Cancer is not quite the ferocious killer that it used to be. Millions of Americans are living with cancer, not just dying from it. Reasons for the diminishing death rate include lower smoking rates, earlier detection of some cancers, and advances in treatment.

But the treatment advances are coming at a high price. Treatment costs can easily exceed $100,000 a year. In response, CMS and commercial insurers are establishing alternative payment models, which, in theory, are supposed to slow down the stampeding costs while protecting, and perhaps even improving, the quality of cancer care. 

The Oncology Care Model (OCM) developed by CMS’s Center for Medicare and Medicaid Innovation (CMMI) is certainly the highest profile of these alternative payment model. In November, CMMI announced a successor program called the Oncology Care First (OCF) that for the most part builds on OCM and might push episode payment for cancer care more fully into the mainstream of healthcare. Importantly, OCF will most likely include two tracks that would include downside risk right from the start, and the third will be upside-only for a limited time. But some experts are arguing that value-based cancer care would be better served by a program involving just four of the most common cancers while also changing how costs are  gured so they would relate solely to cancer care.

OCM is a five-year pilot program that began in July 2016 and is scheduled to end next year. CMMI says 175 practices are currently participating Each episode is six months long and is triggered by a patient receiving either oral or intravenous chemotherapy. Under OCM, care has continued to be paid for on a fee-for-service basis: This is not a prospective payment program.

CVS Health Launches New Approach to Oncology Management

But OCM has two types of payments that are supposed to serve as an incentive for controlling costs and improving care. Participating practices are paid a “monthly enhanced oncology services”-MEOS, for short- payment of $160 per patient for care coordination. They are also eligible for shared savings payments if they beat episode-based financial benchmarks and met quality improvement targets. OCM also requires participating practices to provide a number of services, including around-the-clock access to a specialist who has real-time access to patient medical records, care plan documentation, and pharmacotherapy based on nationally recognized clinical practice guidelines.

Views differ on OCM. Some see a well-intentioned start to episodic payment but also a work-in-progress.
	
	“The OCM is an attempt to enhance the oncology care, but I am not sure it’s accomplishing the goal yet,” says Luis Raez, MD, FACP, president of the Florida Society of Clinical Oncology, and chief scientificofficer and medical director of the Memorial Cancer Institute in Hollywood, Florida.
	
	Raez says OCM quality standards have led to improvements in care but that the program needs an upgrade. Enough time has passed-and data collected-for researchers to begin studying OCM. An evaluation of its first year that was commissioned by CMMI identified declines in the use of intensive care units and emergency departments by patients of OCM practices, but not much, if any, effect on the lowering of costs. CMMI gave some details about OCF when it unveiled the program with an “informal request for information” in November.

Here are some of the important diferences between OCF as proposed and OCM:

 OCM limits the MEOS payments to practices to patients who are receiving chemotherapy. OCF would expand that population to include patients receiving hormone treatment. Patients not getting any cancer-related drug but under active surveillance or whose care is being otherwise managed by an oncologist would also be counted. This proposed expansion pertains only to the monthly payments, not to the patient population assigned to practices for the purpose of possible performance-based payment.

 In OCF, practices could team up and pool their patients for the purposes of hitting benchmarks for the performance-based payments.

 Under OCM, the enhanced services were 24/7 access to a clinician, patient navigation, preparation of care plans, adherence to guidelines, use of certified electronic health record, and using data for continuous quality improvement. OCF adds electronic patient-reported outcomes, or ePROs, to that list. CMMI’s informal request for information says ePROS can be used to monitor patient symptoms and identify high-risk patients.

 Keely Macmillan, a senior vice president at Archway Health, a healthcare consultant that specializes in bundled payments, says that under OCM practices get claims data on a quarterly basis, which creates too much of a lag between when the care is delivered and steps that practices might take to address practice transformation issues. Macmillan says CMMI is committed to providing OCF participants claims data more frequently.

Expansion of care covered by monthly payments.

 As proposed, under OCF the monthly payment would include payment for enhanced services and an “administration component” that covers administration of drugs. OCM’s monthly payments are designed to cover just the enhanced services. Macmillan says it is still unclear whether additional services such as imaging or lab services will be included in the OCF monthly payments, but the intent is to make a greater share of the payments to practices prospective rather than fee for service.

 Under OCM, CMMI does not set monthly payments or novel therapy adjustments specific to cancer type. Macmillan says Archway’s analysis of data from 20 OCM practices revealed problems with lumping cancers together in that way. For example, lung cancer cases were strongly correlated with negative performance-based payments, an indication of a model that doesn’t properly take into account the care needed. Likewise, colorectal and small intestine cancer were correlated with positive performance payments. As proposed the OCF monthly payment would take into account the type of cancer and whether the patient received chemotherapy or hormonal therapy. The OCF informal request for information also floats the idea of dividing a subset of cancers (breast, bladder, prostate) into highand low-risk categories for the monthly payment “in recognition that spending patterns are significantly different for high-risk patients receiving chemotherapy and low-risk patients receiving hormonal therapy.” The informal RFI also suggests calculating novel therapies adjustments by the type of cancer.

