OptumLabs CONNECTIONS 2020
Our five-part virtual miniseries explored some of health care’s biggest challenges through the lens of opportunity for action.
Building a better health system
CONNECTIONS 2020 brought industry leaders together around big ideas to make the health system work better for everyone. Major themes included designing for health equity, integrated behavioral health, health in the home and telemedicine, and chronic kidney disease.
Engage with us through a diverse mix of keynotes, short talks, and interactive panel discussions with the videos below. You can download our accompanying viewing guide here.
Designing-in health equity
How can we center on equity within the health care system? This session explores the interconnectedness between structural racism, social determinants and our health system, and calls for shifting our perspectives to reach the root cause of these inequities.
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Kevin Larsen:
Hello, everyone, and thank you for joining the first webinar of the OptumLabs Connections 2020 series. I'm Dr. Kevin Larsen. I'm the senior vice-president for clinical innovation and translation here at OptumLabs and I'll be your host. We're really excited to welcome you today to the Connections 2020. This is a virtual session that has historically been a rich conversation that we arrange every fall through an in-person research and translation forum. However, this year, as with many other of the sessions you've attended, we are virtual. This is an intentional dialogue between the research community and operations. Operations here at United Health Group and operations in other places. We realize there is a lot of opportunity to design a better health system, given all that we've been collectively experiencing this year, and we welcome you to a set of five sessions showcasing national thought leaders on important themes, spotlighting key research. Many of these results have been generated from the Optum Labs and it's partners as well as other national research experts.
Kevin Larsen:
Here is the series that we are going to have over the next seven weeks. Excuse me, first, I'm going to highlight who we are as OptumLabs. So OptumLabs is a collaborative organization that's part of United Health Group. We collaborate with internal and external partners across the country. Academic research partners as well as community organizations such as AARP, academic partners such as the Mayo Clinic, Johns Hopkins, UC Health and government partners like HHS. Together we combine our healthcare expertise and deep knowledge of research, healthcare data, and data science techniques and work with one of the industry's leading data assets to extract insights that can help our mission. We have longitudinal data that is rich and diverse, it contains both commercial claims as well as MediCare claims, as well as one of the largest electronic health record data sets in the country. Combined with socio-economic data and social instrument health data, this is carefully curated and enhanced with different tools that we do research on. Like typical health services research, health care economics research, as well as artificial intelligence and machinery research.
Kevin Larsen:
Here are the sessions that I promised you before. We have five sessions over the next seven weeks. Today is session number one, designing in health equity to make the system work better for everyone. Next, the day after the election we will have integrating behavioral health to drive the quadruple aim. Following that, we have virtual idea exchange. This is highlighting some of the best of the research that's come from our research network over the last year and a number of sessions with those researchers telling us what they have found and what they are learning. The fourth session, in mid-November, is living better through health in the home. This is focused on the post-COVID world of telemedicine, home-monitoring, digital health and others. And finally, an important topic, chronic kidney disease. We will be focusing on lots of work that we've been doing in chronic kidney disease in the poly-chronic population.
Kevin Larsen:
Today, we are proud to have a list of speakers that are from across the country and a number of different organizations, representing a number of different points of view. Our keynote today is Dr. Giselle Corbie Smith at the UNC Center for Health Equity Research. We also have Leo Eisenstein at the NYU Bellevue Hospital. After that, we will have a panel moderated by Dr. Aric Coffman, who is from OptumCare, one of our care delivery organizations, and in that panel we'll have Ana Fuentavilla from Optum Population Health Solutions, Atum Azzahir, the CEO of the Cultural Wellness Center in Minneapolis, Elena Rios from the National Hispanic Medical Association, and Chyke Doubeni from the Mayo Clinic.
Kevin Larsen:
With that, I will turn this over to Dr. Giselle Corbie Smith who will be talking to us about answering the call for equity in a post-COVID world. Dr. Corbie Smith, we are very excited to have you.
Giselle Corbie Smith:
Thank you so much, Kevin. I'm so excited to be with you today. I want to warn our audience that we will have some audience participation but first, I'm going to start with a story.
