New point-of-care (POC) tools that promote communication between providers and patients are establishing themselves as next generation shared decision-making solutions, especially when it comes to medications and issues of insurance coverage, price, and out-of-pocket costs. 

“When compared to traditional shared decision-making tools, there’s an increased emphasis not just on improving measures such as medication adherence by involving the patient in his or her own care but also on using this education and engagement to improve patient satisfaction,” says Chuck Lee, MD, senior director of clinical knowledge and Meducation at First Databank, a San Francisco company medical data company. 

Meducation, which uses research-based health literacy approaches to simplify medication instructions, was focused solely on providing key instructional and adherence tools related to medications self-administered at home. Now its new content is designed to directly address Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction questions on newly administered inpatient medications, including 200 new intravenous drug forms and hospital-administered medications. 

Lee says that access to these point-of-care tools has been enhanced. With Meducation, all patient education materials are automatically made available through the patient portal or via a standalone portal. It’s a brand new, patient-facing world for these POC tools.

“Many of the older shared decision-making tools were designed to be used exclusively by providers of care and not to interact with patients,” notes Heidi Polek, RPh, senior manager, independent pharmacy solutions for DrFirst, an e-prescribing and patient medication management company in Rockville, Maryland. 

Joel Jones, PharmD, director, population health informatics for Epic, says the new tools are being embedded directly into physicians’ workflows with built-in next steps that allow them to easily and efficiently swap in a more cost-effective drug. Alan Wheatley, president of Humana’s retail segment, agrees that one of the primary old vs. new differences in decision-making tools is that the new ones can be integrated into a physician’s workflow. There’s also added interoperability. 

Humana has partnered with Epic to integrate IntelligentRX, its real-time benefits check tool, into Epic’s e-prescribing workflow. The result is real-time access to a patient’s medical history, health insights, and treatment options. 

Preparing Pharmacy for Performance-Based Reimbursement

The EHR software enables clinicians to immediately estimate the cost of a medication and share it with a patient by factoring in copayments, deductibles, and a need for prior authorization. The application sends an alert about less expensive options. The software also helps physicians to avoid gaps in care by, for example, reminding a patient that she is due to have a mammogram soon. 

“Our relationship with Humana is an opportunity to help patients and prescribers work more collaboratively with payers, streamline procedures, and integrate information into a doctor’s workflow,” says Jones.  

One of the benefits, Jones continues, is limiting prescribing fatigue on the part of providers because they are dealing with information that is accurate and can be acted upon, based on a patient’s coverage. It also promotes communication among payers, clinicians, and patients and puts data on a common platform, he says.

Humana’s Retail Segment President, Alan Wheatley, says there is more interest in the tool than expected, and he anticipates it will improve quality and positively play out in CMS’ Star Rating system.

Other companies are also folding insurance coverage information into workflows and platforms. Allscript, a Chicago EHR technology company, offers a transparency feature from Veradigm, a health information technology company, called TruePriceRx accessed through its electronic prescribing platform to improve adherence and reduce the need to change a patient’s therapy because of unexpected cost or prior authorization. TruePriceRx offers real-time prescription pricing information within the prescribing workflow-all at the point of care. Providers can use the information to discuss pricing options with their patients, increasing consumer empowerment and satisfaction, and when that happens, the likelihood of medication adherence increases.

“The tool helps get patients on the right therapy and improves patient-physician dialogue because a clinician receives the price of a drug in the EHR to pass along to patients -before they go to a pharmacy,” says Jill Helm, vice president, product management, Allscripts. Then, says Helm, the physician may have the opportunity to recommend an alternative medication that is less expensive or one that might be ordered for 90 days instead of 30.

“It is difficult for patients to admit they cannot afford a drug and force them to ration it-or not take it at all,” says Helm.

