The Blockbuster Drug of the Century: An Engaged Patient

So why, oh why, is patient engagement such a big part of MU and the Medicare shared-savings program for ACOs?

All this is so different for healthcare providers. It’s like a great restaurant learning that their new business is going to be – in addition to continuing to provide a great in-restaurant experience – teaching people how to cook at home. What? This isn’t what we do!  It’s impossible!

Actually, it’s surprising that it has taken us this long to focus on patient engagement because the results we have thus far are nothing short of astounding. If patient engagement were a drug, it would be the blockbuster drug of the century and malpractice not to use it.

Let’s first take a look at the evidence, and then see where we can go from here.

First, the evidence for blockbuster drugs. In Dr. Eric Topol’s book “The Creative Destruction of Medicine,” he takes a deep look at the evidence for statins, possibly the biggest group of blockbuster drugs the last 20 years. Statins are a requirement of Meaningful Use Stage 1 clinical quality measures, as well as key measures for the CMS hospital quality measures used by many organizations, internal and external to the hospital, to grade the quality of care at a hospital. Prescribing statins, in many instances, is no longer optional. Topol states that “of every 100 patients taking Lipitor to prevent a heart attack one patient was helped, 99 were not.”  These drugs cost $4 per day per patient and $1500 per year. While they are great at lowering cholesterol, it remains unclear that they do much to prevent heart attacks.

Now let’s take a look at a 2009 Kaiser study of coordinated cardiac care. Compared to those not enrolled in the study, coordinated care “patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.” And, “clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.”

“Recognizing the importance of early treatment and intervention, every patient who presented with CAD was enrolled in the program for both short- and long-term care.

“Physicians, nurses, and pharmacists, using proven CAD risk-reduction strategies, work collaboratively with CAD patients to coordinate care. Activities such as lifestyle modification, medication management, patient education, laboratory results monitoring, and management of adverse events are all coordinated across a multifunctional team.”

Can you imagine what the headlines would be if a new cardiac drug showed this kind of effectiveness?

Patients were actively engaged, physicians were coordinated, and ongoing monitoring was taking place.

Certainly, statin use was part of the monitoring they described, which leads me to believe that the strange discrepancy we see between lowering cholesterol and fewer heart attacks may lie somewhere in patient engagement and behavior change. When we have more data through Meaningful Use and accountable care, I suspect we’ll be able to see this answer and what the relationship might be.

A similar example at the VA’s Coordinated Care and HomeTelehealth (TELEMEDICINE and e-HEALTH.  DEC 2008; VOL.14 (10): 1118-1126) program (h/t to Mark Blatt, MD, Global Medical Director at Intel) showed similarly stunning results about coordinated care for chronic disease management, including:

  • 19.74% reduction in hospital admissions
  • 25.31% reduction in bed days of care
  • 86% patient satisfaction
  • $1,600 average cost per patient per year, compared to $13,121 for primary care and $77,745 for nursing home care
  • 20% to 57% reduction in the need to be treated for the chronic diseases studied, including diabetes, COPD, heart failure, PTSD, and depression

Can you imagine if a drug reduced the need to go to the hospital by this amount? Again, it would be malpractice not to use it.

Healthcare must be built on a foundation of Health IT-supported care coordination and patient engagement, there is no other way to consistently and quickly scale improvements and care, and to accelerate the overall learning of the health care system.

As Topol points out, this is the path to real, personalized medicine, and away from the population-based studies and results that we’ve seen with statins. Medicine and the people it treats are complex adaptive systems; we need a complex adaptive systems approach to medicine because each person reacts differently. We can only treat the population for so long and get great results; we need to use data and engagement to continuously learn how to improve care for each individual.

So how do we get there? Engagement is just the very first step of what I think will become a new science of behavioral economics and behavior change in healthcare. It’s no accident that in both the examples here, the providers and the payers were tightly aligned, because the economics have to be aligned before any of this will work. ACOs are a positive step. Based on the results above, there’s plenty of potential for shared settings, if it’s done right. To do it right, we’ll need experts from other domains who have been honing their skills and engaging people for years.

Ultimately, we’re talking about cultural and behavior change. There are many resources available from other disciplines to help healthcare move to where it needs to be in terms of patient engagement and understanding consumer behavior and medicine as a complex, adaptive system. There are some great minds working in this space, including behavioral economists, user experience designers, community leaders, interaction designers, software developers and game designers, risk managers, data scientists, and actuaries.

In my next article, I’ll review where we can find them and how we can put them to work with caregivers and patients on stuff that matters. We can’t afford not to.