Not to take anything away from the Senator’s apparent concern for his constituents’ real, valid frustration with the health system, but is his villain the right one? Is it a fundamental misreading of the facts of the US health ecosystem to believe that there is any one villain in the system at all? The real, underlying reason that the US health system is so fragmented is that the system itself is the problem. And, as it must be, the system will be the source of any viable solution that makes navigating less challenging and more holistically unified.

Stop Blaming Individual Sectors — Look at the Aggregate

High drug prices are just one symptom of a health ecosystem already becoming increasingly fragmented several decades ago. The problem was well-established and recognized when economist Dr. Alain C. Enthoven wrote about it in the American Journal of Managed Care more than a decade ago, positing that inefficient allocation of resources negatively impacted quality, cost of care and medicines, and patient outcomes.

Since then, little has changed. In 2016, FINN Partners released a survey showing that the fragmented health ecosystem was placing an ever-greater burden on patients, the people the system is supposed to protect and serve — and was increasingly failing. Eight years later, the results of this survey will not have changed significantly.

For decades, payers, patients, policymakers, product innovators, and providers turned a blind eye to fragmentation. And while policymakers prefer to spotlight a popular villain — drug cost — the relentless search for villains won’t fix fragmentation. If we attack one piece of the ecosystem rather than look at the problem, we will fail to make meaningful change. While putting pharmaceutical company CEOs under the glare of the Senate HELP spotlight may provide a tremendous election-year photo-op, bipartisan grandstanding is antithetical to addressing the health system’s continued splintering.

If the System Were a Patient with Multi-System Failure, Would We Treat Only One Organ?

We now know beyond a doubt that the health system is fragmented and has a cost impact. It is time to move from this era of fragmentation into the “post-fragmentation” period. Rather than finger-pointing and finding scapegoats, what’s needed is a fuller understanding of how the system works — and fails to work — for the patient. This requires looking at the full picture objectively, without accusation, to understand better how the different players in the system can work together to support the same goal: a health system in which the patient, not the system itself, is the health system’s true beneficiary.

It’s a fact: prescription drug prices in the United States are higher than in other nations, averaging 2.78 times those seen in 33 different countries, according to the February 2024 RAND report. But are pharma companies the sole cause of this patient burden and health-system chaos? Absolutely not: drug costs comprise about 11 percent of the total $4 trillion in US health expenditures. In reality, provider and hospital services total almost half of US health spend (31.4 percent and 20.3 percent respectively).

Fragmentation Adds to Patient Care Burdens and Costs

Fragmentation leads to out-of-control spending across the system. According to a 2018 Commonwealth Fund study, Medicare recipients “with three to four chronic conditions and highly fragmented care are 14 percent more likely to visit the emergency department, and six percent more likely to have a hospital admission.”

If the US health system were a publicly traded corporation, this hemorrhaging of cash would have been decisively stopped years ago. Taken together, the $4 trillion in annual US healthcare costs can be laid on the doorstep of nearly every player in the ecosystem, from insurance companies to PBMs, pharmacies, pharmaceutical companies, government, hospitals, and venture capital, to name a few — even endless consumer demand and neglected preventive care.

Operating with a business-as-usual approach will carry steep costs in money and lives. When the system fails to engage people proactively with heightened risk for heart disease, cancer, diabetes, and other non-communicable illnesses, when it denies patients diagnostic procedures ordered by their physicians, when it shifts patients from working medications to substitute therapies due to a non-medical switch decision, curiously, some parts of the system benefit to the detriment of patients.

These situations shouldn’t be, as the consequences of the current line and the decisions they reward can be dire, leading to rising costs, diminished patient care, and even death. Ultimately, the chaos around care delivery comes from considering patients a necessary fly in the system’s ointment. The patient is not the health system customer. The system is a customer unto itself.

Can We All Focus On Why the System Exists — To Heal Patients?

We recognize the health system’s failings but must also identify its strengths and potential for improvement. This will allow us to reorient our thinking and ask, “Now, what do we do to put the patient back into focus as the ultimate customer and the preferred beneficiary of the system?”

Stanford Physician Ilana Yurkiewicz, an internist, hematologist, and oncologist, in her book Fragmented: A Doctor’s Quest to Piece Together American Health Care, published by W. W. Norton, argues that it’s actually fragmentation that’s the central failure of health care today, resulting in a system that uses more than twice the economic resources other developed nations dedicate toward health and which results in poorer life expectancy outcomes:

“There’s an unspoken assumption when we go to see a doctor: the doctor knows our medical story and is making decisions based on that story. But reality frequently falls short. Medical records vanish when we switch doctors. Critical details of life-saving treatment plans get lost in muddled electronic charts. The doctors we see change according to specialty, hospital shifts, or an insurer’s whims.”