The OCF would have three risk tracks, two with two-sided risk right off the bat. The upside-only track would be available only for two performance periods.

OCF has been characterized as a thoughtful upgrade of OCM-a tweaking that will solve some problems. Not everyone sees it that way.

“I like that OCF is moving to downside risk, but otherwise there’s not a lot I like about that program,” FranÃ§ois de Brantes said in an email to Managed Healthcare Executive.

De Brantes, a senior vice president at Signify Health, says that by emphasizing total cost, OCM and OCF mean oncology providers stand to gain (or lose) payment based on services that have nothing to do with their patients’ cancer care. He also said the programs don’t adjust enough for dierent types of patients and the dierent types of cancer.

An article published on the Health Aairs blog post in December, de Brantes and four colleagues argued that OCF could be improved by focusing on breast, lung, colorectal, and prostate cancer, partly because the treatment strategies for those cancers are well known and established. Limiting the program to those four cancers could also “sharpen the eorts to measure quality in a more meaningful way,” they wrote. De Brantes and his colleagues also made a case for focusing the model on the most eective, appropriate treatment for patients, not necessarily its price, which, they said, may be largely out of the providers’ control.

Jennifer Gershman, PharmD, CPh, is a pharmacist and medical writer residing in South Florida. 

The successor, Oncology Care First, will likely include two tracks with downside risk right from the start.

The Oncology Care Model and Its Heir Apparent

Healthcare experts agree that nonmedical, social factors such as housing, nutrition, and access to recreation can play a significant role in shaping people’s health. With that being said, Medicare Advantage (MA) plans can now cover benefits that address some of these social determinants of health (SDoH).

But last year, a relatively low percentage of plans offered the benefits permitted by CMS to address SDoH. A Milliman report identified only 102 plans as offering new SDoH services, cost, funding, and novelty are some of the impediments. MA plans can use their rebate money-the difference between their estimated costs (and profit) and county-level financial benchmark-to pay for SDoH and other “supplemental” benefits for their members (the rebate money can also be used to lower cost sharing). However, according to an Urban Institute report, the average rebate in 2019 was $107 per member per month. That is not much money for tackling the complex, often deep-seated problems that come under the heading of SDoH.

Sean Creighton, a managing partner at Avalere Health, says MA plans are beginning to ramp up their SDoH-related coverage. Many are creating partnerships and referrals to community and other organizations. Examples include Humana’s Bold Goal program, a population health strategy focused on both community and business integration to improve the clinical and social health outcomes, and CVS Health’s Building Healthier Communities, a five-year, $100 million commitment that supports critical programs and partnerships with local and national nonprofit organizations.

Social determinants of health can be defined in many different ways. At a simple level, they can be thought of as almost anything nonmedical and nongenetic that has an influence on people’s health. Some definitions emphasis the notion of “place”-conditions in the environments where people are born, live, learn, work, and play. There are various estimates of the effects of SDoH; some say they account for 80% of people’s health status. But teasing out the effect of just one of them to focus may be difficult. In addition, the effects can be measured in myriad ways: quality of life, years of life lost, morbidity, mortality.

Is Healthcare a Social or Medical Issue? SDoH Make it Both

Among the supplemental benefits that CMS allowed MA plans to offer last year were adult day care services, home-based palliative care, in-home support services, medically approved nonopioid pain management, transportation, and home and bathroom safety devices. This year, CMS added more to the list for MA beneficiaries with chronic disease, including an expansion of the meal delivery benefit, transportation for nonmedical needs like grocery shopping, and “home environment services” if they relate to the chronic illness. In a press release, CMS gave the example of a MA plan covering home air cleaners and carpet shampooing for someone with asthma because they could reduce irritants that would trigger an asthma attack.

So far, MA SDoH supplemental benefits have focused mainly on housing, nutrition, transportation, and social support, according to Creighton.

“The services are intended to assist beneficiaries maintain themselves in their homes (in home health services), access providers to stay healthy (transportation or telehealth), help people with functional limitations (home modifications) and address other daily needs (nutrition),” he says.

Wren Keber, managing partner at Cardinal Consulting Group, a Los Angeles healthcare consulting firm, says payers, providers, and public officials are all starting to realize the value that addressing SDoH carries in improving physical and mental health outcomes.

When researchers at NYU and Columbia searched LexisNexis and Google to find public announcements about health system SDoH programs in 2017, 2018, and most of 2019, they identified 78 unique programs involving about $2.5 billion in funds. Housing-focused programs accounted for $1.6 billion of the spending. They reported their results in the February 2020 issue of 

The Urban Institute conducted 10 “semi-structured” interviews to prepare its September 2019 report titled, “Are Medicare Advantage Plans Using New Supplemental Benefit Flexibility to Address Enrollees’ Health-Related Social Needs?” The answer to that question is yes, but in a limited way. None of the insurers that the institute interviewed had extended coverage on nationwide basis. The new benefit flexibility was not accompanied by additional funding, the reported noted, and the interviewees mentioned that the availability of community organizations that can provide the services varies from area to area.

“For Medicare Advantage plans, rebate dollars fund supplemental benefits, so the idea is that SDoH services will fold into plan supplemental benefits for 2020,” says Keber. “There is an increasing body of evidence that managing social determinants of health for an at-risk or rising-risk population can result in improved quality and financial outcomes.”

