By Dave Chase
 First Posted at Forbes.com on 9/9/2012

Dave Chase, Co-Founder & CEO, Avado

The insight of the year goes to Leonard Kish, a health IT strategy consultant, for making that statement regarding patient engagement. The corollary to this statement is a game changer: What happens when effective patient engagement becomes the Standard of Care?

Used to determine whether a doctor is liable for medical malpractice. The standard of care is important because it determines the level of negligence required to state a valid cause of action.

It’s hard to overstate the implications of doctors being held to the Standard of Care. Many argue that the basis of unnecessary and duplicate procedures is the fear of malpractice. Doctors understand that in a malpractice case one of the key items that is analyzed is whether they met the Standard of Care. [Others argue that the "do more, bill more" reimbursement model has been at least as big of a driver. Regardless, malpractice concerns related to the Standard of Care are a big driver]

Comparing Two Blockbusters
Kish compares the statins blockbuster with the patient engagement “blockbuster”. [See Kish's full article here.]

First, the evidence for blockbuster drugs. In Dr. Eric Topol’s book “The Creative Destruction of Medicine,” he takes a deep look at the evidence for statins, possibly the biggest group of blockbuster drugs over the last 20 years. Statins are a requirement of Meaningful Use Stage 1 clinical quality measures, as well as key measures for the CMS hospital quality measures used by many organizations, internal and external to the hospital, to grade the quality of care at a hospital. Prescribing statins, in many instances, is no longer optional. Topol states that “of every 100 patients taking Lipitor to prevent a heart attack one patient was helped, 99 were not.”  These drugs cost $4 per day per patient and $1500 per year. While they are great at lowering cholesterol, it remains unclear that they do much to prevent heart attacks.

Now let’s take a look at a 2009 Kaiser study of coordinated cardiac care. Compared to those not enrolled in the study, coordinated care “patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.” And, “clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.”

Kish goes on to share another example from the VA that shows similarly astounding results and then asks the salient question.

Can you imagine if a drug reduced the need to go to the hospital by this amount? Again, it would be considered malpractice not to use it.

Expecting Restauranteurs to Teach Their Patrons How to Cook
Kish states the expected pushback from healthcare providers when they are held accountable for their patient’s actions.

All this is so different for healthcare providers. It’s like a great restaurant learning that their new business is going to be – in addition to continuing to provide a great in-restaurant experience – teaching people how to cook at home. What? This isn’t what we do!  It’s impossible!

While this is an understandable perspective for them to have given that they haven’t been accountable for their patients’ actions, I think clinicians underestimate their own influence. Consider that Gallup’s recent ranking of the most trusted professions are as follows:

  1. Nurses
  2. Pharmacists
  3. Doctors

Clinicians may not think in these terms but consider some of the less-than-pleasant things they regularly convince patients to endure. Whether it’s something that is life-threatening or not, doctors have proven to be persuasive. As I outlined in Doctors Success Hinges on Transactor to Teacher Transition, the root of the word doctor is teacher and it is through instruction of their patients that people are willing to deal with various disagreeable items such as the following:

  • Oncologists convince their patients to endure chemotherapy with its well-known side effects of going bald and extreme nausea.
  • Listen to just about any pharmaceutical advertisement to hear some nasty side effects — some are quite common.
  • Surgeons regularly convince obese patients to staple part of one’s stomach (bariatric surgery) where studies have shown 1% of patients die and 40% have complications.
  • When I worked in an OR, the nurses sensitized me to the significant risks of anesthesia yet most don’t question their doctor if they are told they are going to be put under for a surgery.
  • Caesarean Sections: The rate has gone up more than 50% in the last 15 years for a whole host of reasons. Clearly doctors have influenced that whether it’s for outcomes or malpractice reasons. Women are well aware of a longer recovery time, scars and other side effects but trust their doctor’s judgment.
  • Surgeons have convinced their patients to inject botulinum toxin (aka Botox) into the face of a patient on a regular basis. As Wikipedia states, “botulinum toxin can cause botulism, a serious and life-threatening illness in humans and animals.”

The efficacy of the items above are impacted by patients after they leave the clinic/hospital. The biggest difference is complications from the procedures above are an opportunity for additional revenue whereas they generally wouldn’t be in an accountable model. The key reason doctors, nurses and pharmacists are able to persuade is their trust and credibility. Not only are clinicians trusted, most remember their classmates who went into medical careers as some of the smartest people they grew up with.

 

Success Goes to the Behavioral Scientists

Doctors are human. As I’ve heard said, “if you want to understand a sales person’s behavior, study their commission plan. If you want to understand a doctor’s behavior, understand their reimbursement model.” As Kish stated, “It’s no accident that in both the examples here (Kaiser and the VA), the providers and the payers were tightly aligned, because the economics have to be aligned before any of this will work.”

At the root of the success of the Direct Primary Care organizations I have written about before whphysio are the “Triple Aim” (lower cost, improve the patient experience and improve outcomes) champs is their understanding of criticality of building trust. It simply isn’t possible in a 7 minute “drive-by” appointment so common today. As in any relationship, trust is built on a firm foundation of communication. Read more on communication being the medical instrument of the future.

Qliance

If you would like to be notified when the seminal paper on Direct Primary Care is published this Fall, please contact me via my LinkedIn profile – http://www.linkedin.com/in/chasedave.

