Wasted Time = Wasted Life
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Keynote presentation for Indiana HIMSS Midwest Fall Technology Conference on October 24, 2017, honoring the life of patient advocate and healthcare industry change champion, Jess Jacobs. Addresses the value of "value-based care" from the perspective of a chronic and complex patient who captured, quantified, analyzed, and shared her journey navigating her care - and specific ways we, collectively, can improve similar experiences for others.
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Wasted Time = Wasted Life
- 1. Wasted Time = Wasted Life
- 2. 2 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.2 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Everything about healthcare is time-sensitive 60 minute OR blocks 7 minutes face-time per office visit 23 hours in OBS 2 midnights before rehab 90-95-120-365 to file claim CCDA in 24 or 36 hours
- 3. 3 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.3 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. We know what % revenue goes to resources for administrative activities. We know that 1/3 of all healthcare costs are attributed to waste. If we’re wasting 1/3 of our money, how much life are we wasting?
- 4. 4 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Architect, Health Resources & Services Administration’s Text4Baby promotion program Innovation Fellow, FDA – co-founded Center for Drug Evaluation and Research’s Health IT Council Healthcare Policy Advisor, ONC and White House, started “Investing in Innovations” and mHealth collaboratives Director of Innovation, Aetna Died August 14, 2016, age 29 Jess Jacobs
- 5. 5 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. #UnicornJess and some of her “unicorn squad”
- 6. 6 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Elhers-Danlos (EDS) Cyclic Vomiting Syndrome (CVS) Postural Orthostatic Tachycardia (POTS) Faulty connective tissue, severe joint pain, GI issues, fatigue Dizziness and racing heart, fainting, nausea, fatigue, pain Severe bouts of vomiting lasting hours or days Imagine telling her she’s too sick and too needy to be your patient. Imagine hearing that, as a patient, from a PCP…multiple times
- 7. “It’s OK that you are not a specialist in the condition. I am.” “I need help now…If you are not willing and able to help me, who in your practice is?” “Would have liked to have this conversation with you in person but you have no availability this month.” “It’s OK that you are not a specialist in the condition. I am.” “I need help now…If you are not willing and able to help me, who in your practice is?” “Would have liked to have this conversation with you in person but you have no availability this month.” Is this the “value” the healthcare industry keeps talking about delivering with “value-based care”?
- 8. 8 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.8 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. 3 “Big Pink Binders” of paper medical records
- 9. 9 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.9 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. 10” 2” 3” How much “value” do you think Jess got out of the weeks she spent buried in this paperwork?
- 10. 10 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Each stakeholder in healthcare views value differently EVERYONE wants to save $EVERYONE wants positive outcomes EVERYONE wants a good experience Value is perceived, not dictated. And that perceived value can be measured.
- 11. 11 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.11 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. What is the value equation?
- 12. 12 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.12 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. ܸ݈ܽ݁ݑ = 𝑛=1 ∞ ( 𝑂𝑢𝑡𝑐𝑜𝑚𝑒𝑠 + 𝐸𝑥𝑝𝑒𝑟𝑖𝑒𝑛𝑐𝑒 𝐶𝑜𝑠𝑡 )Value is what we are willing to pay for a benefit What have we been paying to live longer?
- 13. 13 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. 29 years 48 years 58.5 years 71.4 years 0 10 20 30 40 50 60 70 80 1750 1800 1850 1900 1950 2000 2050 LifeExpectancy Year Life Expectancy Miraculous health-value: MedTech, Pharma and Facilities Data Source: Our World in Data 1970 - Today $183 per person per year, globally, in healthcare costs $356 per person per year, in the US, in healthcare costs
- 14. 14 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. $356 $1,110 $2,854 $4,559 $7,932 $9,892 $183 $615 $1,180 $1,794 $3,232 $3,956 $- $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 1970 1980 1990 2000 2010 2016 USA average Emerging Value Gap, 1970 to today USValueGap Data Source: Our World in Data Infant mortality 1970: 20 per 1,000 Infant mortality 2014: 6 per 1,000 20% increase in life expectancy 1970-2016 20% increase in life expectancy, at 54 times the cost
- 15. 15 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved.15 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. ܸ݈ܽ݁ݑ = ( 2 5𝑥 𝑂𝑢𝑡𝑐𝑜𝑚𝑒𝑠 2.5𝑥 𝐶𝑜𝑠𝑡 ) Act 1Act 2 (1970 – today) . Continuing to quadruple the percent of GDP spent on healthcare to double, or even quadruple our life span, is not achievable. In 2016, US healthcare costs exceeded $10,000 per person for the first time.
- 16. 16 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.16 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Moving beyond value to health-value equations: The measurable enhancement or maintenance of health status realized by individuals through their personal actions or engagement with the services, tools, products and content of the broad health ecosystem
- 17. 17 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.17 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. What health-value should we demand?
