|THIS WEEK AT GIST—ON THE ROAD
What we learned this week from our work in the real world.
Where population health and consumer value meet
This week I delivered the keynote presentation to kick off the annual Learning Symposium for the New York State Delivery System Reform Incentive Program (DSRIP)—and got a glimpse into one of the largest Medicaid transformation programs in the country. Launched in 2014, New York’s DSRIP program uses a longstanding 1115 waiver to reinvest savings from its Medicaid redesign efforts into ongoing care transformation. Over five years, $8B has been allocated to two dozen Performing Provider Systems (PPS), regionally-organized provider networks who have developed and implemented plans to improve care for local Medicaid beneficiaries—with the ambitious goal of reducing hospitalizations by 25 percent. The symposium brought together PPS providers from across the state to present their care transformation strategies and facilitate collaboration.
My role was to share our thinking on the policy and market forces driving the emergence of a consumer market in healthcare. I’ll admit I was a little worried that some participants might not find our insights on consumer value directly relevant, given that much of their work has focused on care management and social support for patients who don’t have a lot of choice when accessing care. And New York, being one of the bluest of the “blue states”, is unlikely to build consumer financial incentives into their Medicaid program in the way that Indiana and other states have. But seeing these providers from across the state showcase their care management strategies revealed just how much their work to improve outcomes for the Medicaid population is delivering value to consumers. PPS networks have built virtual care and telemedicine solutions, care coordination teams, home-based access and care management programs—exactly the kinds of resources you’d need to make care more affordable, accessible, reliable and personal for any consumer, regardless of income.
We’re often asked whether health systems need to shift their strategies away from population health toward consumerism. This is a false choice. The vast majority of tactics that enable success in “population health”—improving health outcomes while lowering cost of care for a population of patients—dovetail with the goals of delivering value to individual consumers with growing choice and financial responsibility for their healthcare. Readily-available, lower-cost access, seamless care coordination, tailored care plans, and financial models that enable care delivery in the most appropriate setting are just a few of the strategies that are foundational for both. With participants covering the Bronx to New York’s rural North Country, the DSRIP program is large-scale experiment worth watching, one that shows how providers can increase value for low-income residents across very diverse markets, and use this work as a catalyst to improve care for the larger communities they serve.
It’s enough to give you high blood pressure
If you’ll indulge me, I’d like to vent for a moment about some recent healthcare experiences that call into contrast the difference between how healthcare usually works and how it ought to work. Last year, approaching the ripe old age of 50, I finally gave into reality and got myself a primary care doctor. Having heard colleagues rave about them for years, I decided to sign up with One Medical, the concierge-lite, consumer-forward practice that promises same-day access to a doctor, telemedicine services, a redesigned clinic experience, and a personalized approach to primary care. For a nominal annual membership fee, it’s been the perfect solution for me, given my heavy travel schedule and limited patience for healthcare’s endless bureaucracy. It’s not for everyone, and your mileage may vary, but I’ve been happy with it. During my annual physical, my doctor put me on a low-dosage ACE inhibitor to treat my borderline hypertension. For the first couple of months, my doc encouraged me to take periodic blood pressure readings, and I was able to enter the data in the One Medical app and send them along to him easily. Once he adjusted the dosage appropriately, I was off and running (literally, three times a week…in case my doctor is reading this). So far, so good.
Enter my insurance company, and specifically, their pharmacy benefits management (PBM) subsidiary. On my first visit to the retail pharmacy to pick up my prescription, I noticed that it was only a 30-day supply of the daily medication. I asked the pharmacist if it was possible to get a larger supply of pills, or if I really had to come back every month to pick up more. Turns out my PBM restricts my refills to 30 days unless I sign up for their in-house mail-order service. I get it, that saves them money. But given travel, that model isn’t convenient for me, so I settled on a monthly routine of refills. Shout out to Walgreens for their excellent app, where I can scan the barcode on my pill bottle and pick up a refill at any Walgreens store, which I’ve done in several cities. I recently needed my prescription renewed, and with One Medical—dead easy. I clicked a button on their app and sent a recent blood pressure reading, and within ten minutes a new prescription was sent to the pharmacy.
Again, enter the PBM. When I went to pick up my next refill, I noticed that my copay had gone up from $1.08 to $6.43. Same plan, same drug, same generic manufacturer. That’s almost a 600% price increase! Look, I can swing the six bucks, but what’s going on? I asked the pharmacist, who replied that my PBM changes their copay amounts all the time, with no explanation. Sure enough, a month later the price had bounced down to $2.30. And it’s been different every month since.
To summarize: my consumer-friendly, digitally-enabled primary care practice makes it super easy to manage my (one, admittedly minor) chronic condition. My pharmacy is making it simple to refill my prescription on my mobile phone, anywhere in America. But the giant middleman PBM wants me to conform to a supply method that’s cheaper for them but inconvenient for me and sets payments in a seemingly irrational and certainly opaque way. Isn’t it in the insurer’s interest to make sure I manage my hypertension, especially given my family history of stroke? And I’m the simplest sort of chronic disease patient. Surely it’s much worse for a lower-information, less-advantaged, polychronic patient who needs several expensive medications. What’s been a minor nuisance for me, multiplied millions of times over, is a symptom of a broken approach to managing health. Let’s hope the future of healthcare is more like One Medical and Walgreens than the PBM—and let’s keep working on fixing this crazy system.