Industry Outlook: Healthcare
Here, leaders in Utah’s healthcare industry tackle issues ranging from the state’s opioid crisis to rising pharmaceutical costs, along with the industry’s effort to better manage population health in order to improve outcomes and drive down healthcare costs.
Scott Barlow, Revere Health
Brian Carter, Diversified Insurance Group
Dr. Ed Clark, University of Utah Health Sciences
Eric Hales, Regence BlueCross BlueShield
Steve Kieffer, Big-D Construction
Dr. Joe Miner, Utah Department of Health
Juliana Preston, HealthInsight
Dr. Nicole Priest, Onsite Care, Inc.
Pat Richards, SelectHealth
Brent Williams, Dental Select
A special thank you to Dave Gessel, executive vice president of the Utah Hospital Association, for moderating the discussion.
There seems to be a renewed movement toward managing population health or wellness. How do we get the public to not only understand they are part of the solution, but get them to be proactive with their health? What are some of the trends you are seeing in that regard?
HALES: The collaboration between the health insurer and the provider in population health is key. There seems to be a culture of misunderstanding or animosity towards the insurance company. But when the insurance company can collaborate with a provider to supply them with the necessary data to understand the patients they are caring for—those who are going to the ER maybe outside of their own systems or their own practice—to find out if the patient is actually getting the care they need. So that collaboration is incredibly important. And without that, providers are left to just continue what they are doing, which is they look at their own claims experience with that patient, but they can’t see anything outside of their own practices.
PRIEST: I have started to implement group visits to address some of these high-risk diagnoses—for example, diabetes. We have a team there: my nutritionist, my nurse practitioner, our gardener, because where I work we have a staff garden that the employees can be involved with. And it’s just a great concept. I want to start one for weight loss with the same company. And prediabetes.
I love this concept. It’s just how do we do it? How do we make it work? As a primary care physician in private practice, if you are going to take half a day out of your clinic and do a group visit, what if nobody shows up? Then you might as well have taken the day off.
CLARK: As a former public health officer myself many years ago, this is a renewed opportunity for public and private partnerships. And creating the frameworks for carrying this out, whether it’s at the work place, whether it’s at our schools, or whether it’s with high-need/high-cost populations, is a catalyst now for us to look at not the short-term but the medium and long-term within our community. And in Utah, we are an optimum geographic and demographic location for looking at how to build programs that are sustainable and cross many different ethnic and economic groups.
BARLOW: In our federal ACO there are about 24,000 signed people, and 351 are 56 percent of the cost. So 1.5 percent represent more than half the cost picture of what’s going on. When you look at that population, they tend to have three or more chronic illnesses; they tend to go to at least nine different doctors during the course of a calendar year; and oftentimes four or five of those doctors are in different health systems. So the ability to do it as a community of care versus siloed care, which is what we have done for so many years in healthcare, really has the ability to get to the root issues some of these patients are struggling with.
I’m excited by the collaborations to figure out how to do it, because none of us are treating them by ourselves. They are all going to different places. And we’ve got to get that care coordinated and integrated with each other. What we often find is if we are not coordinated, we are both in good faith doing things we think helps and but are actually contradictory. So we start fragmenting and confusing the consumer as to what they really need.
These really difficult patients need tremendous oversight and engagement and help and support. And the health system tends to do everything for everyone unless something tells us to do something different. The population health environment provides the means to approach it in a coordinated way.
MINER: A significantly large percent of the high-cost users have mental illness and drug and alcohol use disorders as part of their diagnoses. So integrating those more completely into their care is extremely important.
HALES: I’m not sure it’s simply that we need to help the consumer become accountable. Part of it is that we, as a society, have put the barriers in front of the person. So, for example, we don’t share detailed health information about an employee with the employer because of ERISA laws and things like that. We have a culture where I want to keep my health very private. I don’t want to share that. And so there’s a couple of things that are getting in an individual’s way to navigating the health system.