Giselle Corbie Smith:
I was recently in the mountains of North Carolina. There are beautiful bodies of fresh, clear water in the western part of our state. While we were driving, I reflected on a story that was shared with us by colleagues. So, imagine one day, you go out of your mountain retreat and notice in the lake a fish that's sick and near death. I imagine your first question might be, what is wrong with that fish? The next morning you see more fish, sick and dying, and this goes on for days as you wake and go to the lake, you see more and more fish sick and dying. Initially, okay, trying to advance.
Giselle Corbie Smith:
Initially, you concluded that there was something wrong with the fish but as you reflect on the past days, you begin to wonder whether there's something wrong with the water in the lake. And in fact, as you travel through the mountains, you notice that each lake you've come upon, you see the same scene. A large and overwhelming percentage of fish are sick and dying. What could be happening here? You begin to wonder if something could be wrong with the source of the water in that region, the groundwater, which is consistently feeding the lakes in the area.
Giselle Corbie Smith:
This allegory of the groundwater was shared with me by my colleagues at the Racial Equity Institute. It reminds us to pause and think critically about the source of inequity. In health, when we see disparities we have often focused on the individual: their behaviors, genetics, how they interact with their environment. We have focused on the fish and developed solutions, interventions, that are almost entirely focused on fixing fish.
Giselle Corbie Smith:
However, when we see consistent or persistent patterns of health disparities, it suggests we must look at the lake. The systems that are producing these results and work to intervene at the systems level.
Kevin Larsen:
Would you like me to advance for you?
Giselle Corbie Smith:
Yeah, it's not actually advancing.
Kevin Larsen:
There you go.
Giselle Corbie Smith:
Okay, thank you. In fact, inequalities by race and ethnicity are consistent across a myriad of systems. And in fact, every system. Most familiar to us, is the inequality in the health care system, generally referred to as health disparities.
Giselle Corbie Smith:
What contributes to the challenge of understanding the root cause of inequalities is that we call them by different names in each system. In the child welfare system, it's a disproportionate number of children of color that are served by that system compared to the general population. In education, inequality is called the achievement gap of children of color compared to whites in education and so on.
Giselle Corbie Smith:
But by using the REI groundwater analysis, one might begin to ask these questions. Why are educators creating the same racial inequalities as doctors, police officers, and child welfare workers? How might each of these systems be connected? Most importantly, how do we use the positions in one system, our physicians in one system, to impact the structural racial arrangement that might be deeper than any single system?
Giselle Corbie Smith:
The fish, lake, and groundwater analogy that was developed by the Racial Equity Institute illustrates our tendency to attribute social problems to individual behaviors and decisions, IE, sick fish. Even when we know our nation's history, even when we know about racism and systems, structures, and policies that constitute the root causes of these inequalities. A polluted lake.
Giselle Corbie Smith:
Next slide, Kevin, please.
Giselle Corbie Smith:
So this is a picture of a new geo-physical phenomenon where an hurricane or other strong storm can spark seismic events in the nearby ocean, leading to an earthquake with at least a 3.5 magnitude. These are called storm quakes. There's evidence that more than 10,000 storm quakes have occurred from 2006 to 2019 off the shore of the United States and in Canada. And I show this picture to illustrate that our society is facing some of the most seismic shifts we've seen in our lives. This year has brought the coronavirus, a pandemic, a health system and public health crisis with economic impacts unlike any experienced in the past century.
Giselle Corbie Smith:
At the same time, the ongoing crisis of police violence in Black and Brown communities, reignited the Black Lives Matter movement after several public murders of Black men and women at the hands of police. These defining social and economic issues are all on the backdrop of decades of increasing societal instability. Climate change, a growing populous movement, and political and civil unrest. Technology advances that are outpacing the norms of privacy and veracity. The current environment for leaders is a turbulent world characterized by social, economic, technological, and environmental change occurring at breakneck and breathtaking speed. It can feel overwhelming and hard to think past the newest crisis, however, this is exactly the time for us to look for opportunities to ensure equity.
Giselle Corbie Smith:
Next slide, please.
Giselle Corbie Smith:
This quote is from one of my favorite authors and it sums up the moment I think we're in now. Zora Neale Hurston wrote, "There are years that ask questions and years that answer them." The questions about health and racial equity we've wrestled with for decades have come to a head this year. In the past several months, we've seen deeply distressing and significant differences by race, and ethnicity, and infection, and death during the COVID pandemic.
