Dr. Ralph Snyderman responds to a recent article published in the NYTimes
In her NYTimes article, “Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much“, Elizabeth Rosenthal amply describes the complex and arcane medical reimbursement system that drives up health care costs. A far bigger driver of costs is the ¾ of medical expenses going toward high-tech treatments of episodes of chronic disease rather than for their prevention or effective management.
Health care follows the money and the current “fee for service” system rewards for volume of expensive procedures. Services requiring interactions with patients to encourage prevention or disease management lose money. Thus, the epidemic of preventable chronic diseases needing expensive treatment continues to grow. Fee for service reimbursement is also responsible for the complexity of billing as payers want to justify what services they pay for, contributing to the coding maze.
A solution to this dilemma is to reimburse for the value of the outcomes of care rather than for volume. “Value based reimbursement” is designed to reward more effective care rather than volume of procedures. The switch from fee for service to value based care, being driven by the Centers for Medicare & Medicaid Services (CMS) is at its infancy but expedited implementation could help eliminate much of the perverse incentives that retard more effective care delivery and encourage the rigging of the system to maximize billing.
Ralph Snyderman, MD is Chancellor Emeritus, Duke University, James B. Duke Professor of Medicine, Duke University, and Director of the Duke Center for Research on Personalized Health Care.
With rising healthcare costs and a rapidly aging population, finding sustainable and cost-effective ways to address chronic illnesses is one of the most critical pursuits in health care today. One strategy that has demonstrated promising results is Personalized Health Planning (PHP). An example of its strengths as well as the barriers to implementation can be seen at Duke with a disease management program for patients with Congestive Heart Failure (CHF) that started back in 1998.
What is Congestive Heart Failure?
CHF is a chronic disease that occurs when the heart becomes weak or stiff and is unable to sufficiently pump blood to meet the body’s needs. CHF is common, costly, and potentially fatal.
Heart Failure Info from Novartis
According to the CDC, about 5.7 million adults in the US have heart failure, and the disease costs the nation nearly $31 billion each year in cost of health care services, medications, and missed days of work. This chronic condition accounts for one million hospitalizations annually, and is the leading cause of hospitalization among adults over 65. Moreover, readmission rates for CHF patients are high, due to recurrence of heart failure, as well as low medication adherence, self-monitoring, and follow-up. Strategies to improve CHF prognosis and reduce readmission rates should focus on patient engagement outside of the clinical encounter.
How can personalized health planning benefit patients with CHF?
PHP aims to make health care more proactive, personalized, and patient-centered through methods that engages patients in their care. In particular, PHP integrates wellness training and long-term planning into the traditional appointment model. Many patients with CHF suffer from multiple illnesses or co-morbidities, and need the support of different teams of health care providers (primary care, tertiary care, etc.) to effectively manage their health. PHP empowers the patient to take charge of their own health by engaging them in education and goal-setting through a tailored health plan. It shifts the emphasis of care away from high-intensity, expensive inpatient treatments to preventing, coordinating, and managing the illness in outpatient, or primary care settings. Furthermore, this personalized health plan allows for care coordination across clinical team members and across specialties within a health system.
What happened in the Duke CHF case study?
Duke set up the Duke Heart Failure Program (DHFP) based on the personalized health planning model. Protocols were developed for the management of medications, and a patient education manual was created that covered topics such as the importance of each medication, the potential adverse effects, appropriate actions to take if such effects occur, and resources available to CHF patients. Additionally, clinical teams maintained provider-patient contact through follow-up visits and regular telephone calls, while health coaches provided complementary support and education for each patient. The results were striking. Within two years, hospitalizations per patient-year decreased from a median of 1.5 to zero, and clinic visits significantly increased. The PHP approach improved health outcomes for patients and cut costs nearly in half. Empowered with education and clinical team support, patients showed active participation in the program and a desire to make positive lifestyle changes.
Why did the program get discontinued?
In the end, the CHF program reduced the average cost of treating patients by $8,600, or about 40%, by improving their outcomes and reducing their hospital admission rates. By shifting more of the care to outpatient settings, more money was spent on health coaches and clinics rather than treatments in the hospital. However, Duke faced an unfortunate paradox: the healthier its patients were, the more money Duke lost. Ultimately, it decided that this program was unsustainable because the hospital was losing too much money by reducing readmissions and therefore opportunities for billable care.