If we can find a way to break down some of those barriers … Today you obviously cannot hire or fire based upon somebody’s health status. But it’s being able to allow somebody to share more information with their employer so that they can be a support for them to access the care that they need, rather than be a barrier.
Utah is grappling with a growing opioid process. What is the role of Utah healthcare organizations and state government in dealing with this crisis?
MINER: Utah is fourth worst in the nation for our per capita rate of opioid overdose deaths. Why in the world is Utah there just a couple places below West Virginia? I think we have been trained to expect a pill and be pain free. Hospital care has been strongly encouraged to measure pain and make sure patients are pain free in the hospital. It has carried over to the community, and physicians feel obligated to keep their patients pain free. And the easiest thing is give them an opioid prescription.
But it’s pretty clear that long-term opioid prescribing is not decreasing pain. In fact, it is probably making it worse. It is increasing sensitization to pain. And even though the prescription of opioids has increased four to five fold over the last 15, 20 years, the pain level in the population has stayed flat over that same period. So five times more opioids are not making people less in pain. We really need alternatives to opioids for chronic and long-term pain, and really restrict opioid prescribing to just a brief few days. Seven at a max.
CLARK: This is a multi-dimensional problem. It’s one that has its roots in a variety of causes. Clearly the deaths in Utah—almost 400 deaths a year—the majority of them are related to prescription opioids. How they are obtained is unclear—some legitimate prescriptions, some purchased on the streets, some mixture, and then street drugs on top of that. And now a wave of synthetic narcotics that are coming in from overseas.
We have had a task force that has been working on this now for the better part of a year, and really approaching it from a number of different dimensions. One dimension is we are overprescribing. In our community physicians group at the university, since February we have reduced the number of prescriptions for opioids by 54 percent in that short period of time. We are using care process models, using alternative pain therapies. We actually have, in some of our clinics, advanced practice clinicians, and there can be a warm handoff to them so they can immediately start working with a patient.
We are also looking at how we can partner with the health department, with the state, with other providers through care process models, through better education. What I am concerned about, however, is that legislative action may interfere with the practice of medicine. And there are individuals who benefit from opioids and who will benefit from opioids both in the short and the long term. That’s part of the judgment and the responsibility of physicians. We are looking for that right balance.
WILLIAMS: That overdosing problem is also very prevalent in the dental world. There are now 100 million opioid doses that are not used every year from prescriptions issued by dentists. So if you imagine where those are going—many are ending up on the streets.
PRESTON: The non-pharmaceutical approaches are important. With my background in nursing homes, the clinical practice guideline is that for every pharmaceutical intervention, you need a non-pharmacological intervention. And in all my work there I don’t know that I ever saw one. We prescribe a pain management pill, but don’t ever have the non-pharmaceutical approach. There are so many other things that we are not tapping for our patients that could give relief from pain.
BARLOW: Another thing is the lack of behavioral health resources we have in the state. I’m excited to see again that increasing and resources starting to develop. There’s still a real shortage of behavioral health, and a lot of the issues have a root behavioral health element with them. But there’s not a lot of resources for providers to turn to to get that engagement effectively. So when in doubt, the prescription happens just because they are not able to manage those complicated issues.
RICHARDS: What I’m really excited to see is this growing collective impact, community-wide collaboration, because it is about public awareness; it’s about physician education; it’s about the appropriate disposal of the unused drugs; and then especially the integration behavioral health.
I really like the point about finding alternative ways to manage pain. So much of the chronic use is about chronic pain. We need to look at better pain-management models, alternatives, whether it may even be acupuncture, massage. Because pain is a real issue and there may be better ways to manage that pain.
There’s been heavy debate on medical marijuana around the country in the last few years, including in our legislature for the last two years. Is Utah ready for this type of law? Is it appropriate? What are the pros and cons of such legislation?
MINER: There is some potential there, but very little scientific evidence yet that it really does help. But the placebo effect, the sedation effect you may get from it—a lot of individuals swear by their experimenting with marijuana. You would hate to see medical marijuana become recreational marijuana. And even in states where it still is only medical marijuana, the most common age to be prescribed medical marijuana are men aged 23. You expect that to be a very healthy population, in general. And you fear that it’s easily misused, will contribute to drug use disorders in general.
