‘The chal­lenge in Amer­i­can medicine is one of eco­nom­ics and math­e­mat­ics and less about pol­i­tics’

Modern Healthcare - - Q & A -

Dr. Robert Pearl leads the 9,000 physi­cians em­ployed by the Per­ma­nente Med­i­cal Group, which serves over 4 mil­lion Kaiser Per­ma­nente mem­bers in Cal­i­for­nia and around Wash­ing­ton, D.C. A plas­tic sur­geon by train­ing, Pearl has emerged as a lead­ing cham­pion of us­ing elec­tronic health records and new tech­nolo­gies to im­prove qual­ity while low­er­ing the cost of care. He was re­cently named chair of the Coun­cil of Ac­count­able Physi­cian Prac­tices, or CAPP, which in­cludes med­i­cal groups from the Mayo Clinic, Geisinger Health Sys­tem, In­ter­moun­tain Health­care and other in­te­grated de­liv­ery net­works.

Modern Health­care Man­ag­ing Edi­tor Gregg Blesch re­cently spoke with Pearl about the ad­van­tages and chal­lenges fac­ing physi­cians work­ing in large in­te­grated de­liv­ery sys­tems. The fol­low­ing is an edited ex­cerpt.

Modern Health­care: What are some of the tech­nolo­gies with the most po­ten­tial to im­prove the way we’re de­liv­er­ing health­care?

Dr. Robert Pearl: The first tech­nol­ogy is ac­tu­ally the elec­tronic health record. It’s not just about billing. We use it to pro­vide tremen­dous con­ve­nience to pa­tients so that they can make ap­point­ments on­line; they can send se­cure email to their physi­cian and get a re­sponse in un­der four hours for most rou­tine prob­lems.

We use it as a means of pro­vid­ing physi­cians in­for­ma­tion. It’s why we are able to have 90% con­trol of hy­per­ten­sion com­pared to the 55% in the na­tion, and 90% screen­ing for colon and breast can­cer against 55% in the na­tion.

We use it as a tool to com­mu­ni­cate amongst physi­cians. If a pa­tient comes in with an in­ci­den­tal find­ing like a lung nod­ule, the ra­di­ol­o­gist can tag that to make sure the pa­tient does not fall through the cracks. They send the in­for­ma­tion out to an expert tho­racic sur­geon, pul­mo­nolo­gist and on­col­o­gist. Within 24 hours the pa­tient has a com­plete game plan. In a se­quen­tial re­fer­ral process, that could take many, many weeks to ac­com­plish.

MH: What other new tools are you us­ing to en­hance pa­tient care?

Pearl: A sec­ond tool is video. It elim­i­nates time. It elim­i­nates dis­tance. It can be used to serve as a con­sul­ta­tive tool. It can be used as a post-treat­ment fol­low-up tool. It can al­low the physi­cian, rather than to see the pa­tient in­ter­mit­tently, to in­crease the num­ber of touch points so that they can see how the pa­tient is do­ing on a more con­tin­u­ous ba­sis.

And then there is the op­por­tu­nity to use tech­nol­ogy for data an­a­lyt­ics, pre­dic­tive an­a­lyt­ics. We sur­vey on a con­tin­u­ous ba­sis ev­ery pa­tient in one of our hos­pi­tals across North­ern Cal­i­for­nia. We use data from sev­eral mil­lion pa­tients we’ve taken care of in the past to pre­dict which pa­tients have the high­est prob­a­bil­ity to de­te­ri­o­rate tonight and be­ing in the ICU to­mor­row. That en­ables us to treat them to­day— ba­si­cally do to­mor­row’s in­ter­ven­tion to­day. That re­duces the mor­tal­ity by 75% com­pared to what they other­wise would ex­pe­ri­ence.

MH: What do you think is the most over­hyped tech­nol­ogy right now?

Pearl: The most over­hyped tech­nol­ogy right now is wear­able de­vices. It’s not that they don’t have tremen­dous po­ten­tial to have an im­pact. We have not yet fig­ured out how to use them to be able to do what I call shift care left: move from the hospi­tal to an out­pa­tient site, the out­pa­tient site to the of­fice, the of­fice to the home.

Doc­tors don’t want a thou­sand EKGs. It clogs the elec­tronic health record. What they want is a smart tech­nol­ogy that, us­ing the best clin­i­cian think­ing, us­ing the rec­om­men­da­tions of the pa­tient’s own pri­mary-care physi­cian or car­di­ol­o­gist or other provider of care, is em­bed­ded into the de­vice and al­lows the per­son to know how they’re do­ing.