- 18. 18 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved.18 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. “Only 4.75% of outpatient visits and .08% of my hospitalizations are spent actively treating my condition. I spent two solid months (1540 hours, 64.2 days) of this year waiting instead of healing.” “On Wasting My Time: The Numbers” Useful vs Useless Healthcare Activities: Jess Jacobs’ simple health-value equation “Stop wasting my time. Stop wasting my life.”
- 19. 19 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Jess Jacobs LEAN analysis of useful/useless visits Total Visits Useful Visits Useful Visits Useless Visits Outpatient Cardiology 7 3 43% 57% Endocrinology 1 1 100% 0% Gastroenterology 6 2 33% 67% Hematology 2 1 50% 50% Neurology 1 0 0% 100% Ophthalmology 1 1 100% 0% Pain Specialist 8 3 38% 63% Primary Care 15 2 13% 87% Psychology 11 2 18% 82% Rheumatology 4 0 0% 100% 56 16 29% 71% Inpatient Emergency Room 20 9 45% 55% Hospitalizations 9 8 89% 11% Hospital Days 54 10 19% 81% Ambulance 7 3 43% 57% Useful Outpatient Visits: Result in treatment, or change in treatment Useful ER Visits: Result in treatment, new diagnosis, or necessary hospitalization Useful Inpatient Visits: Unavoidable Useful Hospital Days: Include test or treatment
- 20. 20 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Jess Jacobs LEAN analysis of time expenditures per visit Average Visit Breakdown (In Minutes) Outpatient Sched Wait Rm Pprwk RN Student Consult Visit Total Cardiology 15 50 10 10 5 10 100 Endocrinology 0 15 5 15 0 5 40 Gastroenterology 15 120 5 10 5 5 160 Hematology 120 15 10 10 5 10 170 Neurology 30 10 0 0 0 5 45 Ophthalmology 0 20 10 0 0 30 60 Pain Specialist 15 50 5 10 15 2 97 Primary Care 20 30 10 10 5 15 90 Psychology 15 60 5 0 5 45 130 Rheumatology 20 120 10 10 5 5 170 Inpatient Wait Rm Pprwk Waiting RN Student Consult Visit Total Emergency Room 180 15 240 15 15 10 475 Hospital Days 30 15 1320 60 30 5 1460 Ambulance 15 15 30 0 0 0 60 20 hours average wait to get a hospital bed “Valuable” experiences: 48 hours in an on-call room. 27 hours in a hallway with PE.
- 21. 21 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved.21 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. “Value” of 48 hours in an on-call room…
- 22. 22 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Value-add vs wasted time: Jess’ outpatient equation Outpatient ܸ݈ܽ𝑒ݑ = 𝑛=1 ∞ ( 𝐶𝑜𝑛𝑠𝑢𝑙𝑡𝑠 + 𝑁𝑢𝑟𝑠𝑖𝑛𝑔 + 1 𝑃𝑎𝑝𝑒𝑟𝑤𝑜𝑟𝑘 𝐸𝑝𝑖𝑠𝑜𝑑𝑒 𝑆𝑝𝑒𝑐𝑖𝑎𝑙𝑡𝑦 )
- 23. 23 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Value-add vs wasted time: Jess’ inpatient equation Inpatient ܸ݈ܽ݁ݑ = 𝑛=1 ∞ ( 𝐶𝑜𝑛𝑠𝑢𝑙𝑡𝑠 + 𝑁𝑢𝑟𝑠𝑖𝑛𝑔 𝐸𝑝𝑖𝑠𝑜𝑑𝑒 )
- 24. 24 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Jess’ equation for the health-value benefit of time Total ܸ݈ܽ݁ݑ Quotient = 𝑛=1 ∞ ( 𝑉𝑎𝑙𝑢𝑒 − 𝐴𝑑𝑑𝑒𝑑 𝑇𝑖𝑚𝑒 𝑇𝑜𝑡𝑎𝑙 𝑇𝑖𝑚𝑒 )The healthcare system wasted 2 months of her last year.
- 25. 25 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.25 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.
- 26. 26 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Why did healthcare waste so much of Jess’ life?
- 27. 27 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Pressures affecting health-value Pressure to Bend the Healthcare and Health Insurance Cost Curves Pressure to Improve the Quality of Medicine and Care Delivery Changing definitions of value and price Models Better Suited to Populations and Chronic Disease Trends Consumer Expectations for an Improved Patient Experience Shifts in Government Healthcare/Health Insurance Policy and Payment Provider Unilateral quality measures Rigid insurer policies Inadequate network Poor care coordination Insufficient staffing Lack of claim denials management
- 28. 28 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.28 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. How should we manage health-value?
- 29. 29 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.29 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Health-value management: the business of personal benefit Business model that orchestrates and monetizes health-value …and it can be achieved through transformative initiatives as well as everyday tweaks.
- 30. 30 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Health-value of new business models Think Jess would have found value in a digital diagnosis?
- 31. 31 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.31 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. HUGE health-value of everyday tweaks 90% Initial claim denials are preventable Let’s just take, for example… Revenue Cycle Management 63% Claim denials winnable 65% Claim denials unresolved
- 32. 32 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.32 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. How many more weeks of life could Jess have had back if she didn’t have to manage mountains of paperwork due to preventable claim denials?