Transparency tools are gaining traction and it's anticipated that when the regulation requiring Part D sponsors to adopt one or more real-time benefit tools that are capable of integrating with at least one prescriber’s e-prescribing system or EHR goes into effect next year, adoption will really pick up steam, she says. Helm also attributes the growing interest and adoption to the complexity of benefits and to the trend away from simple copays toward high deductible coverage and high out-of-pocket costs. An Allscripts’ survey found that 60% of participants said adherence improved when patients received pricing information.

Helm says the price transparency tool also helps patients choose the best pricing model through their insurance plan or whether to pay cash. It can also help select a pharmacy that will support the best adherence to prescription therapy.

Polek says that DrFirst offers a patient engagement tool called RxNotification, a single secure message from a participating prescriber or pharmacy to a patient, with information on pricing and affordability; why the drug has been prescribed; clinical information; how to take the drug; and cost savings.

“RxNotification helps reduce adherence barriers and alleviate cost issues,” Polek says. “It also combats issues of price transparency because patients can see prices before a prescription is complete and decide if they can afford it, thus reducing drug abandonment.” The  tool has proved to reduce drug abandonment by 6%, according to Polek.

Another tool, Backline, is a web-based, HIPAA-secure service environment in which all shareholders-providers, hospitals, long-term care facilities and pharmacies-ask questions and share patient data via encrypted, text-style messaging, replacing phone calls, texts, faxes and emails. Polek says Backline sold to hospital and physician practices and later to insurers, enables participants to exchange messages about whether a drug is covered under a patient’s plan.

RxAdvance, a national, full-service PBM, leverages its Collaborative PBM cloud platform to provide all stakeholders with a comprehensive view of a patient’s health and medication regimen. The platform allows review and optimization of a member’s prescription regimen to proactively prevent adverse drug events and eliminates duplicate therapies.

“The cloud model reduces costs and allows for more efficient and streamlined communication amongst stakeholders in the field of care,” says John Sculley, former CEO of Apple and co-founder of RxAdvance.

Sculley attributes the rise of pharmacy tools to a higher demand for a streamlined and data-driven process as more patients receive care at home. He says the egregious cost of drugs is another factor. RxAdvance has enabled a 10% to 12% reduction in overall pharmacy costs; a 10% to 15% reduction in specialty pharmacy costs; and a 20% to 25% reduction in avoidable drug-impacted medical costs.

“Using RxAdvance’s collaborative PBM cloud can empower pharmacists to make critical decisions at the point of sale to help improve adherence and also to reduce avoidable medical costs,” Sculley says.   

Mari Edlin, contributor based in Sonoma, California.

Articles

New point-of-care tools offer greater transparency.

Point-of-Care Tools in Pharmacy Take Off

Intermountain Healthcare is a Salt Lake City-based nonprofit healthcare system, providing hospital and other medical services in Utah and Idaho and offering integrated managed care under the insurance brand SelectHealth. 

Charles W. Sorenson, MD, FACS, has been an influential reason for its  success, having served as president and CEO of Intermountain from January 2009 until his retirement from this position in October 2016, when he became founding director of the Intermountain Healthcare Leadership Institute. 

“My best trait is the ability to hang out with people who are far more capable than I am,” Sorenson quips. “I am not intimidated by working with people who are smarter than I am.”

Under his leadership, Intermountain implemented a disciplined and systemwide focus on best clinical and operational practices aimed at producing measurably better outcomes for patients while controlling  costs: “I’ve always been focused on best care for our patients.”  

Sorenson also sees the culture at Intermountain as having a ripple effect. “We had nearly 40,000 people working there who spent more time at work than with their families,” he notes. “Whatever culture they had at work, they would surely import to their children and families. “

Prior to his time in the top job, Sorenson was Intermountain’s executive vice president and chief operating officer for 11 years. He  was instrumental in making clinical process improvements and developing Intermountain into an integrated delivery system.

“This is a great career for making a difference for multiple people every day,” Sorenson says. “At the same time, it’s a career you continue to learn from and improve your skills. I’d do it all over again in an instant.”