What are the lessons we’ve learned from that case study?
The current reimbursement system continues to primarily reward old models of care, and not more proactive, preventive models like personalized health planning. Alternative payment models are necessary to incentivize proper disease management, coordination of care, and activities such as follow-up calls that are currently not reimbursed in the fee-for-service, volume-based payment system. Models such as bundled payment and Accountable Care Organizations (ACOs) aim to shift payment in health care towards focusing on value and quality, rather than volume of services provided.
Today, Duke offers the Same-Day Access Heart Failure Clinic, which offers counseling, dietary management, and medical adherence support to CHF patients. Part of the motivation to establish this program came from the Centers for Medicare and Medicaid Services (CMS). In 2012, the CMS announced financial penalties for facilities with readmissions for the same condition, such as CHF, within a 30-day timeframe. To prepare for these changes, Duke established the Clinic to offer an alternative to the emergency room to avoid unnecessary hospital stays. Patients are taught self-management and given tools to promote successful transitions from hospital to home. Clinicians provide follow-up care consisting of phone calls 24-48 hours post-discharge and biweekly to weekly office visits until the patient is stable.
Since its initiation, the Duke University Health System has seen a 15 percent reduction in readmissions from CHF patients. Due to the CMS regulation, it is now financially feasible and necessary for Duke to establish programs that engage patients and improve outcomes, in order to avoid payment cuts incurred from high readmissions rates.
This program demonstrates the power of proactive disease management programs, and the necessity of financial incentives to establish these programs. Research and practice continues to show that preventive and personalized approaches are crucial to creating better outcomes for patients while controlling costs. Now we need to continue restructuring delivery and payment mechanisms to meet this imperative.
The first East Coast Precision Medicine World Conference, the 12th PMWC, will be hosted at Duke University on May 24-25. The conference is co-chaired by Dr. Ralph Snyderman, Chancellor Emeritus, Duke University, and Dr. Geoff Ginsburg, Director of the Duke Center for Applied Genomics & Precision Medicine. The main focus of the conference is “translating the power of precision technologies into better health care.” Click here for a note from the conference co-chairs.
The conference will center around topics related to data science to advance precision medicine, the importance of patient engagement, the impact of technology to drive genomics and medical practice, updates on data and regulatory policies, metabolomics in precision medicine, the emergence of single cell genomics, monitoring infectious disease, an update on the PMI, mobile health and how it is changing healthcare, liquid biopsy, the microbiome, and much more – for more information see the developing themes. Major speakers for the conference include Robert M. Califf, Francis S. Collins, Mark Levin, Chris Cournoyer, Kathy Giusti, Richard Klausner, Keith R. Yamamoto, and Janet Woodcock.
There is still time to register, so we hope to see you at PMWC DUKE in May!
On Friday, February 3rd, Dr. Ralph Snyderman spoke about “Taking Health Personally” at the NC CEO Forum. He introduced the concept of Personalized Health Care, the inflection curve of disease development, personalized health planning, and outlined the role of the individual in proactively managing their health and healthcare.
The image below is Dr. Snyderman’s “Prescription for a Personalized Health Plan”, which was featured in his presentation.
Please continue to check back with this website. In the future, we hope to provide you with information to help you get started in your own personalized health planning and information for you to bring to your primary healthcare provider to enable the creation of your annual personalized health plan. If you’d like more information in the meantime, please email us at firstname.lastname@example.org.
The Duke Center for Research on Personalized Health Care
On December 28th, Ralph Snyderman, Caroline Meade, and Connor Drake of the Duke Center for Research on Personalized Health Care published an article in NEJM Catalyst’s “Care Redesign” section. The piece, titled “To Adopt Precision Medicine, Redesign Clinical Care” highlights the importance of care redesign for more effective use of personalized and precision medicine (PPM) technologies. It outlines our vision for a 5-step clinical workflow, personalized health planning, that can deliver individualized care grounded in proactivity and patient engagement.
