Patients and health-care providers are facing changes if they hope to build a system of patient-centered care. Excerpt from the talk on Thursday, March 8, 2012.

JENNIFER BROKAW, MD, Founder, Good Medicine

SEAN DUFFY, Co-founder and CEO, Omada Health

WAYNE PAN, MD, Chief Medical Informatics Officer, Health Access

Solutions; Chief Medical Officer, Pacific Partners Management Services Inc.

MARTY TENENBAUM, Founder, Cancer Commons

SARAH VARNEY, Health Reporter, “The California Report” – Moderator


SARAH VARNEY: In the Affordable Care Act we have many different levers coming at the hospitals and the providers – and patients, for that matter. We’ve got these accountable care organizations, which are essentially trying to knit together specialists and primary care and hospitals. But we’ve tried this before. We all went through managed care, and patients didn’t like that very much. Marty, what’s different this time?

MARTY TENENBAUM: I wanted to pipe in the patient’s perspective, which is based on recent personal experience. I was up in Seattle helping take care of my mother-in-law, who at 92 had had a heart attack, sitting in the hospital, and all of her family – she has a big family – stuffed into an intensive care room, and Mom on a ventilator. We’re trying to figure out what questions to ask the doc when he comes in and graces us with 10 or 15 minutes of his time, if we’re lucky. Then the doc goes away, and we spend the rest of the night contemplating all of the implications for what happens tomorrow when Mom goes off the respirator. What do we do if she doesn’t breathe?

From a patient’s perspective there’s a lot of care-giving that goes on that has nothing to do with medical professionals, and in this day and age I think you’ll all agree that the supportive care team is spread all over the country. This is an opportunity for information technology to find a way to be able to bring the family together, not just those who can stuff into the emergency room. That’s where we can worry about advance care directives, and we can worry about being able to provide information or advice on what questions to ask the physician and how to make decisions when you get the answers. Information technology has many roles to play, but this whole system is going to fall apart if it’s not for the 60 million people who volunteer their time to take care of parents and grandparents and so forth.

SEAN DUFFY: Patient-centered medical [practice] is just an amazingly sexy and awesome concept that I think could be progressed in a really interesting way. It seems like a delivery entity can apply for patient-centered medical home recognition by meeting certain standards, and the standards are very patient friendly: it’s online scheduling; it’s communication between different providers. It’s the sort of thing where patients out there should be demanding that their care is provided by a patient-centered medical home, but when you go out and talk to people who are in the primary care world and they’re looking for doctors, the first thing they think of when they hear the words “patient-centered medical home” is a house, a funeral home, a nursing home – it’s incredibly unclear what that is. Taking the concept of a patient-centered medical home and re-branding – where it becomes this amazing gold seal that all of the best primary care centers out there have – will spark some of the consumer demand, which will prompt some of the financial reform required to make it an actual practicing reality.

TENENBAUM: It needs a different name.

JENNIFER BROKAW: I suggest “Good Medicine.”

DUFFY: This is a Good Medicine-approved primary care center, and everybody knows that that’s what they need to ask for when they go look for their doctor.

VARNEY: Most of the presenters are for-profit. Is this a contradiction in good care for community? Is there a way in which you’re simply adding to our cost problem, or can you guarantee us that you’re going to lower our insurance premiums? Sean?

DUFFY: Our company’s in a rather fortunate place in that there’s been a number of ROI studies done on the original diabetes prevention program this trial, and they’ve spoken very favorably of the economics at a certain threshold, which we’re hoping to be able to hit because we’re delivering this online. If we can hit the same primary outcomes as this clinical trial, it’s easy for us to make an argument that the ROI holds. In terms of us being a for-profit versus a non-profit, very early on, we felt very convinced that we had to find a business model that fit into an ROI framework that self-insured employers and insurance companies could be comfortable with, because I don’t think it’s a reasonable goal to deliver prevention at the scale that it needs to happen in the U.S. if you don’t have the financial incentives aligned. Theoretically, the more people we can bring through our system, and the more entities we can convince to pay for it, the more people we prevent from getting diabetes. It’s a rather nice alignment that I don’t think you find in too many places, but for us it works.

VARNEY: Have you found so far in your work that there are certain populations that this seems to work for, or is this really a population-based tool? It’s going to work in South L.A.? It’s going to work in Fresno?

DUFFY: Sure, sure, sure. It would be helpful to just give a little context for how this feels from the patient standpoint. If you find out you have pre-diabetes: We take people with pre-diabetes, and we match you up – algorithmically, kind of like, into groups of about 10 people – and then we bring you all through the curriculum from this clinical trial at the same time, with the help of the health coach, who’s involved in working with not just one group, but many groups.

VARNEY: An [audience] question: “Is there any way for a patient to get a list of charges with explanations of treatment that they will be getting, even for simple things like related costs for lab tests?” Then it says, “P.S. A timeline for future bills would also be nice.” To be noted.

BROKAW: It’s really incredible how little we understand about our health care. If I were to ask this room if you knew, to the dollar, how much was spent on you personally by your insurance company for your health care last year, I doubt any of you could tell me. Even worse, doctors have no idea how much they spend of our total health care dollars when they order tests. There are new efforts being made to really bring that back. In the 1980s, during that managed care revolution, there was this, “Mother, may I order a CT scan?” “No, you may not,” and that’s going to come back, in a way. There are going to be flags built into the system – into the electronic health records – that say, “This patient had an MRI last month. Why are you re-ordering an MRI?” or, “This medicine that you’re ordering costs $200 a month. Could you use this less expensive alternative?” Price awareness is coming back.

Ultimately, the consumer has to come to the table, though. There are some companies out there now doing just that, making health-care costs transparent by using Medicare data: what Medicare has charged by certain hospitals. For instance, within the Bay Area, you could get a colonoscopy at Stanford, you could go to Seton Hospital or you could go to UCSF, and the charges are divergent. When those charges are transparent to the self-insured employers that are big purchasers of health care, they’re going to say, “Dr. X, or Hospital X, why are you charging three times as much as this other hospital?” The answer might be, “We’re better at it, and this is why,” and that would be a valid response, but show us the data!

VARNEY: A person in the audience asks, “Arrogance within medical practice is a given. How does one change the culture to one of teamwork and patient safety and not about egos, i.e. the surgeons?” Dr. Pan?

WAYNE PAN: I’m an orthopedic surgeon. I can understand that. Part of the issue is here that we have a provider-centric system where you have to go to a provider to get information. You have to go to the hospital; you have to go to the lab. We need to change it to a patient-centric system, which is all about what the patient-centered medical home is.

I really don’t think that just having a stamp of patient-centered medical home, or having it certified, is what you’re going to get or experience. People and practices need to understand that there’re only two questions you need to ask. The first is, “How does whatever I’m doing benefit the patient?” and the second is, “Can I make it easier for the patient?” If you can do those two things, you’re on the way to patient-centeredness. This transformation is going to take a long time, because proprietors in the past have been trained to be: “You come to me. You sit in my waiting room for five hours. I don’t care, because you have to see me.” Now that we have a bit more openness and cost-transparency, there’ll be patients who will say, “I don’t really want to sit there for five hours. My time is just as valuable as yours, and I’m going to go somewhere else.” This customer-service model, which is really patient-centric models of health-care delivery, [will] prevail.