That’s what they want to know. Am I OK or am I not OK? Should I call my physi­cian? Should I change some­thing about my care? And that kind of smart an­a­lyt­ics, pre­dic­tive an­a­lyt­ics, doesn’t ex­ist to­day in­side wear­ables.

MH: What’s hold­ing that back right now?

Pearl: The big­gest chal­lenge is the fear of mal­prac­tice by the de­vel­op­ers of wear­ables. It’s a lot eas­ier to de­velop a de­vice that sim­ply cre­ates

“The op­por­tu­nity is to use busi­ness prin­ci­ples. Busi­nesses are in­te­grated. They work to­gether as one.”

the data in­for­ma­tion and just sends it to the physi­cian. If you look at an­other tech­nol­ogy—the left ven­tric­u­lar as­sist de­vice— we ac­tu­ally have tech­nol­ogy em­bed­ded into the de­vice that will no­tify the clin­i­cian when the de­vice fires. But that’s the only tech­nol­ogy that I’m aware of that does it to­day. Most of the wear­ables sim­ply cre­ate data and ag­gre­gate it or send it to a physi­cian, nei­ther of which ad­vances clin­i­cal care.

MH: You’ve writ­ten that all physi­cians should have busi­ness school train­ing. Why?

Pearl: In the 20th cen­tury, you had a pa­tient who came in with a new prob­lem, a physi­cian took care of it, and the pa­tient ei­ther got bet­ter or didn’t get bet­ter. It was a very sim­ple set of trans­ac­tions.

To­day it’s far more com­plex. Pa­tients have mul­ti­ple chronic dis­eases. Physi­cians have to work to­gether as a team. Take a pul­monary nod­ule. This is an on­col­o­gist work­ing with a pul­mo­nolo­gist work­ing with a tho­racic sur­geon, linked back in with a pri­mary-care physi­cian and a ra­di­ol­o­gist. Com­plex sys­tems of care are not what physi­cians have been trained to do.

The op­por­tu­nity is to use busi­ness prin­ci­ples. Busi­nesses are in­te­grated. They work to­gether as one. Mar­ket­ing works with sales, works with man­u­fac­tur­ing, works with the cap­i­tal gen­er­a­tion process. They have a de­fined lead­er­ship struc­ture. Most of medicine has none of that. Cre­at­ing those same sys­tems to im­prove care is what’s nec­es­sary in the 21st cen­tury.

If we don’t do that, we’ll find our­selves ei­ther ra­tioning care or do­ing some­thing else that will un­der­mine the ex­cel­lent care of pa­tients. It’s part of why I am the chair­man of the CAPP groups, the 28 largest and best med­i­cal groups in this coun­try. These or­ga­ni­za­tions are in­te­grated, cap­i­tated, physi­cian-led and tech­no­log­i­cally en­abled. They are try­ing to move health­care into the 21st cen­tury us­ing tech­nol­ogy, sys­tem re­or­ga­ni­za­tion, col­lab­o­ra­tion and co­or­di­na­tion. Those are all skills that we teach in the busi­ness school that we don’t teach in the med­i­cal schools.

MH: Is it pos­si­ble for providers and in­sur­ance com­pa­nies to achieve the same level of in­te­gra­tion and ac­count­abil­ity un­der a dif­fer­ent model of looser af­fil­i­a­tions with val­ue­based con­tracts?

Pearl: If you look at the Na­tional Com­mit­tee for Qual­ity As­sur­ance data­base, the or­ga­ni­za­tions at the very, very top—given a rat­ing of 5 both in com­mer­cial and in Medi­care—are the CAPP­type groups. If you look in­side Kaiser Per­ma­nente, we’ve low­ered the chances of our pa­tients dy­ing from heart dis­ease 30% be­low the com­mu­ni­ties around us, low­ered the chances of pa­tients dy­ing from sep­sis 40% be­low the com­mu­ni­ties around us.