PRIEST: I’m so torn on this subject. I look at some of the things I can legally prescribe and I think how much harm, potentially, am I doing? We just talked about the opiate epidemic. And the thing I find so fascinating about marijuana is there’s no toxic level that is going to kill somebody. I have heard somebody would have to smoke like 800 cigarettes of marijuana to potentially die. So in my mind it’s pretty intriguing that I could potentially use a medicine that does not have an overdose amount for pain, for nausea, for insomnia. Whereas I potentially could give one patient a 10 milligram oxycodone that could be fatal for pain.
I’m also very scared, having young children and just knowing that marijuana is a gateway drug. I know that. And if we are then prescribing it, that gives the impression this is coming from my doctor so it’s OK. And maybe this child is going to use their parent’s medical marijuana. So it will be very interesting to see what happens in the next few years. I’m on the fence. I can see both sides. I would like something that would be safer to prescribe for pain.
CLARK: There is a lot of opinion, a lot of emotion, but what’s missing is research. If you ask the three things we look for as healthcare providers, we want to know what the pharmaceutically active element is, we want to know what its efficacy is, and we want to know about safety. We have done that since we changed from grinding up leaves of the foxglove plant for digoxin and bark for antimalarial drugs.
Allow us to do the research. We can identify the pharmaceutically active elements and we can figure out what the right dose is and what the effects that we are looking for will be. That is the missing element, and the one we are hampered by right now because of the classification of the drug. We have studies going on at the University right now in our child neurology group looking at it as an effective antiepileptic drug, and there is benefit there. We are moving forward. We have studies in the antiepileptic drug discovery program. We have tools for looking at cannabinoids receptor activation with our very sophisticated MRI devices. Our problem is the limited access to the purified pharmaceutical-grade components of cannabinoids. There may be 90, some people suggest 120 forms of cannabinoids. There are some that are going to be valuable and some that are not going to be valuable and may be potentially toxic. Let’s approach this as we do with other pharmaceuticals.
How much is personalized medicine—genetic targeting, home health tests, even health apps—changing consumer and provider behavior?
BARLOW: Anything we can do to make care more patient-centric is a good thing. A lot of this is new. The ability to target therapies based on genetics has real promise, but real cost. Again, it’s trying to figure out that right niche.
The technology is where we see the most activity. That ability to offer convenience and resources to the consumer is generally good. But what we are seeing right now is it is further fragmenting the healthcare. The data sets don’t move very well amongst systems. We have patients coming in after having an e-visit in the evening, and they don’t know for sure what was or wasn’t done or said, and the records aren’t readily available to providers.
So the promise is there, but I worry the tools haven’t developed to meet the consumer’s desire for more information ahead of the system being able to really use that information effectively. We have to be cautious about making sure we continue to build foundational pieces. Because we don’t believe that fragmenting care further will be in the best care of patients long term.
Right now the telemedicine tools, there’s virtually no movement of information out of those tools sent to the providers. So that is making it very difficult to be able to do any follow-up or any of the things that are more necessary beyond just that initial episodic treatment experience. That’s the part we want to see improved—better capability of that being a population tool set, not just a marketing tool that fragments care even further than it already is.
CARTER: Going back to pharmacy again, some of the really high-cost prescriptions are being prescribed to people that they probably shouldn’t be prescribed to. Genetic testing is one of the ways you can determine whether this is going to be an effective approach for them. So we are seeing employers embrace those models where they are looking for more assistance in managing the high-cost pharmaceuticals. They are looking for PBMs, pharmacy benefit managers, that are looking to control pharmacy through genetic testing. We would love to see mainstream carriers that embrace that to help manage some of these high-cost pharmaceuticals we are seeing.