We are excited to share this work with you through NEJM Catalyst-if you’re interested in reading the piece, click HERE
Image from http://catalyst.nejm.org/adopt-precision-medicine-personalized-health/
During his fifteen years as chancellor, Dr. Ralph Snyderman helped create new paradigms for academic medicine while guiding the Duke University Medical Center through periods of great challenge and transformation. Now, he has written a book chronicling his experience.
Ralph Snyderman’s book is 336 pages and is available for purchase
Under his leadership, the medical center became internationally known for its innovations in medicine, including the creation of the Duke University Health System—which became a model for integrated health care delivery—and the development of personalized health care based on a rational and compassionate model of care. In A Chancellor’s Tale Snyderman reflects on his role in developing and instituting these changes.
Beginning his faculty career at Duke in 1972, Snyderman made major contributions to inflammation research while leading the Division of Rheumatology and Immunology. When he became chancellor in 1989, he learned that Duke’s medical center required bold new capabilities to survive the advent of managed care and HMOs. The need to change spurred creativity, but it also generated strong resistance.
Among his many achievements, Snyderman led ambitious institutional growth in research and clinical care, broadened clinical research and collaborations between academics and industry, and spurred the fields of integrative and personalized medicine. Snyderman describes how he immersed himself in all aspects of Duke’s medical enterprise as evidenced by his exercise in “following the sheet” from the patient’s room to the laundry facilities and back, which allowed him to meet staff throughout the hospital. Upon discovering that temperatures in the laundry facilities were over 110 degrees he had air conditioning installed. He also implemented programs to help employees gain needed skills to advance. Snyderman discusses the necessity for strategic planning, fund-raising, and media relations and the relationship between the medical center and Duke University. He concludes with advice for current and future academic medical center administrators.
The fascinating story of Snyderman’s career shines a bright light on the importance of leadership, organization, planning, and innovation in a medical and academic environment while highlighting the systemic changes in academic medicine and American health care over the last half century. A Chancellor’s Tale will be required reading for those interested in academic medicine, health care, administrative and leadership positions, and the history of Duke University.
“Dr. Snyderman has presented readers with a critical, reflective, personal, and at times painful account of his thirty-five-year tenure at Duke. He presents a perspective of Duke, and of a growing academic medical center, as honestly and frankly as possible, without being harsh. His candid reflections are refreshing, given most leaders’ tendencies to either sugarcoat the past or vilify those who have stood in their way. A Chancellor’s Tale provides invaluable insights into the workings of a large and respected U.S. academic medical center and into the mindset of one of its top leaders who steered the ship through rough seas and calm waters, raising Duke to its current national and international prestige.” — E. Albert Reece, MD, Vice President for Medical Affairs, University of Maryland
“Compassionate physician, award-winning biomedical scientist, successful pharmaceutical executive, medical educator, and administrator, Ralph Snyderman’s remarkable and multifaceted career spans the full range of biomedicine. Here he describes in vivid detail how, as Chancellor, he transformed Duke University Medical Center into a powerhouse integrated health system while pioneering the innovative and widely emulated approach now known as prospective or personalized medicine.” — Robert J. Lefkowitz, MD, Investigator, Howard Hughes Medical Institute, James B. Duke Professor of Medicine, Duke University
“Providing a unique perspective on the internal politics at Duke, Dr. Snyderman exposes many of the complexities and problems inherent in the governance of any academic medical center. A Chancellor’s Tale is also a story of what Dr. Snyderman witnessed through his eyes and ears and of his creative leadership. I admire him greatly for what he accomplished at Duke.” — Michael M. E. Johns, MD, Interim Executive Vice President for Medical Affairs, University of Michigan
“Dr. Ralph Snyderman is a doctor’s doctor, the best of the best in American medicine. In A Chancellor’s Tale, he effectively synthesizes his extraordinary breadth of experiences into something more than the sum of its parts-a visionary, transformative view of what true health care can be at a time when it is most needed. If you only read one book on transforming health care this year, this is it. Highly recommended!” Dean Ornish, MD, Founder & President, Preventive Medicine Research Institute, Clinical Professor of Medicine, University of California, San Francisco
About The Author
Ralph Snyderman, MD, is Chancellor Emeritus, Duke University, James B. Duke Professor of Medicine, and Director of the Center for Research on Personalized Health Care at the Duke University School of Medicine. He previously served as Chancellor for Health Affairs at Duke University and as the founding President and CEO of the Duke University Health System; Dean of the School of Medicine at Duke University; Chair of the Association of American Medical Colleges; Senior Vice President, Medical Research and Development, Genentech, Inc.; Director, Laboratory of Immune Effector Function, Howard Hughes Medical Institute; Chief, Division of Rheumatology and Immunology at Duke; and Senior Investigator, National Institutes of Health. Dr. Snyderman has received numerous honors, including the Personalized Medicine World Conference Pioneer Award (2016), the North Carolina Life Sciences Leadership Award (2014), the Association of American Medical Colleges David E. Rogers Award (2012), the Industrial Research Institute Medalist Award (2008), the Ellis Island Medal of Honor (2003), and the CIBA-GEIGY Award for Lifetime Achievement in Inflammation Research (1992). He has authored almost 400 manuscripts and is the editor or coeditor of several books. Dr. Snyderman lives in Durham, North Carolina.