No longer are we debating whether the system is fragmented or not. We must shift our mindsets and drop the mistaken belief that identifying bad players in the ecosystem will fix the problem. With ecosystem fragmentation as the diagnosis, what is the treatment path to better management? This is where “Health System Kinetics” (HSK) enters. HSK fosters collaboration and leverages health information technologies — AI, ChatGPT, GenAI, and LLMs — to create an eco-dynamic that prioritizes people’s well-being and works toward longer, healthier lives.

The Health System is Greater Than Its Sector Parts — Study its Kinetics

Health System Kinetics objectively studies factors and sector-to-sector relationships influencing individual and collective health outcomes. It includes biological, environmental, social, and economic determinants of health. Understanding health system kinetics will allow the health system to evolve for the better, benefiting its stakeholders and addressing gaps and inefficiencies in people’s care by fostering a proactive, positive approach.

Understanding why fragmented care is a system-wide illness is a starting point we passed long ago. Looking at the health ecosystem as an ever-changing aggregate — kinetics — rather than separate sectors at fault is the opportunity to move beyond the present chaos.

Fragmentation goes beyond the left hand, not knowing what the right is doing. Too often, it means that the left hand won’t acknowledge the right hand’s very existence. While rising costs concern everyone, it’s essential to keep our eye on the goal of keeping people healthier at home, out of the hospital, and, if possible, far away from illnesses. To do that, we must address the misalignment of incentives and lack of coordination in the health ecosystem.

Applying Health System Kinetics will allow us to understand better how we can do this to provide better patient care, reduce health professional burnout, and give patients with chronic conditions greater attention. The objective study of the interconnectedness of the parts of the healthc system will promote a better understanding of how these components work together now — and how they can be changed to work better together in the future. Failing to take this approach means we won’t see meaningful change, and that’s not an option.

Do Not Let the Virus Kill its Host — the Health System

We have diagnosed the illness that plagues our health system; it’s a virus called fragmentation. It’s time to examine our biases, behaviors, and business goals. The primary mission is to recognize that we are people — sometimes patients — all seeking to enjoy a healthier life. Suppose fragmentation is the wall that separates us from better access to care. In that case, health professionals in every ecosystem sector can be empowered to pursue their calling with passion and tear down that wall.

Looking for a villain in the health ecosystem, something lawmakers have been doing for the last several election cycles, may be suitable for campaigning but not for progress — not for continued innovation and patient care. Progress can only be achieved when we get past the mindset of the period in which we have been — the period of acknowledging the system is fragmented — and move into the post-fragmentation era, in which we view the system through the lens of health kinetics and eco-dynamics.

When we look at and understand how all parts of the system work together — or fail to –we enter an era in which we no longer debate who’s to blame. Proper understanding will allow us to compromise, adjust our aims, improve our practices, and finally, make changes that remove the health system as its own beneficiary, replacing it with the patient as the system’s customer.

[Special thanks to John Bianchi for his review of this health policy economics article that shifts the conversation from sector-to-sector blame to a forward-looking perspective; to industry friend and mentor John Nosta for encouraging me to put these thoughts into publication and to Dr. Dean and Anne Ornish, pioneers in preventive and consumer empowered health and co-founders of Ornish Lifestyle Medicine.]

The post We Know the Health Ecosystem is Fragmented, Resulting in Rising Costs and Poorer Patient Outcomes, But What Are We Doing About It? appeared first on Medika Life.

Such problems vary across types of insurance but include such things as denied claims for care they thought was covered, difficulty finding an in-network doctor or other provider, and delays and denials of care that involved an insurer’s prior authorization. 

At least half within each of four major types of health coverage – employer, Medicaid, the Affordable Care Act’s marketplace, and Medicare – say they had a problem using their coverage in the past year. 

Such problems are more common among people with greater health care needs. For example:

• Two-thirds (67%) of consumers who rate their own health as “fair” or “poor” encountered a problem in the past year.
• About three-quarters (74%) of those who received mental health treatment in the past year reported a problem.
• More than three-quarters (78%) of those who received a lot of health care (more than 10 provider visits in the past year) reported a problem.