Becoming a physician was something that was always in the cards for Sorenson. His father was a dedicated internist in Salt Lake City. Sorenson says he didn’t see much of his father growing up because of the long hours his father put in, he knew his dad loved his patients and never once heard him complain. Sorenson’s mother was a nurse and was equally dedicated.

“I was a pretty good student, and I wanted to go to medical school because it was the hardest thing I could think of doing,” he says. “I always felt like doing hard things was good for me, and I always felt like this is what I always wanted to do.” He dreamed of going to medical school on the East Coast. An acceptance letter from Cornell turned that dream into a reality. He quickly rose to the top of his class.

Sorenson ended up liking surgery and enjoyed his residency: “Even though it was long hours, I never felt burdened by that.” He specialized in urologic surgery, returned to Salt Lake City in the early ’80s, and practiced at Intermountain’s largest hospital, and was on the teaching staff at the University of Utah. “I thought life was good,” says Sorenson.

In the early ’90s, Sorenson noticed a worrisome trend in healthcare: Physicians buying their own surgical centers, urologists buying their own lithotripters,  and a general trend of physicians taking control of services that make money for hospitals out of the hospitals.

“In fee-for-service medicine, you get paid really well for some procedural things and you don’t get paid at all for taking care of patients with long-term medical illnesses, behavioral health issues, and managing people on Medicaid,” says Sorenson.  “I felt like things were fragmenting.” Sorenson says he talked to some of the leaders at Intermountain about starting an integrated medical group. In 1994, Sorenson was one of the founding members of the Intermountain Medical Group, an integrated practice of approximately 1,500 physicians and advanced practice clinicians employed by Intermountain, serving as the founding chair of the Medical Group Board from 1994 to 1998.

“I was continuing in my clinical practice and also on the Intermountain board at the time, and they asked me a couple of times if I wanted an administrative responsibility instead of clinical work, but I didn’t really want that then,” explains Sorenson. “In late 1997, things were changing, and they asked me if I would be willing to go full-time in leadership role, and after thinking about it a long time, I felt it was important and did it.”

He admits he wasn’t excited about leaving clinical practice but hoped to spend a morning every week in the operating room helping colleagues on major surgical procedures to stay involved. 

“I learned on the job. They didn’t want me to get an MBA. They needed someone who understood the clinical processes and could relate to frontline clinicians-physicians and nurses-and focus on providing healthcare affordably and achieving Intermountain’s mission.”

Jumping into the CEO and president positions wasn’t something that Sorenson was planning on doing, but when he was asked, he accepted and stayed in that role until he passed age 65. Then, Sorenson pursued something he was really passionate about-developing leaders at the intersection of clinical and operational expertise at the Institute for Healthcare Leadership. In addition to his administrative responsibilities, Sorenson has also continued to be involved in the practice of urologic surgery, with a primary focus on urologic oncology. The institute got off the ground because of a “very generous” gift of $20 million from Kem Gardner, a Utah real estate developer, Sorenson says. It is focused on values-based leadership principles to help healthcare leaders more fully develop the combination of character and competence that inspires trust, which Sorenson notes is at the core of great leadership. 

“I thought it was important to train people to combine clinical expertise and knowledge with operational expertise,” Sorenson says. “There were a number of great leadership programs around, but most of them focus on business skills. Those are important, but I’d come to recognize that we needed those who also had a value-spaced leadership, who were focused on integrity, courage, had emotional intelligence, and people skills.” The target audience is mid-career, high-potential clinical and operational leaders from respected nonprofit systems. The institute has a unique center where participants practice leadership scenarios using simulation and case studies.

“Our faculty has really felt the engagement of our participants in this very interactive program. It’s very motivating to see how well it’s been received,” Sorenson says. “It’s been great and the cohorts have really gelled. These are the kind of leaders it will take to change healthcare around the world.”

Sorenson and his wife, Sharee, reside in Salt Lake City and are the parents of four adult children.