Robert W. Seligson, executive vice president and CEO of North Carolina Medical Society, is among those spearheading the state’s efforts to address SDoH. North Carolina recognized the importance of SDoH impact early on and has embedded SDoH within the financial incentives and quality measures of its Medicaid program, he says. North Carolina’s Section 1115 Medicaid waiver allows the state to implement a five-year, $650 million pilot program that will test the impact of using Medicaid dollars to pay for evidence-based, nonmedical interventions related to housing, food, transportation, and interpersonal safety, Seligson explains.

“We are hoping to improve outcomes so others can recognize that SDoH are an important focus area that all healthcare stakeholders need to address to deliver high-quality care and maximizes resources,” he says.

By incorporating SDoH in payment and care delivery reform, physicians will be given the tools necessary to improve their patient’s health holistically while reducing costs and administrative burdens, says Seligson. Physicians are not SDoH neophytes; they have long recognized the impact of social and environmental conditions on patient outcomes, costs, and the physician-patient relationship. He points to a 2018 survey by the Physician Foundation of more than 8,500 physicians. Ninety percent reported that patients had a serious health problem linked to poverty or other social conditions.

SDoH is certainly buzzy but quality and financial metrics haven’t caught up to the trend and are largely silent on the subject. For example, the metrics the CMS uses its Shared Savings Program, its largest ACO program, don’t use SDoH-related measures or adjustments.

“If we are to improve health and bend the cost curve, ‘social risk’ and SDoH must be accounted for in payment models and risk adjustment,” Seligson says.

As CMS updates existing payment models and develops new ones, it is essential that incentives to address SDoH are built into them, he argues.

Still, Theresa Hush, CEO of Roji Health Intelligence LLC in Chicago, sees the inclusion of SDoH-related benefits for Medicare Advantage plans as a critical first step for deepening services for vulnerable individuals, especially the many beneficiaries with dual eligibility in Medicare and Medicaid.

“Since MA plans typically attract healthier and younger beneficiaries, the specific provision of SDoH should enable plans to broaden coverage within the Medicare population,” she says.

But just adding benefits is not enough, asserts Hush, who noted that accurately assessing patient needs is difficult. Add to that network and interventions needed to address those needs.

Hush says providers under contract with MA plans will need financial and other support, such as with analytics and data tools.

“Plans must measure and assess individuals’ needs better and standardize quality and outcome measures, data capture, and risk assessments,” says Hush.

She sees an opportunity for MA plans and providers collaborating to achieve lower costs and better outcomes.

Creighton at Avalere suggests a pick-your-battles approach.

“One challenge is narrowing down actionable items for a health organization,” he says. “Healthcare organizations’ impact on communities can be huge, but organizations must decide where to direct their resource.”

But he also sees an opportunity for larger health systems’ potential impact on communities to extend well past patient outcomes to employment, improved income, and possibly even environmental improvements to their communities.

But there’s also a need for better data collection to identify and prioritize, on a micro level, people’s greatest need, Creighton says. “It’s a huge issue because while there is data that will tell you about the relative advantage or disadvantage of particular communities, we need to get down to a very local level to figure out who needs something done to improve their health.” Right now, plans are offering what Creighton calls a “smorgasbord of approaches and ideas.”

“The aim is to get to a certain nexus between our day-to-day social and economic life and our health by integrating aspects of the healthcare system with the social and community services delivery systems,” he says. “And there are a lot of different initiatives going on to do so.”

Creighton see progress in the growing number of programs in the “food category” of meals and wellness and housing. In new ways and with different purposes, the SDoH surge is bringing back the house call.

“If you look at the social support aspect of this, there’s also been a big increase in the provision of in-home services which get at social support and other aspects of social determinants,” says Creighton.

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.

Medicare Advantage plans are now covering more benefits than they have in the past for those facing social determinants of health in their daily lifestyles.

Medicare Advantage Plans Covering More SDOH Benefits

, heart disease, cancer, diabetes, obesity, and Alzheimer’s disease are currently among the most expensive health conditions in the United States. The price tags are staggering.
	
	The CDC says chronic disease-along with mental health conditions-accounts for 90% of the $3.5 trillion in annual U.S. health care expenditures. But calculating health care spending by condition or disease is complex with a welter to consider.

Several years ago, researchers at the Institute for Health Metrics and Evaluation at the University of Washington set out to estimate spending by disease category. They wound up using 183 different sources of data to tally up the spending on 155 different conditions. When the federal Bureau of Economic Analysis (BEA) calculated disease-based healthcare spending for 2016, the largest category, at $334 billion, was a catchall of “ill-defined” conditions that includes colds, allergies, and preventive services. To further complicate matters, cost gets defined in different ways. Sometimes it is used to refer to direct costs on medical services. Other times, the indirect costs of lost income get factored in-and not just those for the people affected by the disease, but also those who take care of them.

Short-Term Health Plans Leave Patients Vulnerable to Major Medical Bills

Yet, despite this Rubik’s cube of variability, caveats, and judgment calls, there is fairly broad agreement on which health conditions are going to be most costly for the American healthcare system over the next decade.