There is growing recognition that a re-orientation of our nation’s health care system towards prevention and quality is underway. The Affordable Care Act (ACA) seeks to forge a path to a new era of health care reimbursement based on the “triple aim”: 1) improving the patient experience, 2) facilitating better health outcomes, and 3) reducing the per capita cost of health care. It turns out that it matters how and what we pay for to improve the delivery of care.
What is the fee for service reimbursement model? What’s wrong with it?
The fee for service (FFS) reimbursement model is the way most health care services are financed and is the system most familiar to Americans when visiting their provider. In short, it is a way of billing the payer for each health care service delivered (like an office visit, test, or procedure). The health system or health care provider sends you or your insurance company an invoice with the services that were delivered.
Why is this a problem? Economists worry it incentivizes physicians to bill for more treatments, labs, or visits because the payment they receive is dependent on the quantity of health care services they deliver. By doing this, it creates a potential conflict of interest with patients since health care systems are rewarded for performing duplicate tests, over-prescribing medications, providing more health care services than is required, and other strategies to maximize the amount of billable care.
One of the most concerning and perverse problems with the FFS reimbursement model is that it is not aligned with efforts to prevent disease and promote health. As health deteriorates, it results in more opportunities for billable health care services (e.g. more lab tests, visits to the doctor or emergency room, and prescriptions). Since efforts to engage patients in prevention and health promotion have low reimbursement rates, or are not reimbursed at all, health systems are effectively penalized financially for developing innovative care models that keep people from getting sick. In other words, it makes more financial sense from the health system’s perspective to bill for an expensive surgery than it does to have a health coach or nurse work with patients to make lifestyle changes to prevent or alter the trajectory of their disease, perhaps eliminating the need for expensive and invasive surgery.
Where has this approach led us?
In the US we pay far more than any other country in the world for health care, but all of that money doesn’t translate into the best health. Despite our highest per capita spending on health care, we have a lower life expectancy compared to other developed nations. It demonstrates the need for a system that encourages greater efficiency and a focus on prevention.
What’s the alternative?
It will take a nuanced approach to balance the competing goals of reducing costs and improving the health of patients. Whatever the funding mechanism, there’s a moral and financial imperative to create a system that incentivizes a more rational approach to reimbursing for health care services.
An often-underappreciated aim of the ACA is the focus on moving away from FFS towards a model of health care financing that takes into account quality and efficiency. Included in the ACA, the Accountable Care Organization (ACO) is a new type of healthcare organization that aims to improve quality and reduce the total cost of care for a population of patients. This can be achieved via different types of payment plans. The alternative being tested by emerging ACOs and larger health systems is known as a value based reimbursement model. The goal is to incentivize and reimburse based on what everyone agrees is the ultimate measure of a successful health care experience, better health. Collecting data to understand which health care services improve health outcomes and penalizing health systems that bill for unnecessary testing or are constantly readmitting patients due to complications are critical first steps.