My be­lief is that we pro­vide care that’s 10% to 15% bet­ter in qual­ity, 10% to 15% more con­ve­nient and prob­a­bly 10% to 15% lower in cost. That com­bi­na­tion re­quires move­ment from fee-forser­vice to pay-for-value. It’s go­ing to be dif­fi­cult, or at least it will take a while, for peo­ple who are com­pletely in a frag­mented prac­tice, prac­tic­ing alone with­out tech­nol­ogy, paid sim­ply on a fee-for-ser­vice ba­sis with­out any abil­ity to re­ally co­or­di­nate with their col­leagues ex­cept in­ter­mit­tently or through mail or fax, to be able to de­velop a 21st cen­tury in­te­grated de­liv­ery sys­tem.

Peo­ple in small groups can come to­gether and work to­ward be­com­ing an ac­count­able care or­ga­ni­za­tion. Peo­ple who are in ac­count­able care or­ga­ni­za­tions can ac­tu­ally be­come very much like a CAPP-type group fo­cus­ing on the qual­ity, the pa­tient con­ve­nience, the tech­nol­ogy, and do­ing it in a way that is so much more ef­fi­cient that the costs be­come more af­ford­able.

MH: How are ris­ing drug costs play­ing out for your prac­tices and your pa­tients?

Pearl: The over­all cost of health­care—and specif­i­cally as it plays out in phar­ma­ceu­ti­cals—shares a com­mon point of ref­er­ence, which is that the cost of health­care is ris­ing faster than we as a na­tion can af­ford it. And much of that cost is be­ing trans­ferred to in­di­vid­ual pa­tients. The out-of-pocket ex­penses in much of Amer­i­can medicine are ris­ing. Seven years ago, some­thing like 25% of peo­ple had a high­d­e­ductible pro­gram. Now it’s moved to 40%. We’ve seen Amer­i­can wages stag­nate.

So fig­ur­ing out how we can re­struc­ture Amer­i­can health­care so that it’s in­te­grated, that it’s pre­paid, tech­no­log­i­cally en­abled and physi­cian-led at the point of care de­liv­ery would al­low us to address ris­ing health­care ex­pense.

Specif­i­cally with phar­ma­ceu­ti­cals, we have a bro­ken sys­tem. We’ve cre­ated a sys­tem ba­si­cally of oli­garchi­cal and mo­nop­o­lis­tic pric­ing. We have to think about it very dif­fer­ently than other prod­ucts. Most prod­ucts you have a choice. If you don’t want to stay at a fancy ho­tel you don’t stay. When you have a dis­ease, you have no choice but to buy that prod­uct.

If only one com­pany has it and they have un­lim­ited pric­ing abil­ity, what you’re go­ing to see is goug­ing of the pub­lic. And that’s what we’re see­ing in Amer­i­can medicine to­day. The ques­tion is go­ing to be­come whether ac­tion hap­pens to make drug pric­ing be more ra­tional. What’s hap­pened in the past five years is that drugs that are well-es­tab­lished, that re­quire no more R&D in­vest­ment, are hav­ing their prices go up 100, 200, 500, a thou­sand times more. To me, it is sim­ply not con­scionable.

MH: What’s an ap­pro­pri­ate pol­icy re­sponse?

Pearl: First you need trans­parency. Drug com­pa­nies should be re­quired in re­turn for hav­ing the patent pro­tec­tions they have to dis­close the R&D cost of de­vel­op­ment and to have it au­dited, ei­ther by the gov­ern­ment or by an agency. Some type of group needs to look at whether the value gen­er­ated jus­ti­fies that price. And then the drug in­dus­try needs to be held ac­count­able for mak­ing sure that the pric­ing of the drug is con­sis­tent with that value that’s cre­ated and with the re­search and de­vel­op­ment dol­lars that have been in­vested.

MH: What is your great­est hope or your great­est fear for how re­peal and re­place plays out in the next ad­min­is­tra­tion?

Pearl: My great­est hope and fear is re­ally more about Amer­i­can medicine. I think that the chal­lenge in Amer­i­can medicine is one of eco­nom­ics and math­e­mat­ics and less about pol­i­tics. Pol­i­tics will play a part across time. But in the longer time pe­riod, we have to find ways to raise qual­ity; we have to find ways to help peo­ple change their life­style. We have to find ways to be able to pro­vide pre­ven­tive care in a way that’s go­ing to be cost-ef­fec­tive.

My great­est fear is we’ll de­volve into ra­tioning. My great­est fear is we’re go­ing to see the peo­ple get­ting in­sur­ance through the com­mer­cial realms find­ing they are un­able to get the care that they re­quire.

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