	Virtually, every list puts cardiovascular disease (CVD) at the top of the cost charts. The American Heart Association’s 2019 heart and stroke update put the 

 of CVD at $351 billion-most of it ($214 billion) in direct costs.

In the BEA’s disease-specific tallies, CVD at $249.4 billion, was second only to the ill-defined conditions categories as the costliest disease. Sheer prevalence is a major factor in the expenditures for CVD. The AHA says nearly half of American adults have CVD. New guidelines that expanded the definition of high blood pressure are one of the reasons such a large proportion of American population are categorized this way.

CVD is not only expensive and common, it’s often deadly. In fact, heart disease remains the leading cause of death in this country despite real progress in prevention and treatment. In 2017, heart disease caused 

 American deaths, or 23% of the total for that year.

In the next 10 years, many of these numbers are expected to increase because risk factors for CVD are still major problems, notes 

, MD, MPH, the chief medical officer for L.A. Care Health Plan, a Medicaid managed care health plan in Los Angeles that is the nation’s largest publicly operated health plan.

True, smoking rates have been on the decline for decades and are at all-time lows. But in 2017, an estimated 14% of Americans adults were “every day” or “someday” cigarette smokers. That translates into a 34 million smokers, a sizable number by almost any standard. Obesity rates have been climbing for decades; almost 4 out of every 10 American adults are obese. Of course, obesity is a risk factor for type 2 diabetes, and the 

 says that more than 9% of Americans have diabetes, an all-time high. Seidman points out that adults with diabetes are two to four times more likely to die from heart disease than those without diabetes.

Treating CVD involves a wide range of costly medical services: diagnostic tests, ambulance trips, hospital stays, angioplasty, bypass surgery, to name just few. The pharmaceutical armamentarium for CVD is large, and generics have lowered the expense of some classes of medications-statins are the prime example. Yet, the American Heart Association 

 that one in 8 in eight heart patients skips their medication because of price and affordability.

“Until we can bring the costs of medications down, noncompliance will continue,” Seidman says. “People who don’t adhere to their medication regimen will get sicker, raising costs even more.”

Cancer is common-1.8 million new cases will be diagnosed this year, according to the American Cancer Society. It’s also lethal-roughly 600,000 Americans will die from cancer this year, although the mortality rate has been dropping. The 2.2% decrease from 2016 to 2017 was the largest decline in a single year, according to the cancer society. The flip side to declining mortality is an increasing number of cancer survivors. If projections made by NCI researchers almost 10 years ago are holding true, there are now more than 18 million cancer survivors in the U.S.

Given these numbers, some of the cost estimates for cancer are surprisingly low. The BEA put the cancer price tag at $135.8 billion, and the Institute for Health Metrics and Evaluation arrived at a figure of $115.4 billion, which is considerably less than its estimate for CVD ($231.1 billion) and mental and substance use disorders ($187.8 billion).

Howver, those estimates were made before the current surge in expensive cancer treatments and, more particularly, the advent of the costly immunotherapies. Prices of more than $100,000 a year are no longer the least bit surprising.

“While new therapies are more effective and individualized based on a patient’s individual genomic makeup or the cancer’s genomic makeup, overall cancer treatment is becoming much more costly on a per patient basis,” says 

, MD, MMM, FACP, chief physician executive CareMount Medical, a multispecialty medical group in a health system in Chappaqua, N.Y.

Expensive treatment in combination with benefit design that leaves patients and their families exposed to high costs made “financial toxicity” a major issue in oncology. Scott Ramsey, MD, PhD, director of the Hutchinson Institute of Cancer Outcomes Research in Seattle, has conducted the leading studies on financial toxicity. Ramsey and his colleagues have shown that cancer patients are 2.6 times more likely to declare bankruptcy than people without cancer. Drug companies and healthcare systems have a variety of ways of insulating patients from sky-high prices, but it isn’t complete protection by any means.

Apart from price and the vast array of prevention and treatment choices, demographic and other trends are likely to push cancer incidence and prevalence up in the coming decade.
	The march of the baby boomers into their seventh and eighth decades will be a factor.

“The number of cancer diagnoses will likely continue to climb as the population continues to age,” says Seidman, pointing out that in 10 years’ time all the boomers will be older than 65.

Alcohol consumption is a risk factor for several types of cancer, according to Seidman. Several years ago, results reported in 

 that were based on an analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions showed that more Americans are drinking alcohol, and more are drinking to a harmful level. Obesity is another potent, ascendant risk factor. Much of the evidence comes from observational studies, so it has some iffiness to it, but the associations are strong for liver, kidney, endometrial, and several other cancers.

“With obesity continuing to rise in the United States, the costs of treating such cancers will also rise,” he says.

In its ranking of 2013 spending on 155 health conditions, the Institute for Health Metrics and Evaluation ranked diabetes as the most expensive one at an estimated $101.4 billion-most (57.6%) of the money paying for pharmaceuticals.

