New Hep C drug cost $84K. Pt agrees to sign DNR for tx.

1. AN ECONOMIC MODEL
FOR EXCHANGE OF
VALUE BETWEEN
PATIENT, PROVIDER
AND PAYER.
I will happily trade you the last
hospitalization in my life for a course
of treatment for Hepatitis C and
coverage of Continuous Glucose
Monitoring Equipment

2. A plea to the American Public
Dear America,
I am writing you as a collective since it is your political processes
which ultimately determine the policies determining payment for
health services and products for American Citizens. Most think they
have no control over private and public sector financing of medicine
but ‘trust me; this is an illusion. If you are not a patient today, you
will be one at some point in your life. So pay attention, empower
yourself and forge the change you need.
Right now I HAVE SOME NEEDS so read on…

3. A little about me:
• Just a regular 58 year old fella
• Married to my soul mate
• Physical conditions:
• Diabetes type 1, hepatitis C, Reflex Sympathetic Dystrophy
• Occupation
• Retired Healthcare Executive with 33 years experience in direct
care, chronic disease program management, biomedical
instrumentation research and the health informatics revolution.
• Currently able to volunteer and work for case rate assisting
physicians build practice culture and technology to support PCMH
standards.
• I will soon lose this capability due to loss of continuous
ambulatory glucose monitoring equipment.

4. A little more about me
• I spent the last 30 years studying the economics of healthcare in the
USA. I worked in all sectors of the industry and frequently needed
to justify costs, set prices, assist various non-revenue generating
people in health care such as case managers to prove their ROI and
use prospective health risk models to define community care
coordination needs.
• Basically, I can diagram monetary inflation in our system of care
through all levels of care.
• So if you do not mind, I want to review a couple of special
characteristics about healthcare cost in America, then make a case
to you on how I would like to barter for my life.

5. Who qualifies for healthcare in America
Even after ACA
Our society never considered medical treatment to be a ‘right’ or
‘entitlement’ for its citizens. So where we all have a right to self-determination
and our constitution states we are concerned for the
welfare of our citizens: Wellness is not something we planed to
guarantee.
Regardless of what you want, this is what we get. Well until you are
an elder or become disabled, bankrupt or are a poor infant.
In the 1960s the reality of human suffering among ill seniors, ill poor
and the disabled was addressed and we created a system of care for
that segment of our population; Medicare and Medicaid. So I
suppose enough folks changed the system to assure bodies did not
accumulate in our streets. (note, the most cost efficient system of
care has turned out to be Medicare)

6. Please hang I with me so you can
understand the logic behind my
plea.
SO LETS TAKE A LOOK
AT AMERICAN
HEALTHCARE COSTS

7. Most other nations considered healthcare a natural right and adopted
universal coverage. All we can say is that for some reason they have better
healthcare outcomes for ½ the cost per capita. We currently spend $7500 per
person per year. I have a business model contrast presentation if folks want
more detail. Note, the gap in cost over age of 60 is not due to “death panels”

8. Health Care Costs from Birth to Death
Society of Actuaries
Dale H. Yamamoto
June 2013
These data recently compiled by Yamamoto
after and exhaustive study of HCC in America
reveal average expenses per year of life to
assist us with planning. I will use the $130,100
number as an argument for treatment
shortly. Essentially I will forfeit the difference
between 80 ($250K) and 75 ($130K). If I die
before the age of 75 the loss of me from the
insured population will save $120,000

9. This slide illustrates the difference in healthcare cost between those who die and those
who survive in any given year between 1977 and 2006. So, If I would have received
normal treatment in 2006, typical cling to life scenario with failing heart and kidneys in
end stage diabetes the cost would have been far north of $39,000

10. So here are my problems
• I have been notified by both Medicare and Blue Cross that the
technology I use for tracking my blood sugar trends will no
longer be covered. This is a technology that allows me to know
that my blood sugar is low, keep my drivers license and have
sufficient energy to work a few hours per day. It also allows me
to make decisions hour by hour on controlling my blood sugar.
My measure of 90 day treatment effectiveness is Hemoglobin
A1c. My A1c is 6% with a target of <7%. Essentially I have been
rewarded with preservation of my eyesight, kidneys and vascular
system.

11. This technology not only prevents loss of consciousness while
driving my car but facilitates long term clinical control which
translates to lower healthcare costs from comorbidity.
Could it be the folks warning us of death panels were correct?

