although no formal statistical analysis was performed, the numbers remained essentially unchanged before and after the debate. One hour of intense discussion among three physicians and a national health care reform expert in the presence of medical students, health care professionals, and members of the public resulted in more of the same – not unlike what we’ve seen in the last two years across both the political and private sectors. . It’s clear people’s opinions on health care reform reflect core moral, political, economic, and philosophical beliefs, and those don’t often shift over the course of an hour-long discussion or a three-minute news splash.

Despite the heated discussion, there were several points that both the “conservative” and “liberal” panelists agreed upon. They agreed that the current system is broken and that PPACA is unlikely to fix it. They agreed that physicians need to be more involved in discussions of health care reform. They agreed that cost-effective care, guided by cost-effectiveness research, is important to improving health care efficiency. They agreed that patient care needs to be coordinated among providers and systems.

Prospective health care provides a solution that cuts across political and personal mores. This approach provides regulation not by government or private companies, but by physicians in partnership with their patients. It provides cost-effective care, not by mandate, but by physician and patient cooperation. It supports rational reimbursement based on documented outcomes. It is a non-partisan, non-government, non-private, but physician and patient based approach that avoids the devastating road-blocks that plague current “debates” on health care reform. Dr. Kussin advocated for an American Solution several times during the debate. If the United States is to find a uniquely American solution to the question of health care reform, it will take all of America, not just one-half. Focusing on the development and implementation of models of reform such as prospective health care provides a real solution for how to provide rationale care, reduce costs, improve outcomes, and increase patient satisfaction. And who can’t agree on that?

Personalized Medicine: A non-partisan solution for health care reform?

Much has been made about the Republicans gaining control of the House in the midterm elections. Potential explanations of why the change in power occurred abound. Conservatives have championed the election as a mandate to reduce health care spending or even scrap the recently passed health care legislation and start over from scratch. On the flip side, others have implied that changing public opinion may be more a function of Americans simply wanting something until they get it. Regardless of political ideology, everyone more or less agrees we’re spending too much money for not enough results.

The focus of controversy in both recent debates and legislation has been largely about insurance reform. What has been absent from these discussions is how health care reform can 1) change how we approach the delivery of health care and 2) support improved health over the life of an individual. Currently, care is sporadic, reactive, uncoordinated, and based on a reimbursement which rewards treatment of disease rather than prevention of disease. If you have any doubt of this just look at any of the highest paid medical specialties – cardiology, radiology, oncology, gastroenterology, and surgery – all procedure based specialties that are well-reimbursed under our current system. We at the Center believe that we can do better than this reactive, procedure-based approach to medicine. Through the use of personalized health plans, providers can quantify patients' health and health risks, identify strategies to mitigate risks and/or treat disease, deliver personalized care, engage patients in their care, and measure outcomes over time. This set of tools can then be used to more effectively implement coordinated care and more accurately measure performance for reimbursement. While PPACA and its attempts to address inadequacies in health insurance and coverage may be stalled by political turmoil for some time, the health care community can use personalized health planning to start to work towards meaningful health delivery reform now. And as we argue in a recent commentary in Academic Medicine, PPACA’s focus on the development of coordinated models of care, provider reimbursement reform, and personalized health planning is a significant opportunity for academic medical centers to lead the way in health care reform.