A 2018 report from the Milken Institute on the cost of chronic disease identified diabetes as the second only to CVD in direct costs ($189.6 billion vs. $294.3 billion CVD). Prevalence, as usual, is one of the reasons for the expenditure. The American Diabetes Association says there 30.3 million Americans with diabetes, a figure that includes 7.2 million people who haven’t been diagnosed. A 

 in 2017 projected that number of Americans will increase in the 2020s and reach 54.9 million by 2030.

Latinos are a growing proportion of the American population, and diabetes is more prevalent among Latinos than other groups; for example, Latino adults are 1.7 times more likely than non-Latino white adults to be diagnosed with diabetes.

“Diabetes will continue to be an expensive medical condition 10 years from now because of the many complications that occur, most of which are related to sedentary lifestyles and unhealthy diets,” says Richard Dal Col, MD, MPH, chief medical officer, of EmblemHealth, a nonprofit health insurer in New York. “The longer someone has diabetes that is not well-controlled, the higher their likelihood of complications over time-including renal and cardiac failure.”

The dramatic jump in the price of insulin is also having a significant impact on the cost of diabetes care. A congressional 

 stated insulin costs jumped nearly 300% from 2002 to 2013.

“Government leaders at all levels have been pressuring drug companies to do something about these rising costs, but the companies argue that the high price is due to new insulin formulations that continue to be produced,” Seidman says.

Furthermore, the new formulations blunt competition from some lower-priced generics.

Whether obesity is a risk factor or its own health condition might be debated. But there’s no question that more Americans are getting heavy. The latest CDC estimate is that 39.8% of Americans adults are obese, with obesity defined as a BMI of 30 or greater. The estimate for children is 18%, although obesity in children is defined by percentile, not a set BMI.

“Not only are obesity rates increasing but obesity is starting earlier in life, adding more years of exposure to risk,” says Morel. “Combined with increasingly sedentary lifestyles, the prevalence of costly complications from obesity will continue to drive higher costs of care.”

The Milken Institute report says chronic diseases caused by obesity and being overweight (a BMI of 25 to 29.9) accounted for almost half (47.1%) of the total cost of chronic disease in 2016, including $480.7 billion in direct cots and $1.24 trillion in indirect costs.

Migration patterns within the U.S. may further deepen the country’s obesity epidemic.

“There is regional variation in obesity, in part due to differences in the built environment and local lifestyles,” says Adam C. Powell, PhD, president of Payer+Provider Syndicate, a healthcare consulting firm in Boston.

Many states with lower obesity rates, such as California, New Jersey, and New York, where 25%-30% of the population is obese, are experiencing net outflows of people, according to Powell. Meanwhile, states with higher obesity rates, such as Florida, Tennessee, and Texas, where 30%-35% of the population is obese, are experiencing net inflows of people.

The Milken Institute estimated the direct cost of Alzheimer’s disease at $185.9 billion. The Institute for Health Metrics and Evaluation figure of $36.7 billion is far less. In fact, according to the institute’s ranking, Alzheimer’s is the 21st most costly health condition. The discrepancy in the estimates is a reminder that these are just estimates made with differing assumptions and criteria.

More than 5 million Americans are currently living with Alzheimer’s. As the older population increases, that number is expected to increase dramatically. By 2050, nearly 14 million Americans are expected to have Alzheimer’s, according to the Alzheimer’s Association’s 2019 facts and figures report.

Matthew Baumgart, the senior director of government affairs for the Alzheimer’s Association, said the combination of aging baby boomers and improving outcomes for other diseases that affect older people mean that the incidence of Alzheimer’s is likely to increase-and with that, the cost.

Billions have been invested in Alzheimer’s research and drug development, but the results have fallen far short, so high drug costs are not much of a factor-yet-in the cost of Alzheimer’s. But people often live with Alzheimer’s for many years and that can mean years of expensive care in a nursing home or elsewhere.

Often, the cost figures for Alzheimer’s don’t include the billions of dollars of uncompensated care that more than 16 million family members and friends provide, notes the disease advocacy group. In 2018, unpaid care for people with Alzheimer’s and other dementias totaled more than 18 billion hours, at an estimated economic value of $234 billion, according to the Alzheimer’s Association.

“Unless disease-modifying treatments are discovered, these costs will continue to skyrocket over the next decade and beyond,” says Baumgart.

The extended family, including children and grandchildren, used to be the primary caregivers for people with Alzheimer’s and other kinds of age-related dementia, says Morel.

“But with higher rates of dual-income families, more individuals with Alzheimer’s and dementia are moving to long-term care facilities or rely on home health, adding a huge expense going forward,” he adds.

In addition, folks will see an increased number of hospital admissions for the frail and elderly with cognitive issues, but many will be unable to go directly home after discharge,” he says. “Instead they will require additional care in subacute or rehabilitation facilities, further adding to care costs.”

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.

There is fairly broad agreement that conditions like cancer, diabetes, and more will be the most costly for the American healthcare system over the next decade.

What Will Be the Most Costly Medical Conditions In 10 Years?

The healthcare industry is rapidly transforming to a consumer-based, technology-driven system that is built around the physician and patient relationship. Many of us involved in this endeavor are confident that our efforts will not only help stem the rising tide of chronic diseases that challenges our nation but will also enable us to create a more sustainable system.