The health care delivery model of the future will be one that embraces the ethos of personalized, patient centered and proactive care. It will be designed to predict disease, personalize prevention and treatment, and collaborate with patients to help them reach the highest levels of wellness. Providers and health care systems are capable of developing these types of innovative delivery models, so long as we accelerate movements towards reimbursement reforms that support and incentivize this more rational and compassionate approach to medicine. By incentivizing quality over quantity, we’re moving in the right direction.
Big Data in Healthcare Many industries have been quick to invest in and adopt infrastructure to support “big data” in recent years, but what exactly is “big data”? And how can it be applied to the healthcare industry? “Big data” differs from regular data in that it is less structured and exponentially larger, and requires much more effort and expertise to manage and maintain. Analyzing the information contained in big data sets has the potential to inform strategies for care delivery to improve overall health outcomes.
Big data in healthcare comes from a multitude of sources: medical records, biographical information, clinical results, medical surveys, and even fitness, sleeping, and eating data tracked by new wearable technology. This infographic by IBM summarizes where big data in health is coming from and in what forms.
The Institute for Health Technology Transformation claims that healthcare organizations have produced over 150 exabytes of health-related data to date. For reference:
How can big data make care more personalized? Though analyzing large, non-uniform data sets is a complex process, the findings can be used to tailor care to individuals. This allows more efficient and cost-friendly medical care. Big data enables a more complete analysis of a patient’s overall health and behavior, which allows medicine to be more personalized to each individual experience through personalized risk assessment alongside management and treatment choice. Siemens, a health care engineering firm, summarizes the emergence and practical applications of big data in healthcare in this video.
Big Data in Risk Assessment Big data has the capability to improve assessment of a patient’s risk for certain health problems through both lifestyle tracking and genetic testing. Because we now know that an individual’s health is based on both their genetic risk and their environment, the more data we have about an individual, the more comprehensive the picture we have of their health. Risk-assessment tools are capable of utilizing big data inputs about a patient, including their family medical history, lifestyle choices like exercise and diet, biographical data, and clinical records. Once this is collected, comparisons can be made between the patient and hundreds of thousands of others who share similar backgrounds or diagnoses, allowing an assessment across multiple dimensions. When combined with a full genetic profile, an individual’s risk for a variety of health-related issues can be pinpointed with more precision than ever. For example, through data analysis we could determine that males who have a certain gene are more at risk for a certain health problem if they live in certain geographical regions. By recognizing this factor, the patient can take greater measures to lower his risk and prevent the problem.
Big Data in Maximizing Treatment Effectiveness Even for one particular disease, every case is unique and not every patient will have equal success with the same treatment. This is because diseases interrupt biological pathways in different ways and require different treatments to target their effects. Big data leads to a greater understanding of this disease complexity that contributes to variance in treatment success. Even the effects of non-biological treatments, like behavior-change interventions, can be analyzed, which can help identify certain barriers to healthy living that are common across similar groups of patients. This can allow us to personalize interventions to certain individuals, making them more effective.
There are a number of nationwide initiatives attempting to aggregate big data. President Obama’s Precision Medicine Initiative (PMI) is one of them. This cohort program has a goal of collecting data from at least 1 million volunteers in the nation, in addition to other projects like the Million Veteran Program (MVP). Hopefully, the PMI will be able to overcome the challenges of big data and provide a base model for future big data initiatives in healthcare.
Just last week, I attended a workshop titled “Staying Out of Debt and Planning for Your Retirement”. Sounds like a bore, right? Not so much. Though the only incentive offered was free lunch, this workshop was highly attended, and attendees actively took notes and asked questions throughout the entire presentation.
During the workshop, we were asked to create a plan outlining what we want savings for in the future, both in the short term (1-5 years) and the long term (10+ years). Though each attendee had different priorities, everyone’s lists had similarities; luxuries that most people want to have and work their lives towards obtaining. Buying a house, having children, paying for college, traveling, purchasing a new car, and many others were on the list. As I sat in this workshop learning about how to plan for my retirement, it struck me that my retirement savings will mean nearly nothing if I am not healthy. If I were to develop a chronic illness, not only could it potentially be very costly to pay for medications and medical bills, but also without my health, how will I be physically able to enjoy any of the luxuries I worked so hard for?