- 34. 34 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved.34 © 2017 Gartner, Inc. and/or its affiliates. All rights reserved. Wasted Time = Wasted Life
Editor's Notes
- “I know all too well how complicated and rare POTS is. I’ve lived with this diagnosis for five years. It’s ok that you are not a specialist in the condition. I am. Since I was diagnosed, I've read every single peer reviewed article on the disease published since 2000. My succinct Health Plan and Summary includes a table at the end that summarizes treatment options from these articles and my experience with each option. As to the realities of the condition – I haven’t left the house to go anywhere except physician appointments this year. I have a wheelchair. I refuse to go down stairs for fear of another knee subluxation. My last relationship ended over it. I have tried 27 different pharmacologic therapies. I currently take 15 pills a day. I stab myself 6 times a day - 7 if I have to access my central line. I get it.” As to the pain and condition prognosis, please remember that POTS is secondary to my underlying Ehlers-Danlos. Ehlers-Danlos is also the reason my joints swell, pop in and out of place, and are a source of pain. So, yes, there is idiopathic pain in my chest; but there is also pain with an identifiable musculoskeletal source. This has been evaluated by 3 separate pain specialists who concur that opiates are appropriate for my disease state. Seeking out another pain specialist will not change this fact. A friend who is a physician remarked that most pain management clinics in San Francisco refuse to give prescriptions for opioids, instead giving the recommendation to the person’s PCP to reinforce the PCP as being central to the patient’s care. Her point being that if this was indeed your office policy it precludes chronic pain patients from being members. I was so curious that I called the central group number and found out that your office does not have a blanket policy and does opioid management on a case-by-case basis. In other words, you lied to me. In addition to several community neurologists and cardiologists, I've seen POTS specialists at Stanford, Hopkins, and Georgetown. My most recent cardiologist has tried different therapies, which is far more than his predecessor did by saying that I’d grow out of it. I do not need to see another POTS specialist. I do, however, need to see a rheumatologist and neurologist. The rheumatologist scheduling song-and-dance routine took over a month and two hours of my time; the neurologist you referred me to didn't have any availability until June. The majority of my friends are allied the healthcare field – doctors, health lawyers, nurses, health administrators – and all ask “who’s coordinating all of this?” to which I say I am and then they all stress about who is going to take over when I start puking and can’t get off the floor on my own. I’m not sure where they got the notion that my primary care physician should coordinate my care, maybe they were looking at NCQA’s patient centered medical homes model, or found a copy of the Accountable Care Organization regulations from CMS, or listened to people discuss Obamacare on Late Night with Jimmy Fallon. All I know is that they all say that a PCP is the person to coordinate care. In my search to figure out what this actually means, a physician friend turned me onto Vernon Wilson’s 1969 article entitled “Prototype of a Doctor.” Wilson postulates that as a continuing medical advocate for their patient, a PCP’s job is to evaluate and coordinate patient care and “accept responsibility not merely pass it along – utiliz[ing] specialists rather than surrendering to them.” By telling me that my condition is complex and stating that I should just see additional specialists, you are surrendering. And not even surrendering to anyone in particular – your referrals are not likely to materialize for months. I've been living in my friend's guest room since being discharged from the hospital a month ago because it's unsafe for me to live alone. I need help now, and, as these specialists are unavailable to provide the care, my primary care physician should provide it. So, this leads me to ask: If you are not willing and able to help me, who in your practice is? Would have liked to have this conversation with you in person but you have no availability this month. Best, Jess” Now, it may be somewhat unusual for a PCP to essentially fire a patient for being too complicated and needy. But on the flip side of that equation, how do PCPs really feel about their ability to deliver value as the de facto “voluntold” quarterbacks of the care team? Care coordination for patients with any complex needs, whether situational or ongoing, can be a full-time job by itself (as many caregivers would attest); is it reasonable to expect that a doctor whose job is being a diagnostician should also manage the often labrynthian referrals and authorization processes – AND monitor the outcome (like, did the patient actually SEE that specialist within the time they should have)? The process of generating the referral has no value if the consult doesn’t happen. Which brings me to a more common complaint. We all know that Jess’ frustration finding timely access to specialist care isn’t unique to rare disease patients. It’s not that the specialists don’t WANT to see all the patients referred (right?), but there are only so many specialists in a geography, and only so many network contract arrangements, and only so many appointment windows. The 3 month plus waiting period she referenced here isn’t unusual, and we don’t have to look any farther than the scandal at the VA to know the poor outcomes that happen when those who need care can’t get it in time. Months of waiting without help. PCPs firing patients for being desperately sick. Is this the value we’re supposed to be delivering with “value-based care”? Jess sure didn’t think so – and she kept sharing examples of the ways we were failing her.
- What is the e=mc squared of health-value? How would you define it?
- Read “On the Worst Healthcare Experience of my Life”