While it is a common understanding that too much of the $3.6 trillion we spend on healthcare is not wisely spent, there are opportunities for the industry to make some changes. Recently, colleagues from Humana [Shrank was the lead author] and the University of Pittsburgh School of Medicine conducted a review, published in JAMA, assessing the amount of waste in the U.S. healthcare system. 

The researchers concluded that 25% of the total amount spent on American healthcare annually, which comes out to be between $760 billion and $935 billion, can be classified as wasteful spending across six waste domains: failure of care delivery, failure of care coordination, overtreatment/low-value care, pricing failure, fraud and abuse, and administrative complexity. They also calculated that savings from identified interventions that would reduce that waste, apart from administrative complexity portion, would tally up to between $191 billion and $286 billion.

Humana Study Shows Billions Wasted on U.S. Healthcare

So what can we do as physicians to address this waste? Here are four actionable ways to decrease wasteful healthcare spending:

1. Interoperability is essential for empowering physicians.

 By allowing care teams to access the entire health record, quality of care is improved. Providers have context around the care that has been given and unnecessary duplication of services are eliminated.

2. Looking holistically at the patient. Patients don't live at the doctor's office.

 Barriers exist for patients that are not obvious unless we specifically ask about them. Consider transportation. Seniors who can no longer drive may not have access to food or medicine or may not be able to use smartphones to order food or transportation. Visual and hearing impairments may contribute to loneliness and depression. We need to address these barriers to help our patients stay as healthy and independent as possible.

3. Transitioning to value-based care leads to better outcomes.

 As physicians and health care providers, we get significant gratification when our patients do well. Experience has taught us that putting patients at the center of the care equation improves outcomes-and better outcomes, ultimately, also help reduce costs. Accelerating our adoption of value based-payment arrangements can help usher in a new patient-centered era of American healthcare that will bring with it interoperability and a holistic view of our patient. Value-based care is also a way to address some of the domains from the JAMA study: failure of care delivery, failure of care coordination, low-value care, and pricing failure.

4. Help seniors stay in their homes and out of the hospital.

 Working to keep seniors in their homes by delivering personalized, convenient care will improve both the patient experience and reduce costs. The light of curiosity that guided our path as physicians into healthcare can be used to help solve these issues in our broader health care landscape. As we work to improve interoperability, address social needs, and help physicians transition to value-based care, the other domains responsible for wasteful healthcare spending will become far more manageable.

William Shrank, MD, is chief medical and corporate affairs officer at Humana and serves as an editorial advisor for Managed Healthcare Executive. Meera Atkins, MD, a board-certified obstetrician and gynecologist, is currently participating in Humana’s Executive Immersion Physician Program.

While it is a common understanding that too much of the $3.6 trillion we spend on healthcare is not wisely spent, there are opportunities for the industry to make some changes.

Opinion: Can Physicians Reduce Waste?

With approximately 2 million apps available from either Google Play or the App Store from Apple, it’s true that for lots of things there is, in fact, “an app for that.” MHE asked 12 healthcare executives what apps they have on their phones, whether for work or play. 

For Nicole Latimer, CEO of Staywell, a leading health and wellbeing organization in multiple locations, it's got to be 

 to stay connected with her family while she's away on business. “I use 

 to stay updated on new trends and industry news, 

 to track my steps and workouts and participate in fun challenges against coworkers,” Latimer says.

Jay Wohlgemuth, MD, is senior vice president of research and development, medical, and chief medical officer for 

“Quanum allows me to order labs for patients I see, and has an option for e-prescribing at any pharmacy in the United States,” he says.

 to check on drug prescribing by drug class or disease area, verify what is indicated, and review side effects and other considerations. For his own well-being, it’s 

 in Minneapolis provides healthcare business intelligence solutions powered by social determinants of health. Stephen Sigmond, co-founder and chief financial officer, says he constantly uses 

. “It’s the primary way our team members communicate-for everything from product development to sharing vacation pictures.”

Nick Woods is co-founder and chief technology officer of 

 in San Francisco, which provides free healthcare for K-12 students in school via virtual medical clinics.
	
	“I use 

 because it’s connected to my digital scale, 

 app if I have an appointment or follow-up,” he says. 

“My apps tell the story of my weekday life, somewhat pitifully, but then again, they make things manageable,” says Darcey Schoenebeck, executive vice president of business development at 

, a digital health company in Boston. For administering her life from a different state, she uses 

. “It finds me deals on whatever I’m buying, then applies the discount automatically and makes it so cheap I can't afford not to buy it!” 

Because vision is important in daily work, it's 

. “Oh man, this one: It's a magnifying glass. If you are age 50 plus, no explanation needed,” laughs Schoenebeck. “If you're not yet, enjoy your vision while you can.”

She says life as a sales executive requires 

, “for no futzing with the credit card to pay the taxi guy, and no taxi guy asking me to pay cash. It’s a win-win!” And “for getting from Point A to Point B," she is all about 

 “with its bag tracking notifications that are genius.”

Delta’s app also gets points from Chris Ingersoll, vice president of product development for 

 in Chicago, a technology-enabled revenue cycle company. 