The related insight is recognition that it’s going to be impossible to succeed in a value and outcome based reimbursement model if the provider doesn’t recognize that 75% of healthcare spending is on chronic disease. The majority of decisions that most influence outcome are made by patients and their families — not clinicians. This is expanded upon in Health Systems Ignore Patients at their Own Peril It’s particularly true in primary care which is why IBM has catalyzed primary care by changing how it buys healthcare.

However, it’s not limited to primary care. Two healthtech startup colleagues of mine are Eric Page and Russell Benaroya who previously owned sleep centers. While the industry benchmark for adherence to  CPAP  therapy programs was 40%, they achieve 79%. They have shared that their “secret” was building trust using techniques that are commonplace for consumer marketers. Much of that revolved around creating an emotional connection with their organization via their team members. Consumer marketers, for better or worse, understand how to change behavior. If they didn’t, we wouldn’t have any of these fashion or food choices.

   
 

An example of where the consumer marketer mindset must take hold was highlighted by the pioneer healthcare organizations who shared lessons learned. In a nutshell, proactive communication is the “inoculation’ to biggest fears these organizations have — system leakage (i.e., patients getting care outside of their network). If the organization isn’t top-of-mind at their patient’s moment of truth when some medical need arises, it’s guaranteed they’ll have significant system leakage. This is a disaster for organizations given a block of money to care for patients and then they have to pay a third-party health system for the services that those patients received when they “leaked” outside of the system.

What Comes Next After Blockbuster Drug Marketing?

Matthew Herper wrote last year that The Blockbuster Drug Comes to an End. For the fourth consecutive year, pharmaceutical advertising declined in 2011. Not surprising since between 2007 and 2012, drugs worth some $63 billion in sales lost market exclusivity. And between 2011 and 2015, the New York Times says, the total is $100 billion. Any business dependent on blockbuster drug marketing has taken a big hit with no end in sight.

Now imagine that the blockbuster “drug” is patient engagement. Already we have seen organizations such as Jenny Craig, Weight Watchers and online sites such as eDiets increasing their advertising. After all, managing one’s weight is a form of patient engagement. As patient engagement programs such as managing high blood pressure prove themselves, it’s only a matter of time before prime time TV and WebMD are filled with advertising that seeks to engage groups of patients in healthy behaviors.

Online media properties are particularly well positioned as they can target consumers based on attributes including what company they work for. It’s not hard to imagine General Motors or other large employers targeting ads to their employees while they are on WebMD or Yahoo Health. Rather than ad sales reps calling on the marketing department, they will start calling on the HR/benefits department. Who knows, they may start calling on the Finance/Investor Relations department. When public companies such as Safeway have demonstrated they can reverse healthcare hyperinflation, other public companies will find that a cost as significant as healthcare that is unmanaged is a dereliction of fiduciary responsibility. Broad reach and targeted sites such as WebMD and Yahoo Health may prove they can have a material impact on getting employees engaged in their health.

Med School Wasn’t Easy Either
There are 3 trillion reasons why healthcare has to change but also 3 trillion reasons why incumbent organizations are resistant to change. After all, one person’s cost savings are another’s revenue. The government has sent a shot across the bow of healthcare providers with the strings attached to Medicare reimbursement. In addition, the federal stimulus dollars driving the adoption of electronic medical records has been tied with the demonstration of “Meaningful use”. The second tranche of dollars is tied to requirements that were recently rolled out. The item that received the most pushback related to demonstrating patient engagement. The American Hospital Association came out strongly against these requirements.  In response, the government lowered the requirement from 10% to 5%.

The professional associations representing healthIT professionals and the medical professions are responding with tools and training to help with the transition. For example, the association for healthIT professionals (HIMSS)  has commissioned a book on patient engagement I was honored to be asked to co-edit and write the Patient-Provider Communication chapter. Patient engagement will be a major theme of the 2013 HIMSS conference which is likely to be their biggest yet with Bill Clinton, Karl Rove and others as speakers. The book will come out in advance of the conference to guide healthcare organizations into this new world.

One can certainly empathize with the challenge facing hospitals. How many organizations get penalized for the very thing they where rewarded for shortly before that? In the past, a hospital readmision to an organization operating like a hotel (i.e., more beds filled being a good thing) was great news. Starting October 1st, the U.S. starts to act like most of the rest of the world. That is, most hospitalizations are considered a failure in the system. That is, something wasn’t caught early enough to prevent hospitalization. Through the use of commonplace technology, places such as Denmark have dramatically reduced hospitals and hospitalizations — reductions of well over 50%. Fortunately, there is an overlap with consumer desires. For example, at one time more than 50% of people died in hospitals. Most people want a few simple things when they die. They want to be warm, dry, pain-free and with family. Today, 93% of people die at home as a result of remote monitoring, video conferencing, and house calls. As a nice byproduct, it’s also far more cost effective.

Virtually all clinicians will be expected to change like most other professions who’ve already had their work styles radically changed over the last 10-20 years. All of these changes make it clear that it’s a full employment act for change management consultants to help navigate these turbulent times.  However, as the most trusted professions and with healthcare consuming nearly 20% of the economy, Voltaire stated it eloquently “With great power comes great responsibility.”