RICHARDS: I really agree with what Scott said about the telehealth visits. SelectHealth was maybe a little later in introducing these tools, but we work, of course, through our parent company, Intermountain Healthcare. And we launched a program called Connect Care. And the beauty and the difference of this is that we integrate both clinically, so that any of the e-visit records are put in the clinical data repository so that the primary care physician and other caregivers can see that. And we’ve also had a breakthrough where we are linking the telehealth visit to the financial aspects of the health plan. So if there is payment for a telehealth visit, that applies right to the deductible or co-insurance or if you have a health savings account.
So it took us a while longer, but I believe we have integrated both clinically and financially. And that will help make telehealth really feasible in the future.
Kaiser Permanente now does 52 percent of their care visits in a virtual environment, either electronic or home monitoring. This is something they have been working on for years. And Gartner has suggested that in the next five years probably about 40 percent of all primary care visits will be electronic. So this is something that is coming. We all need to figure out how to do it well.
I also wanted to mention innovation from a service standpoint. We serve many age groups. Millennials have different needs than somebody on Medicare. Our whole objective at this point is to better understand the individual needs and preferences of our customers so that those that want text messages can communicate by text; those that want to still talk on the phone can communicate on the phone; others, maybe in a different situation, would like a personal home visit. So what we are trying to do is not just a one-size-fits-all, but really understand the individual needs and individual preferences of the consumer.
CLARK: There are three principles here that we are looking at. Innovation alone is not going to be sufficient. It is the issue of integration—how do you bring this into your system—and then it’s implementation and operations over time. So often the flash is the innovation. But the real long-term benefit comes from integration and implementation that allow us to provide higher value care to our population.
HALES: In the future there will be more adoption of precision medicine. Now the costs are too high to have your own genetic makeup done for your own personal needs. It’s $5,000 or $6,000. And until that cost comes down and you are able to then use the information in a meaningful way—because even though you may have some genetic markers for a particular disease that doesn’t mean you are going to develop the disease—until we have advances in our understanding of what those markers mean, it is going to be some time before we get there. We will eventually get there. But it’s one of those things that needs to be solved first.
How are we doing in providing high-quality care and where can we improve?
PRESTON: While we are doing well in some areas, we still tend to trend along with the rest of the nation. For example, obesity. We are still under the national average, but our trend looks very much like the national trend.
But on the positive side, Utah does very well with Medicare cost measures. We are lower than the national average. We battle between Idaho on the best score in the nation on 30-day readmissions. Our admissions to hospital care are low. So we are doing a lot of things right.
HALES: Utah is very, very high in its ER utilization. And I don’t know what’s causing that. Is it lack of access to the primary providers, because of our shortage? Is it a lack of consumer education of where I need to go to navigate the health system? That’s an area where we can do a much better job of providing access to the right care at the right place.
RICHARDS: As a state we do very, very well in many measures. There’s a lot of positives. But what worries me are the trends we are seeing in a couple of primarily public health areas. We have a low prevalence of smoking, for instance. Utah ranks 7, which would be a very enviable position. But if you look over the last 20 years, we used to rank number 1 or 2. Then we dropped to 3 or 4, and then to 5 or 6, and now we dropped from 5 to 7 this past year. Other areas include the high rate of drug deaths and opioid use and suicide.
One of the areas where we score very low on a national basis is the limited availability of primary care. The other one that worries me is the low rate of immunizations and pertussis, the whooping cough. We are 44th in the country. So for some of these basic public health measures that in the ’50s improved care dramatically, we have become a little complacent or there’s a different level of understanding of the importance of the basic immunizations.
MINER: The U.S. in general ranks last among all high-resource countries in measurements of general health of the population. We are 30th among the top 30 in the traditional measurements—life expectancy, infant mortality, maternal mortality, low birth weight. The U.S. is extremely good at rescue care, high-tech care. In fact, we would be first in the world. But essentially last among all high-resource countries in basic measurements of population health.
We don’t have a system that encourages prevention. You almost need to pay people to have preventive care rather than discourage them, not offer it because my preventive care will not help my health system 20, 30 years down the road.