“I’m at the age when I kind of reflect back on life and I’ve spent a lot of hours in the hospital and a lot of hours at work,” he says. “I’m trying to spend more time with my kids and grandchildren.” His two oldest children have followed his example and came back to Utah. Eric is a surgical oncologist at Intermountain and Scott went the business route. His daughter is a nurse in Minneapolis,  and his youngest son is a mechanical engineer in Ann Arbor, Michigan.

Sorenson and his wife spend time volunteering together and work with refugee families from Central Africa. “It’s been really fulfilling for us to spend some time doing that,” he says. “These are some wonderful people.”

He also recently joined MEDI, the largest executive coaching firm in the nation dedicated exclusively to the healthcare industry as an executive coach. “When I was still in the CEO job, before starting the Institute, I realized I needed to understand what coaching is,” Sorenson says. “I ended up going to Columbia’s program in 2017, and I like it in the same way I like medicine. A new client is like a new patient. You enter a relationship where you don’t know this person at all but to be successful you have to develop a high level of mutual trust and the goal is to help them.”

Reflecting on his life, Sorenson considers himself very lucky He mentions having opportunities to learn from amazing people in college and every step of the way at Intermountain. 

“I feel a big responsibility at this time in my life to give back, and if I can help people whether it’s through the Leadership Institute or doing volunteer work, that’s important to me,” he says.   

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

A look at the president and CEO's experience in becoming an influential reason for Intermountain Healthcare's success.

Featured Exec: Charles W. Sorenson, President and CEO Emeritus of Intermountain Healthcare

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. 

Montefiore clinicians saw 118 unique patients in the first three months of the partnership. “These are patients who would otherwise likely never see a physician at all,” observes a  spokesperson. 

Michigan has been hit hard by opioid epidemic. In 2017, its opioid overdose death rate was 15th highest in the country.

Christina Barrington, PharmD, vice president of pharmacy programs at Priority Health, Michigan’s second-largest health insurer, says the company is trying to make sure that members have adequate pain relief while also working to prevent accidental overdoses and misuse of opioids. Starting in November 2017, the Grand Rapids, Michigan, nonprofit started limiting access to short-acting opioids for acute pain to a 15-day fill and long-acting opioids for chronic pain to a three-day fill. It also reduced its copay for Narcan (naloxone), the drug for reversing opioid overdoses. 

In other moves, Priority Health  took steps to reduce opioid dosage to a maximum of 120 MEqD (morphine-equivalent dose) daily and keep track of members who get opioid prescriptions from multiple physicians. a health services.  

Barrington says Priority Health has also introduced “pain contracts”: The patient agrees to receive opioid-based medications from a single physician. The physician who signs the contract receives a report of all the doctors who prescribed opioids to their patients. If patients get opioid prescriptions from another physicians, the physician who signed the pain contract can choose to stop treating those patients or taper their medications. 

Within one year of launching the program, use of opioids by Priority Health members has declined by 47% among commercial members, 36% among Medicaid members, and 18% among Medicare members.

 several years ago showed that acupuncture is effective when managing chronic pain. The study focused on patients with nonspecific back or neck pain, shoulder pain, chronic headache, or osteoarthritis. Another study published in 

 last year found that acupuncture is helpful as an adjunctive therapy to treat pain associated with chronic stable angina.

Last year, Capital Blue Cross in Harrisburg, Pa., started covering acupuncture to treat pain. More than 200 members “took advantage of the opportunity to use an alternative treatment for their pain,” says Jennifer Chambers, MD, the insurer’s chief medical officer. 

“I’m a personal proponent of [acupuncture] to treat chronic neck pain,” adds Chambers, who currently takes no medication for her neck pain. She’s also interested in using acupuncture to treat dry mouth for cancer and heart pain. 

“The conclusion here is we need to be more open to nontraditional, non-Western medicine approaches to treating chronic pain,” says Chambers, adding that biofeedback and mindfulness techniques can also help address the anxiety and stress associated with chronic pain. 

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

Opioid Related Overdoses Decreasing

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

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

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.

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, 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.

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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.

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.

MHE March 2020

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