“This app gives me an excellent, seamless, and comprehensive experience-one our own consumer-focused industry should emulate,” says Ingersoll. “I can schedule and purchase my flight, choose a seat, check in, check upgrade status, track my incoming plane, and board-all without interacting with staff, making it highly efficient for all involved and promoting brand loyalty to high-revenue customers.”
	
	Forward-thinking providers will invest in building a similarly inclusive mobile capability, in Ingersoll’s opinion. 

 in El Segundo, California, is a telemedicine platform that provides more than 1 million minutes of consultation each month. CEO Jamey Edwards is a fan of Twitter.
	
	“

 concise format forces you to choose your words. Its ability to break news and create value via curated feeds of information is the way relationships that start on Twitter turn into real-life relationships, partnerships and friendships,” says Edwards.
	
	The 

 campaign may be the best evidence of how an effective community of mission-driven people can built via social media, he says.

A self-described "fitness freak," CJ Xia is also CEO of 

 in Pleasanton, California, offering high-quality antibodies and enzyme-linked immunosorbent assay kits to the scientific community since 1993. He’s a huge fan of 

, for anyone dieting or trying to muscle up. The app, he says “is your true friend rather than making fun of you.” It calculates calories consumed and advises how much to eat to achieve a weight goal and connects you with others also seeking to get a daily dose of motivation. “Amazing infographics make data more readable,” he says.

 and its apps. Jim Higgins, CEO and founder of 

 a patient relationship management company, in Lehi, Utah, says “I really admire American Red Cross and what they have done digitally to change the perception of giving blood-turning an otherwise ‘bad’ experience good. It is a charitable act to give blood, and they really see it through to help donors. Kudos to them!” 

Lee Baxter is vice president of brand strategy and communications for 

, a Portsmouth, New Hampshire, company that has developed digital platforms for comparing healthcare prices. Yes, there is an app, and yes, he uses it.

.
	
	“It remembers my favorite destinations and alerts me to potential issues like accidents or roadwork along the way,” he says.
	
	He also champions 

, because “it covers everything health-related from the latest news to ready reference on conditions, guidelines, pill interactions and more.”

 allows me to take a photo of a document-or anything else for that matter-and turn it into a PDF I can email from my phone," says John Specht, vice president of sales and marketing at 

, a population health management and technology solutions company based in Baton Rouge, Louisiana. “It’s an absolute game changer when doing admin tasks on the road.”

“In a modern work world where so much of what we do is remote and it’s easy to feel disconnected, it’s important for our teams to maintain connections,” says Jacob Reider, MD, and CEO of 

 in Albany, New York, an IT and SDoH company.

His team uses the video conferencing app, 

, on their phones. “I like it for device-agnostic, face-to-face conversations from remote locations. I like being able to see nonverbal cues from others during our calls-for example, I can see someone nodding their head in agreement, or can tell when someone is trying to jump in, or when it looks like something isn’t resonating. Mobile video conferencing is definitely better than traditional voice-only calls.” 

, MA, is a journalist, producer, and host in Orange County, California.

Managed Healthcare Executive asked thought leaders: “What apps do you use the most on your phone?” Here’s what they said.

The Apps Healthcare Execs Can’t Live Without

Although there is no cure for rheumatoid arthritis, therapies have greatly improved in the past 30 years. 

“The goals of RA treatment are to stop inflammation, relieve symptoms, prevent joint and organ damage, improve physical function and overall well-being, and reduce long-term complications,” explains Julie Rubin, director of clinical services for 

, a pharmacy management company in Houston.

According to the American College of Rheumatology, RA patients should begin their treatment with disease-modifying antirheumatic drugs (DMARDs) which slow the worsening of joint damage as well as relieve symptoms. Commonly prescribed DMARDs include methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine.

“DMARDs have greatly improved symptoms, function and quality of life for nearly all patients with RA; however, RA treatment is complicated and often progressive in nature,” observes David Calabrese, RPh, MHP, senior vice president and chief pharmacy officer, OptumRx. It is common for patients to switch therapies multiple times in their lives, he notes. People with RA also take medications such as ibuprofen and corticosteroids to manage the pain and inflammation on an as-needed basis.

“While the last few years have seen a string of new drug approvals for RA, there are very few products in the drug pipeline now that are in late stage development,” observes Calabrese.
	
	The most notable, he says, is filgotinib (Gilead Sciences and Galapagos NV), a highly selective, oral Janus kinase (JAK) inhibitor. Janus kinases are tyrosine kinases that play a critical role in the signaling pathways that are increasingly seen as critical to the pathogenesis of rheumatoid arthritis and a number of autoimmune diseases. The new drug application for filgotinib was submitted in December 2019, along with a priority review voucher, which should shorten the anticipated time for review. 

If gets approved and makes it on to the market, filgotinib would compete with previously approved JAK inhibitors, Xeljanz (tofacitinib), Olumiant (baricitinib), and Rinvoq (upadacitinib), explains Calabrese. Rinvoq was just approved last year.

ATI-450 (Aclaris Therapeutics) is an oral MK2 (mitogen-activated protein kinase-activated protein kinase 2) inhibitor currently in Phase 1 trials for the treatment of RA. The FDA approved the investigational new drug application in May 2019, and Phase 1 clinical trials started in August 2019. 

