April 13, 2013

Fast Medicine

How are you feeling today? Do you feel a bit under the weather? Maybe you have some aches and pains, or a miserable flu, or maybe you have some chronic condition like diabetes or asthma, or some other ailment. Perhaps you could benefit from medical attention, but then again getting medical care is so darn inconvenient and expensive and time consuming, and everybody knows that our health care system is broken, and that health care is full of carelessly infected people, who waited many months just to be pushed around, maimed and exploited by arrogant doctors who never wash their hands, before being packed onto jumbo jets that fall out of the sky on a daily basis. Obviously, something must be done, and soon, or we are all going to crash and burn, or worse, go bankrupt.

Fortunately the uniquely American entrepreneurial spirit of innovation, fueled by unimaginable advances in technology, is finally galvanizing its efforts to fix the American health care tragedy, just like it fixed finance, food, retail, transportation and all sorts of other industries, to our utter delight and immense benefit. It’s also nice to see that in the spirit of global cooperation, our friends across the pond are pitching in with innovative ideas of their own. In the April issue of Health Affairs, two top shelf researchers from England are informing us that a “A Key To Slower Health Spending Growth Worldwide Will Be Unlocking Innovation To Reduce The Labor-Intensity Of Care”. Observing that labor costs are the largest contributing factor to the rising costs of health care, the authors reach the inescapable conclusion that “there is great potential to reduce costs while preserving the quality of care by experimenting with delivery models that require a less costly skill mix”, and they have plenty of examples to support this theory. In Mexico, for instance, people “pay $5 per month to access a health advice hotline before setting foot in a physician’s office” and in India, “assembly line–style eye surgery has dramatically reduced cost without sacrificing quality”. The idea is to utilize technology and innovative labor arrangements to deploy health workers with limited formal training “in a variety of contexts”. “Deployed in low- and middle-income countries to address labor shortages, they could also be used in developed countries to reduce the need for the most highly skilled clinicians”. The main epiphany for me here was that poor countries, with billions of unemployed starving people, can have “labor shortages”!!

But other than that, America is way ahead on this one, and since primary care is, well, primary, it is also the primary place to begin the cutting of “highly skilled clinicians”. The latest buzz comes from Walgreens’ announcement that its NP staffed retail clinics will now begin diagnosing and treating chronic disease, thus reducing the need for the highest skilled clinicians. The prices are advertised, of course, and look pretty reasonable at between $79 and $122 for an established patient exam, excluding tests, procedures and complicating factors. To illustrate our savings, the Medicare Physician Fee Schedule for an average established patient visit (CPT 99213) is currently $72.81 (national average). For the most complex office visit for an established patient (CPT 99215), Medicare pays doctors $142.90 on average. Convenience is of course priceless, but some caution is necessary because Walgreens may not be willing to “care” for you after all.

In the same issue of Health Affairs, several folks employed by Walgreens are exploring another technology driven, cost-reducing innovation. Using data analytics and health risk assessments ($89 at its retail clinics), Walgreens is introducing the concept of “impactibility modeling” to be layered on top of predictive risk-stratification analytics in order to identify patients who “may not be amenable to the proposed preventive intervention”. So “[a]lthough certain subpopulations are at high risk, they may be denied preventive care because they are not expected to respond to it”. Basically, why spend money on lost causes, “such as people with cognitive or other mental health disabilities and those who have language barriers. Or an organization may exclude all of the very highest-risk patients, because such patients are sometimes regarded as being less amenable than others to preventive care”. Following a convoluted attempt at explaining the ethical aspects of this innovation, the authors recommend that more data should be collected, that “there should be appropriate ethical reviews” and that some pilots be initiated.

Now that we’re pretty much done with primary care doctors and really sick individuals, perhaps we can take our savings up a notch. Health Affairs seems to be a veritable treasure trove of innovation these days, and in its February issue, we find an article from Health Partners in Minnesota reporting $88 savings for each simple episode of care administered by their Virtuwell platform. I have to admit that the logic behind their savings calculations escapes me, but their exquisitely high tech platform is the epitome of labor intensity reduction. You go online, provide a valid credit card number, fill out a bunch of forms answering questions about your condition and medical history (perhaps Barton Schmitt, or something similar), and in 30 minutes or less you receive your diagnosis and plan, from an NP somewhere, including prescriptions and referrals if necessary, for a flat fee of $40. You may call if you must, and you will receive an electronic message in a few days to make sure all is well. This is way better than the Mexican hotline model as far as eliminating skilled jobs, and with some more intelligence injected into the protocols, perhaps a little Watson style analysis, we could probably get rid of the NPs altogether.

A small step in this direction can be found at Walmart, CVS and Safeway, where SoloHealth is deploying their health assessment stations which provide “free and convenient access to healthcare”. You can screen your vision, blood pressure, weight, body mass index and as many ads as will fit in 7 minutes or less. All for free. This is not really treatment of disease just yet, but the potential is certainly there. Perhaps you can talk to the Station for 7 minutes, then go shopping, and come back in 30 minutes to get your Virtuwell diagnosis and script, and 30 minutes of shopping, particularly with pediatric patients in tow, could be worth enough to the hosting retailers to be able to share a portion of earnings with the Virtuwell platform owners. Isn’t it amazing how innovations can feed of each other to generate cheaper and more convenient innovations?

If you’re still not convinced, here are a couple more things to consider. First, the fee-for-service issue is automatically resolved by switching health services venues, because retail is one of those more advanced “other industries” and therefore perfectly fine with fee-for-service. Second, everybody wins because retail health care, other than being free and very convenient for shoppers and retailers, has a built in operational feedback loop. You go to a convenience store, load up on soda, Cheetos, Doritos, gummy bears and 50% off holiday candy, screen yourself online, go buy some smokes to alleviate the tension, get diagnosed with diabetes amenable to care, get your prescription filled, and on your way out pick up some of the stuff mentioned on the screening station screen, or recommended for purchase on your patient education handouts, and some beer to go with the smokes and the generic Metformin (it’s not like the machine can tell, right?). Rinse and repeat every three months or sooner if you start experiencing chest pain. They do treat cardiovascular disorders too. And don’t worry; you will get plenty of proactive outreach reminders if you forget your next appointment, from the retailer, the various ad sponsors and your dedicated zero-skills care team. How much more convenient can it get? Problem solved.

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