Giselle Corbie Smith:
And while distressing, these are not surprising. The pandemic is exposing the health inequalities that have always been there. As a nation, we've seen inequalities play out in our public health and health care systems for as long as we've been collecting the data on health outcomes. We know that racial and ethnic minority communities bear a disproportionate burden of the risk factors for outcomes in this pandemic.
Giselle Corbie Smith:
However, they still need exposure and so we know that individuals in minority and rural and poor communities are disproportionately represented as essential workers. Employed in positions that have kept this country running over the past several months. Positions that serve the public and are so essential they are not able to shelter in place, limiting their ability to protect themselves or their families, yet often are not earning a living wage.
Giselle Corbie Smith:
We know that individuals at high-risk for coronavirus are also more likely to live in communities that are medically underserved and they themselves are less likely to have adequate health insurance, access to care, and may even have trouble getting tested. However, these factors are part of, and represent larger social and economic structural inequalities. Inequalities that have led to unequal and uneven opportunity in housing, education, and employment, that have been revealed in the disparate impact of this pandemic.
Giselle Corbie Smith:
The pandemic has also revealed to all that health is not just about health care. It's about housing, transportation. It's about food access, it's about educational obtainment and opportunity. It's the ability to be employed, have a productive work and still keep yourself and your family safe.
Giselle Corbie Smith:
The World Health Organization defines social determinants of health as the practices and policy that shape where we live, work, play, and pray. And these practices and policies enable or constrain the opportunities for us to live a healthy life. This is a systems view of social determinants of health and many states, notably North Carolina, where I'm sitting now, have leveraged the MediCaid transformation to target, quote/unquote, social determinants of health. The emphasis has been on programs that screen for and put into place programs within the health care system that address conditions or health-related social needs, like intimate partner violence, transportation access, food and housing insecurity. And these programs acknowledge and fill important gaps for many individuals. However, I would submit that these programs will be inadequate to address health inequalities by race and ethnicity as they continue to focus on the individual without addressing underlying drivers in inequality.
Giselle Corbie Smith:
My colleague, Dr. Camara Jones, talks about health equity and that it requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resource according to need. Just stay on slide 11. Thanks.
Kevin Larsen:
Oops. Sorry.
Giselle Corbie Smith:
It's one that is forward looking, this definition of health equity. Focuses on assets, yet recognizes systems and historical injustice. We often use the term health inequality when discussing differences between Blacks and whites, people of color and whites, but for a minute I want you to shift and think about equity rather than inequality.
Giselle Corbie Smith:
The next slide, please.
Giselle Corbie Smith:
I want to suggest there's three areas that we need to attend to now and in the future if we're going to seize this opportunity to answer this call for equity. We need intentional leadership. We need to center equity and the recovery of health care systems and public health and reinvest in communities for recovery and resilience.
Giselle Corbie Smith:
The next slide, please.
Giselle Corbie Smith:
The first opportunity to ensure equity. Oh, if you could go back one? I think we're both doing it at the same time. Thank you.
Giselle Corbie Smith:
The first opportunity to ensure equity in a post-COVID world is intentionality in leadership. Considering and cultivating the competencies that what leaders need to know, think, feel, and do to be able to lead in this time. So for me, that's a realization that we're all on a journey with no final arrival when it comes to understanding and appreciating differences and integrating an equity lens in our approach to leadership. This journey doesn't end with reading a book, however good they are, or an anti-racism pledge or even an organizational equity plan. Intentional leadership that advances equity in a post-COVID world acknowledges a life-long journey in integrating an equity lens in a way that's concordant and consistent across all the work that we do. Intentional leadership recognizes the need to create a leadership environment and climate that fosters equity within teams. Leadership development that centers equity, diversity, and inclusion competencies to the same degree as other competencies.