“The survey shows that the sheer complexity of insurance is as big a problem as affordability, particularly for those with the greatest needs,” KFF President and CEO Drew Altman said. “People report an obstacle course of claims denials, limited in-network providers, and a labyrinth of red tape, with many saying it prevented them from getting needed care.”

Today’s report captures key results from the nationally representative survey of 3,605 people with health coverage through an employer, Medicare, Medicaid or the Affordable Care Act’s marketplaces. Future reports will delve more deeply into the experiences of people with those types of coverage, as well as people with specific chronic conditions and needs across types of insurance.

The frequency that people encounter specific insurance problems varies by type of coverage. For example, people with employer and marketplace coverage report denied claims more often than people with Medicare or Medicaid, and people with Medicaid and marketplace coverage more often report problems finding in-network providers.

Insurance problems can contribute to unexpected costs, with more than a quarter (28%) of those who reported problems saying they had to pay more for their care as a result. This includes about a third of those with marketplace or employer coverage who reported problems in the past year.

Among those who reported recent insurance problems, half say they were able to resolve the issue to their satisfaction, while nearly as many say either that the issue had been resolved in a way they didn’t like (28%) or that it remained unresolved (19%). Most insured adults (60%) do not know they have appeal rights by law, and three quarters (76%) do not know what government agency to call for help dealing with their insurance.

Consumers’ insurance problems can affect their ability to get timely, needed care. Among those with recent problems, about one in six say that they were not able to get recommended care (17%), they faced a significant delay in receiving such care (17%), or their health declined (15%) as a direct result.

About half (51%) of insured adults report some difficulty understanding at least one aspect of their health insurance, such as what their insurance will cover (36%), what they will owe out-of-pocket for care (30%), or what their explanation of benefits statement means (30%). About a quarter say that they find it difficult to understand terms such as “deductible” or “copay” (25%) and to figure out which doctors, hospitals and other providers are in network (23%).

People with Mental Health Challenges Have More Problems

The report also probes the challenges facing insured people who rate their mental health as fair or poor, regardless of whether they sought or obtained mental health treatment. This includes about one in five of all people with insurance, and one in three of those with Medicaid coverage.

Substantial shares of enrollees in this group rate the availability (45%) and quality (37%) of mental health therapists and providers covered by their insurance as “fair” or “poor.” 

Among those who say their own mental health is fair or poor, 43% say that there was a time in the past year when they did not get needed mental health care. Among young adults under age 30 who describe their mental health as fair or poor, more than half (55%) say they did not get needed mental health care in the past year.

People cite various reasons for not getting needed mental health care, but insurance was a factor for many.  Among all insured adults who didn’t get needed mental health care, more than four in 10 (44%) say they couldn’t afford the cost, and more than a third say it was because their insurance wouldn’t cover it. 

• One in six (16%) of all insured people say they have had problems paying or an inability to pay for medical bills in the past year, including similar shares of those with marketplace (19%), employer (17%), and Medicaid (16%) coverage, as well as 12 percent of people with Medicare.
• Premiums also can be an issue for consumers, particularly for those with employer and marketplace plans.  About half of those with marketplace or employer coverage give their insurance plan low marks for the amount that they pay in premiums and the amount they pay out-of-pocket to see a doctor. Far fewer of those with Medicare or Medicaid rate those aspects of their coverage negatively.
• In spite of the problems people report using their insurance, a large majority (81%) give “excellent” or “good” ratings when asked to rate their insurance overall. 
• Large majorities of consumers with insurance say they would support requirements on insurers that could make it easier to avoid or resolve insurance problems. These include requirements to maintain accurate and up-to-date information about who is in their network (91%) and to provide simpler, easier-to read statements explaining coverage decisions and how to appeal if you disagree (94%), all of which have been enacted by Congress though not all have been implemented.   

Designed and analyzed by public opinion researchers at KFF, the KFF Survey of Consumers Experiences with Health Insurance was conducted February 21-March 14, 2023, online and by telephone among a representative sample of 3,605 adults in the U.S. with health insurance coverage, including 978 adults with employer-sponsored insurance, 815 adults with Medicaid coverage, 885 adults with Medicare, and 880 adults with marketplace insurance. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 2 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher. 

The post KFF Survey Shows Complexity, Red Tape, Denials, Confusion Rivals Affordability as a Problem for Insured Consumers, With Some Saying It Caused Them to Go Without or Delay Care appeared first on Medika Life.