This led me to the question: why do we plan for our savings and retirement, but not for our health? Imagine if we planned for our health and well-being just like we do for our retirement. What would that look like?
2) We all want to plan for different, very personal reasons. Each of our plans should be influenced by why we want to save or be healthy.
3) Meeting with an expert is key to creating a successful plan. The expert’s job is to combine your desires with their expertise to create a workable, realistic plan.
4) We all know what everyday choices and actions are going to keep us “healthy”, either financially or physically. Building the right habits is the key to success. Easier said than done, right?
5) Starting early and taking baby steps can make all of the difference. Small steps are the key to success.
6) Overall, these plans should be a road map for how we are going to save or be healthy over time. This requires creating achievable goals and tracking progress using resources available to us.
While retirement planning has become a relatively successful industry, the concept of health planning is still foreign to most of us. With all of the resources and infrastructure available to support retirement, there’s no wonder so many people are taking their planning for retirement so seriously. Bringing the same attitude towards investing in health and well being is something we could all benefit from. We work hard to enjoy retirement in the future, but bettering our health is something we can do now and reap the benefits of right away. The question is, where’s the plan?
Though the childhood obesity rate has been declining over the past several years, more than 1 in 6 children in the United States are still considered obese. Obesity takes both a physical and psychological toll on children. Obese children are more likely to be bullied, suffer from low self-esteem, and become depressed. They also face serious health risks such as a greater likelihood of obesity in adulthood, heart disease, type 2 diabetes, and cancer. Obesity risk is influenced by a multitude of factors including genetics, environment, access to healthcare, and behavior. However, often times the only factor that can be modified and controlled by the patient is behavioral decisions, which account for 30% of an individual’s health. Personalization of care starting in early childhood could be a strategy for properly targeting behavioral factors such as diet and exercise to continue the decrease in childhood obesity rates.
Childhood obesity is difficult to treat since children do not have full control over their health behavior. In fact, it has been found that parental health behavior heavily influences their children’s eating habits and preferences being formed in the first five years of life. Not only this, but with one obese parent, a child has a 50% chance of becoming obese. With two obese parents, this chance increases to 80%. Change cannot solely come from personal adjustments, but needs family support as well. Thus, treating childhood obesity means improving health behavior for the entire family. Personalized health planning between individual patients and providers has already been developed and is being adopted by many health providers. However, in order to effectively combat childhood obesity, personalized health planning for entire families needs to be further explored.
A study conducted by New York University’s Langone Medical Center found that over 90% of parents believed their overweight children were “about the right weight.” When parents are unwilling or unable to recognize their children’s true health status, it is up to primary care providers to refer children and their families for treatment. One program specifically targeting childhood obesity through family-centered solutions is the Duke Healthy Lifestyles Program. The Healthy Lifestyles Program relies on lifestyle modification with the help of dietary, medical, physical therapy, and behavioral providers. Each family receives personalized treatment options. Unlike with adult obesity, the treatment goal of childhood obesity is usually to stabilize rather than lose weight since children are actively growing. The Healthy Lifestyles Program not only involves medical professionals at Duke Pediatric Primary Care, but also partners with the Durham City Parks and Recreation Department. This unique model connects health care with community resources, which is needed to overcome some of the economic and environmental barriers to beneficial health behaviors. When standard interventions such as the Healthy Lifestyles Program are not effective in combatting obesity, pharmacological options need to be turned to. While there are many medications available for treating adult obesity, Orlistat is currently the only medication approved for treating childhood obesity by the Food and Drug Administration. Even with the personalization of medicine among youth and adults in treating obesity, doctors should examine further personalization among individuals, as Orlistat is less effective in children with type 2 diabetes.
Personalizing care in childhood obesity presents unique barriers because coordination between the child, the family, and the healthcare team is challenging to achieve. Moving towards a personalized, proactive, and participatory care model for children by involving a child’s family support system should be seriously considered in order to effectively combat not just childhood obesity, but also a multitude of chronic illnesses that often begin in childhood.
Wendy Ji is an intern for the Duke Center for Research on Personalized Health Care and a junior attending the University of North Carolina at Chapel Hill.