Giselle Corbie Smith:
We're in a new era of ensuring an anti-racist strategy in medicine and public health. Equity needs to be a strategic priority at every level of organization, especially in the process and structures of teams leading those organizations. By centering equity as the strategic priority, it means that we also understand how to tackle or take a systems view of how we've arrived at health inequalities and how they can be mitigated in the future. This means ensuring policies, practices, norms, that embrace an anti-racism analysis and will require leaders to leverage those policies within organizational walls. It also means that we need to work beyond our walls and use leadership and social influence as the health care system leaders and create new partnerships in our communities that can act on the social determinants of health.
Giselle Corbie Smith:
Next slide, please.
Giselle Corbie Smith:
In this slide, I share with you the disciplinary leadership foci compared to organizational and systems boundaries spanning leadership that's needed to be able to effect this kind of change. And while we have typically cultivated health care provider and researcher competencies, we're now, in leadership development, realizing that we need to shift toward boundary spanning leaders that can really take our organizations to the next level. That are able to span boundaries of insider walls to outsider walls, make connections there as well as within.
Giselle Corbie Smith:
But even this isn't enough. We need to actually think about integrating equity into leadership competencies. We need to teach leadership with an eye towards and a heart focused on addressing inequalities, the root of the social determinants of health.
Giselle Corbie Smith:
So our next slide, please.
Giselle Corbie Smith:
Within the clinical scholars program, we've taken that to heart and brought together leadership teams of inner-professional leaders, of health care providers, collaborating across sectors. We've asked each of these times to tackle significant complex problems in their communities. And hopefully, ultimately, building a culture of health nationwide. We've worked with them to equip these providers from every discipline with leadership tools that are centered in equity, diversity, and inclusion to transform their careers and ultimately the health of their communities.
Giselle Corbie Smith:
But I want to share a little bit of those data here. You see in this slide that we're on, the 25 competencies separated out into four areas. Within each of these four areas, we've integrated equity, diversity, inclusion with typical leadership competencies.
Giselle Corbie Smith:
In the next slide, I share the success that we've had. First of all I will note that the leaders in our program come in at a very high level of competency around equity, diversity, and inclusion issues. And that's our center circle and you'll see the competencies listed on the outside. And yet, even though they've come in at a higher level of EDI competencies and the leadership competencies, we're still able to see statistically significant improvements in not only their knowledge, but more importantly, their application and skill in addressing equity, diversity and inclusion within their leadership roles.
Giselle Corbie Smith:
The next slide.
Giselle Corbie Smith:
The next opportunity is centering equity in the recovery of our public health and health care systems.
Giselle Corbie Smith:
So, if you could move to the next slide, Kevin.
Giselle Corbie Smith:
In order to center equity I want to paraphrase another writer, Audra Lourde. She says that we need new tools to dismantle the systems that create and sustain inequalities in health. It requires, to achieve health equity, going to require us to continually to push beyond the typical methods we've been trained in as researchers, health system leaders, and clinicians. To examine the theories that underlie our work and to interrogate our assumptions about how we're organized as health systems and as research enterprises. Assumptions that we've either been implicitly or explicitly taught.
Giselle Corbie Smith:
One of our first interventions in the community based, participatory, research partnership project Grace that I've had the great fortune to be a part of for the past fifteen years, I was doing the usual health disparities presentation, describing why we needed to focus on this intervention and had bar graph after bar graph of poor health outcomes relative to that region of our state. And one of the participants raised her hand and challenged me, and said, Doc, I'm tired of hearing about all that's wrong with our communities. We have a lot that's right here. For me, that was a defining moment. I realized that I, a minority female investigator, had internalized the oppressive stance of seeing communities of color as less than. This is what I was taught implicitly about, disparities, and morbidity, and mortality in the people who bear that burden.
Giselle Corbie Smith:
This realization hit me like a ton of bricks. It showed me that I had to reframe my work to effectively partner and serve communities of color. I was fortunate that I had a group of collaborators, long term academic partners in the eastern part of North Carolina, as well as at UNC, that supported me in this work. My community partners pushed me to include racial equity training in all of our grants so that we could continue to examine together and individually how modern day oppression operates within our collaboration. In order to be better prepared to serve communities with our work.
Giselle Corbie Smith:
So I would ask you, and urge you, to look at the assumptions that underlie your work. Especially if you hope to advance health equity. Have you considered how inequities are operating in your collaborations? Have you engaged feminists, intersectionality theory, or critical race theories, or any theories that elevate and center the perspectives of oppressed people?