12. It appears the experts in type 1 diabetes agree that
Medicare recipients should be covered
Juvenile Diabetes Research Foundation

13. Next problem: Hepatitis C
• Hepatitis C is the disease of my generation. Suffice it to say, America
has an epidemic of a viral disease that progressively destroys the liver
(kind of important organ). I believe I contracted the disease 35 years
ago. Until this year I had no hope for treatment since the available
therapeutics would cause me to lose my vision. Now I have a 94%
chance of a cure due to an incredible new innovation. Direct Acting
Anti-Viral therapy.
• Having this illness is like living with a wet wool blanket wrapped
around your body. It is a sense of constant discomfort in ones own skin.
People who are ill-informed (many) are frightened of the patient (my
boss in 2006 asked me not to share my dx when telling my story and he
was an MD). On many days it is difficult to muster sufficient energy to
get out of bed (lethargy and depression)
• I have been notified by both Medicare and Blue Cross that the antiviral
medications which have been approved for the general public to cure
Hepatitis C will not be covered.

14. US Prevalence 3.2 million lives
US Incidence 17,000 cases per year
THANKS TO WEB MD!!
As you can see it is a costly disease just due to
the volume of people seeking treatment.

15. Enter HARVONI to save my life!
$1000 per pill or $85K to treat an American

16. After 20 years of research

17. DRUM ROLL PLEASE
These patients
had failed
treatment using
the most effective
medicines
available.
They experienced
a cure rate of 93-
100% when placed
on Harvoni

18. How is it the treatment will cost $85,000 in the
USA yet the manufacturer will assist other
countries to provide the treatment for $300
The manufacturer insists that cost will not
prevent access. As it has for its HIV drugs,
Gilead plans to provide patient assistance
within the U.S., to license the drug (for a fee)
to select generic manufacturers outside the
U.S., and to lower prices in low- and middle-income
countries. In Egypt, which has the
world's highest rate of hepatitis C, sofosbuvir
costs $300 for a 28-day supply.
How long do I
need to wait if
the medication is
available in
Egypt for
$300.00?
WHY IS IT 283X
more expensive?
Does it have to
do anything with
geopolitics or
geo commerce?

19. My proposal
• I would like to negotiate for coverage of these technologies using my history as a
patient and known economic data regarding the cost of care at the end of life as a
proposed value exchange. Essentially, you will never incur the expense of caring for
me in the last year as I will refuse intubation and ICU care involving life support past
the age of 75.
• Looking at last years Blue Cross data I realize they operated at a negative profit
margin with regard to my single case (they call me a member) but keep in mind that
this diabetic has self managed since the age of 10 through tight care coordination
with multiple providers. I never use your disease management services since my
physician is thrilled with the results of my self-management (A1c=6%). I have no use
for the refrigerator magnets that remind me to check my blood sugar they serve no
use save choking my dog Bodie. I have never been hospitalized or used the ER for
diabetes related services.
• On the next slide you will see that most of your costs are from pharmacy. I imagine
these will decrease as America wakes up to the disparity in costs between countries.
However: Since I will continue to experience few hospitalization and ER events
through tight diabetic control and will never require a liver transplant your expenses
will continue to be low in the medical care cost category for this chronic disease
patient.

20. Blue Cross Data
Member Jeffrey Harris
2014

21. Our exchange in value
• If you cover my continuous glucose monitoring and treatment for
hepatitis C I will offer a minimum of $250,000 in cost reduction to
my care In the future by forfeiting certain services in the future as
described below. I will also provide labor if necessary.
• I will prepare an advanced directive refusing expensive care associated with the
last year of life in the slides above.
• I am sure your actuaries will agree with the table presented above describing cost
per year of life beyond the age of 65. I am 58, when I was 19 my predicted
longevity age 45. I imagine that I will save you a minimum of $130,000 by having a
sound exit strategy before the age of 75.
• If you need a direct need to “get something now” I will provide you with 1000
hours of service in any program whether it be data crunching in your predictive
modeling department, systems integration combing insurance and medical home
patient portals, community education or whatever else you might have in mind.

22. All I want is to feel well, add value, love and be loved and not be
subjected to so many hassles “fighting for my health in America”
• Since I do not reside in a country with universal coverage that has
managed to offer-up large populations to scant insurance organizations
thereby diluting the cost of care per capita I need a model that works
here.
• Since I am entitled to be a self determined man I elect to:
• Stay as healthy as possible within using only appropriate technologies and not
extending my natural greed for life into the intensive care unit while my family
argues about my capacity to be self determining in that moment.
• So far in my life my statistics concerning my wellness have been quite accurate.
When My wife and I were married I told her that mid to late fifties would be the
time for onset of diabetic comorbid complications. I was correct.
• I promise to honor my contract regardless of scientific advances.
• I want wellness NOW, and if you do not cover my therapy I will become less
active, have poor diabetic control and experience liver failure. Do you really
want that bill. Not only that, I might require a LIVER TRANSPLANT!

23. So long and thanks for all the fish
Douglas Adams
Me self managing
Sorting EOBS
5 Health Portals
2 calendars
2 insurance portals
LOTS OF STARBUCKS