CLARK: Children who are currently in grade school in Utah are the first generation in the history of our country to be less healthy than their parents. If we do not reverse that trend, our rate of prediabetes and diabetes 20 years from now will look a lot like what we are seeing in China, which is 50 percent of the population in China now at the age of 50 is prediabetic or diabetic.
What we are doing for our children right now will affect them the rest of their lives. It’s an economic issue in terms of healthcare, but it is a societal issue, as well. So to focus on our children’s healthcare needs is going to be a very important part of what we will leave as a legacy in the future. If we ignore it, we will have a population of children who will have the ravages of adult onset disease in their 40s and 50s, compared to their 60s and 70s. And all the projections of long-term survival will not be realized.
CARTER: I feel employers get overlooked in all of this. We have all these efforts to educate and improve health but we are doing it at a physician level, maybe at an insurance company level, a hospital level. Yet employers may have the greatest influence over consumers of any group we have in the state. They are making healthcare decisions for their employees. They are determining which systems they go to by which networks their insurance plans cover. They are determining what education gets into their hands. What wellness programs they have. And employers are getting fed up with wellness programs in that they don’t seem to be effective. And yet, we are talking about some of these huge issues that affect individuals. If we would rally together and help employers, we could change that conversation and maybe have the most effective mechanism of disseminating and influencing healthcare decisions in the state.
One issue that’s becoming more difficult is the trend of rising pharmaceutical costs. Are you seeing that as a problem, and what can we do to curb the growth?
MINER: Where you have pharmaceutical companies that have a monopoly on a certain medication, the sky’s the limit on what they can charge for that medication. There’s even companies that will buy up generics and have a monopoly on generic medications, and then will increase a thousand-fold the cost of a generic medication just to take advantage of the public. We are almost to a point where some of those almost have to be managed like a public utility—that the owner of that drug has a very good return on investment but does not gouge and take advantage of the public.
CLARK: We need to have cost-effectiveness in pharmaceuticals. Not just that they are effective clinically—they need to be cost-effective. That should be a criteria that the FDA looks at.
RICHARDS: The biggest challenge that keeps me up at night is prescription drug costs. Many of us around this table are working very diligently to try to hold overall healthcare costs to be more consistent with the general inflation rate. Right now there are no restraints at any level on drug costs. Ten years ago, drug companies might raise their price once a year. Now they are raising their prices unfettered every month, every day, every week. The trend right now is running at about a 30 percent increase in prescription drugs. This is the third year in a row where prescription drugs have gone up at a rate of over 30 percent. Even older drugs that have been around 20, 30, 40, 50 years, they are going up thousands of dollars because of some of the anticompetitive behavior, with companies buying up other manufacturers and shutting them down.
It’s quite shocking, but the cost to our plan prescription drugs is approaching the cost of all inpatient care combined. That used to be the largest bucket of cost. Now prescription drugs are right there.
It’s critical that there be much more transparency from the manufacturers about what they are doing and their costs. We hear often that if there were any kind of restraint on drug cost, it would destroy innovation. But the truth is we don’t know because the public doesn’t know how much is spent on marketing, promotion, versus true research. So transparency is critical.
Promoting competition, true competition, is critical. Part of that is not allowing the amount of lobbying that goes on both at the federal and state level to put even more restraints on competitive practices. That’s a concern.
Coming back to R&D—we need more transparency about how much of this is really funded already through the taxpayer for basic research that’s done through the NIH, because a lot of the drug companies get their basic research through the public sector, and then they say, “We are investing a lot in R&D.” So if there was one thing to change, it would be much, much greater transparency in drug development.
WILLIAMS: There’s a lack of accountability from the general health consumer about their own health. We are in a take-a-pill society. And we have grown that way over the last 20, 30 years in particular. I read an article recently on the percentage of the population that takes over 10 pills a day now, which has grown just massively. There is a demand for prescription drugs. The prescription drugs companies have responded and are making more and more drugs for everything. As consumers, we think we can take a pill for just about everything. And that’s really not the case. And we are paying the price for it right now in our health plan costs.