Rubin expects more DMARDs and new additions to the JAK inhibitor drug class.
	
	“The RA drug pipeline is focused on minimizing disease progression and immune system malfunction,” she says. “These new drug classes could reduce and, in some cases, reverse clinical symptoms.”

Biosimilars may not be novel therapies, but they are one of the key areas to monitor in RA therapy in Calabrese’s opinion. 

Acceptance of biosimilars-by providers and patients-will be key to determining uptake and realizing their savings potential, he says. Payers are attempting to transition patients from existing branded biologics to less costly biosimilar alternatives with the goal, he adds, “of improving patient care and lowering total cost of care.”   

Erin Johanek, PharmD, RPh is a staff pharmacist at Southwest General Health Center, Middleburg Heights, Ohio.

DMARDs and the JAK Inhibitors have improved RA treatment. But not many new drugs are in the offing at the moment.

Rheumatoid Arthritis Drug Pipeline at a Trickle

The opioid epidemic is far from over, but after years of increasing relentlessly, the trendline for the number of drug overdose deaths in the United States finally turned the other direction. According to federal health statistics, there were 67,367 drug overdose deaths in the United States in 2018, a notable 4.1% decline from the 70,237 deaths that occurred in 2017. 

The rate of overdose deaths from natural and semisynthetic opioids (oxycodone, hydrocodone) and heroin were lower in 2018 than in 2017. It’s not all good news: The rate for synthetic opioids (fentanyl, tramadol) increased from 2017 to 2018.

Combating the opioid epidemic is a popular cause, and many organizations, government entities, and healthcare groups have responded. 

Mothers are more likely to show up for their infants’ check-ups than they are for their own check-ups. It’s a simple maxim followed by clinicians at Boston Medical Center’s Supporting Our Families through Addiction and Recovery-SOFAR, for short-clinic to “hook” mothers into managing their health and maintaining their recovery from dependence on opioids. Launched in July 2017, the program, which is run by largest safety-net hospital in Massachusetts, has seen 200 mother-child pairs since its start. 

PBMI2020: Opioid Epidemic Update, Specialty Drugs Rule, And The "Amazonification" Of Health Care

The mother-child pairs are connected to SOFAR through Project RESPECT, another Boston Medical Center program that provides obstetric and substance use disorder treatment for pregnant women and their newborns. While the infant participates in their well-baby visit, in the SOFAR clinic, the mother receives  treatment for her dependence on opioids, including access to medication-assisted treatment and a mentor who has been through a similar life experience. 

Eileen Costello, MD, chief of ambulatory pediatrics at Boston Medical Center and medical director at SOFAR, and other specially trained pediatricians engage with mothers by asking them about family support, their living situations, and their children. Many of these women are raising  children without the help of a partner, notes Costello. Some are living in group homes or struggling with custody issues. If they are taking one of the drugs used in medication-assisted treatment, such as methadone, they often must deal with criticism from family members and others. To help, says Costello, clinicians educate mothers about the research that shows that opioid-dependent women who don’t take methadone or buprenorphine in the prenatal and postpartum periods are at greater risk of relapse in the first year of their child’s life. 

The program also supports mothers who are struggling with the shame of potentially having harmed their infant by taking opioids during their pregnancy. SOFAR celebrates their efforts and successes by, for example, recognizing the achievement of arriving at 6 a.m. to get their methadone with an infant in tow, especially during a bitter cold Boston winter.

The greatest challenges with launching the program were associated with overcoming “all the silos” in the hospital setting, says Costello; for example, getting internal medicine and pediatric physicians co-located and tracking clinicians’ time effectively for billing purposes.

Data from the program are collected and analyzed to measure its effect. One finding so far: In its first year, clinicians treated and cured 335 of the mothers with hepatitis C in the SOFAR program, says Costello.

Montefiore Medical Center, the Bronx, N.Y

Clinicians at Montefiore Medical Center in the Bronx leave the health system’s campus to treat community members with opioid dependence at a nonprofit called New York Harm Reduction Educators. The East Harlem nonprofit uses a harm-reduction approach to opioid abuse that includes providing safe syringes and working to prevent overdoses.

Montefiore clinicians-typically a physician assistant or a medical resident-are embedded into the East Harlem program, and they can serve as a bridge to Montefiore’s primary care services.  That translates into access into services ranging from medication-assisted treatment to hepatitis C treatment to pre-exposure prophylaxis for HIV. Montefiore’s commitment to social justice and its Bronx neighborhood-and high cost of addressing healthcare needs when they are dire and need to be treated in the emergency department-helped secure leadership support for the partnership with East Harlem nonprofit, says Brianna Norton, DO, a general internal medicine physician at Montefiore. Seed funding came from New York State, although the program has been self-sustaining since March 2019, when the health system started billing public and private payers. 

A typical client is a 50-year-old African American or Latino male, says Norton. Often, the client’s family members live in his country of origin-or have died. Many are homeless and come to the nonprofit to get clean needles or a rapid hepatitis C test. Some just want to take a shower. 

How two hospitals and two insurers are working to turn the tide of the opioid epidemic.

MHE March 2020