The sessions (and meals) – positioned around the exhibit floor were meaty – and welcomely unscripted, offering plenty of time for real-world reflections on the state of health delivery.  Afterward, speakers would mingle on the exhibit floor to answer questions and continue the conversation.  Whether an intended benefit for attendees or not, the meeting structure was a great hit and strengthened ViVE as a go-to community where people can interact and discuss challenges and possibilities. 

The number of attendees was right-sized, where meeting and exchanging thoughts is a priority and at a time when the economy and health system are under a magnifying glass.  The system is broken. That’s a collective given. However, where we go next remains a mystery.

Some 6,000 people were in Nashville for this four-day CHIME intensive, and the schedule of events – official and unofficial – offered plenty of opportunity – need – to catch up.  There were specialty Start-Up, Interop Now, and Cybersecurity Pavilions for the ever-curious and Speed-Connection Forum for deal makers and plenty of action on the exhibit floor.

Some of the add-on gatherings included: the Start-Up Health Transformers Session, UC Davis and FINN Partners Summit on Innovation and the timed release of the Galen Growth Digital Health Report on US Health Provider Systems, the Nashville Entrepreneur Center Evening Meet-Up, and the always fun and welcome Pinksocks Get-Together at the famed Springwater.

MAGIC AROUND THE EXHIBIT HALL

The everyday magic centered around the exhibit hall – home to the mainstage presentations, provided meals, pop-up post-5 PM receptions, and varied entrepreneurial hubs.  That offered plenty of opportunities to connect with innovators who reserved exhibitor space. 

The themed location of exhibits also supported a deep dive for conversation with people looking to improve the flow of information within health systems, better utilize information for preventive care or harness the power of smart tech and wearables.  Most importantly, there was a general acknowledgment from the speakers and vibe that our health system doesn’t lack innovation – it is sorely in need of structural healing. 

ADDRESSING HEALTH ECOSYSTEM PAIN POINTS

In this way, the range of companies appearing on and wandering the exhibit floor made the meeting well worth the time investment.  Many of the companies present at ViVE are worth following (those here are in alphabetical order).  These are among the enterprises that are addressing pain points of the health ecosystem and rallying to pressing patient needs:

• AssureCare, a population-health company connecting payers, providers, pharmacies, and government-sponsored healthcare programs across the US, is taking the long-awaited patient-centric approach using technology to generate better insight through health information. This company is working to converge pharmacists’ and pharmacy data into a bigger population health picture. AssureCare hopes to break down silos in healthcare data sharing from specialty pharmacies to national chains.

• Babson Diagnostics is doing what over-promoted Theranos failed to deliver. Babson is reimagining the diagnostic blood testing experience making routine blood testing less invasive, more convenient, affordable, and empowering people to take charge of their health. The holy grail of patient testing has been to bring it into the retail pharmacy setting using technologies that require one-tenth the sample blood volume of traditional venipuncture methods without sacrificing quality, accuracy, or menu breadth and pushing these diagnostic tests into a well-known setting where convenience corresponds to patients’ upcoming physician visit is in itself a big step in the right direction.

• CereCore® is elevating hospital operational effectiveness.  Its systems are already based in top-performing US hospitals, enabling this health IT enterprise to improve processes, data security and clinical applications. Hospitals remain the most expensive points of care within the US health ecosystem.  Generating insights and learning to mine and apply data earlier in the patient engagement process is key to improving care and reducing costs.  Hospitals cannot go it alone; tapping into a well-proven system is a smart starting point.

• CPSI has combined several companies under its corporate umbrella focusing on health solutions and services for community hospitals, clinics, and post-acute care facilities. These are the health systems that are known to struggle as more and more systems look to align with other, larger entities. The path to system-wide health has been to ensure a better patient care experience, improve financial operations and offer community hospitals and affiliated clinics EHR solutions that can accurately code assignments for reimbursement. While many companies in the field are looking to “innovate,” sometimes the greatest care advances are in strengthening the care system’s capacity to be economically viable.

• eVideon uses smart-room technology to streamline clinical workflow and transform the patient room into an immersive environment. This company enables hospitals and long-term care clinics to integrate EMR and other installed technologies to display real-time information through the in-room Smart TV, digital whiteboard, digital door sign and bedside tablet. The platform is streamlining clinical workflow and reducing the technology burden on clinicians. This system even features in-room surveys and video chat so the patient has a greater real-time voice.

• Harmony Healthcare IT is the data management firm that moves and stores health organizations’ patient, employee and business records. Among the category of veteran players, it continues to pioneer health IT tech in many ways.  Founded in 2006, this company works with more than 550 clinical, financial, and administrative software in the US and Canada.

• HCTec provides services to more than 1,500 academic medical centers, health systems, community hospitals, critical access hospitals, and healthcare provider organizations. While patients are supposedly the health system’s priority, it’s vital to remember that if the care locations are poorly staffed and lack infrastructure, their mission will be severely hampered.  At a time when hospital systems are integrating, getting their staff and EMR systems connected is a mega – even life-saving priority. 

• Interwell Health is a kidney-care management platform in a field that has become one of the most pressing health sector needs.  The Centers for Disease Control and Prevention (CDC) estimates that 37 million Americans are affected by kidney disease, and most are unaware of their progressive condition.  With kidney disease reaching near-epidemic levels, how physicians care for patients and help them navigate a fragmented reimbursement environment is a monumental task. The cascade of care – from diagnosis to dialysis – requires access to practice knowledge and reimbursement.  Learning about an illness is the start of a process and getting the care essential to keeping people on track to prevent additional medical risks is where medical outcomes are judged.

• ixlayer is partnering with payors, retail pharmacies, direct-to-consumer brands, biopharma, health systems, and telehealth providers to create quick and easy diagnostics for common conditions where reducing cost is possible – before an illness is much more severe. This platform “white labels” its tests for major customers with direct patient access and enables numerous testing options and seamless integration with its customers and lab partners. Like many innovation leaders, its goal is to shift engagement to earlier stages when a disease presents and its management has far more cost-effective treatment options.

• Juli was front-and-center at the American Telemedicine Association meeting in San Antonio earlier this year. The consumer-direct platform – available through a convenient app – supports people with chronic health conditions such as asthma, migraine, depression, bipolar disorder, hypertension or chronic pain through several evidence-based approaches. This consumer health empowerment tool integrates information that impacts health and awareness by tracking health responses to environmental data (e.g., weather, air pollution, pollen) through smartphones or popular wearables and aligning health.  The information can help shift the sick-care reactive system to a self-care preventive care approach.

• Lifepoint Health, the Nashville-headquartered provider, has, since its founding, become a national health system serving patients, clinicians, communities and partner organizations across the healthcare continuum.  A spin-out of the pioneering HCA, this system now includes more than 50,000 employees, 62 community hospital campuses, 50 rehabilitation and behavioral health hospitals – plus 200 additional care sites, including managed acute rehabilitation units, outpatient centers, and post-acute care facilities.  It was no surprise that Lifepoint Health was present at ViVE.

• Loyal is among the first companies to offer end-to-end digital and AI-powered solutions tracking the patient journey; its software solutions for improved care utilization can be found within the nation’s top health systems and hospitals. From selecting a provider best suited for treating a specific condition to closing a feedback loop on patient experience, they have demonstrated that feedback is desired and that people who engage their health networks tend to show greater loyalty.

• Sheba Medical Center was part of the expert conversation at ViVE – a surprise for some as Newsweek World’s Best Hospitals five years straight – this medical system sent representatives from more than 6,000 miles away to share insights on how it maximizes technology across its care systems.  Its acute-care hospital, rehabilitation center, research and training programs, medical simulation center, center for disaster response, and the ARC Innovation Center for redesigning global healthcare all tap into the full range of digital and health technologies. At ViVE, its head of innovation spoke about the importance of looking for innovation from within its walls and the benefits of sharing best practices around the globe.  

• Teladoc Health appears to be about accessing care from many locations, but the pandemic demonstrated that the platform could provide much more to improve people’s well-being.  Now, telemedicine has become a given and has shown its value in patient adherence, management of chronic conditions such as diabetes, checking in with people enrolled in clinical trials and dealing with senior care needs.  In post-acute hospital care, telemedicine can support the outpatient process and keep people healing at home.  This global leader in delivering whole-person virtual care – including primary care, mental health, chronic condition management, and more – is the category must-watch innovator.

WHAT’S UP NEXT FOR HEALTH INNOVATORS?

The success of ViVE had many looking forward to April and HIMSS in Chicago, and CNS Summit in Boston this November.  For health innovators planning for 2024, mark your calendars for ViVE February 25 – 28, 2024, in Los Angeles.  If you have already marked your calendar for those dates, it’s a sure sign that #ViVE2023 was a hit!

The post ViVE Was an Out-of-the-Box Hit Among the Digital Health and Health Innovation Tribe appeared first on Medika Life.