Giselle Corbie Smith:
Next slide, please.
Giselle Corbie Smith:
The racial equity training that we undertook was with Visions Incorporated and this is a schematic of the five component parts that we worked on with Visions as we did our work. Visions is a minority and female owned company that works across our region but is centered in North Carolina. We spent a good bit of time, as you can see from this five part process, focusing on the process of our work together. All of us in our partnership have undergone ism's training and while at the time I couldn't understand what it was important, I realized when we wrote the first grant 15 years ago, that this focus on process, on continually interrogating this process of individual capacity building was a critical element of our success. This work was transformative for me and has required me to continuously examine what I bring to the partnership and how the very work we're doing to address inequalities at multiple levels can be reflected in our interactions within our partnership.
Giselle Corbie Smith:
Next slide, please.
Giselle Corbie Smith:
We also came to realize that this work would require a paradigm shift that I've already hinted at, sort of shifting from disparities to equity. I would suggest that a focus on disparity is more of a deficit model, what's wrong or lacking in a group. We've reframed our work to focus on the strengths that communities have and how those strengths can be leveraged to achieve health equity. Bell Hooks in her critique of the feminist movement calls on those seeking gender equity to center the margins. To prioritize the needs and wants of those at the margins. The patients, and I would suggest the patients in the communities we hope to serve, in our work. To democratize the process to include direct participation of those stake holders and making sure of giving them a meaningful voice. To design and evaluate the impact of our research, our interventions, our clinical practice according to stake holder outcomes. And I think this is at the heart of the current emphases on patient and community engagement and patient reported outcomes.
Giselle Corbie Smith:
Next slide, please.
Giselle Corbie Smith:
Throughout the pandemic, there's been real risk to racial and ethnic minorities and rural, underserved communities in our nation. But really, the risk has been multi-modal for individuals, health systems, and communities. And I want to suggest that there is several areas that we can focus on that might provide opportunities.
Giselle Corbie Smith:
The importance of data during and even now in the pandemic can't be overstated. Incomplete data continues to make it difficult for us to understand the full scope of this problem. And in the future, really creates challenges for us to understand whether interventions to prevent the spread of the pandemic are mitigating the inequalities that we're seeing now in this crisis. OptumLabs is in a unique position because of the richness of the data to really lead the country in rethinking and positioning yourselves to lead an anti-racist approach to research, that queries those underlying assumptions that I referenced and that we need to reframe. Everything from the accuracy and completeness of race, ethnicity, and language data to within group analyses and interrogating the use of white race as an unthinking comparison group. To identify even more damning assumptions in the way that we use data.
Giselle Corbie Smith:
Really, the financial and human toll on already strained practices and health care systems that are caring for historically marginalized populations has already demonstrated to be staggering and left many closings, at least in my part of this country, of practices that were so desperately needed in health care shortage areas. Small rural practices and health care systems, federally qualified community health centers, that are all caring for poor, rural, and underserved communities will need some sort of support during and after the pandemic.
Giselle Corbie Smith:
As we face both the short term impact of this crisis, as well as the long term impact for patients, who have recovered from infection, and those that have deferred care, we need to think about how we're going to center equity in the policies related to health, health care and the social drivers of health. Both in the policy as well as the implementation of those policies. We've already seen the risk of tying insurance to employment. It's so starkly evident in this economic downturn and the rising unemployment facing already underserved communities. We need to find ways, particularly in this setting of distressing unemployment, to separate health insurance provision from employment. We need to push for expansion of MediCaid in all states, particularly in states where the majority of racial, ethnic minorities are disproportionately impacted by COVID-19.
Giselle Corbie Smith:
Internet access and telehealth are now critical drivers of ensuring increased access to care and as an infrastructure piece, we know that expanding broadband internet access so telehealth can actually bridge the digital divide not only for the acute pandemic but also to ensure that the uptake for future management of chronic disease and prevention.
Giselle Corbie Smith:
When we think about the pandemics of racism and the coronavirus infection, these co-occurring and synergistic pandemics have led to a shadow pandemic of the COVID-19 pandemic, the mental health crisis. Recovery from trauma will need to be an important element of our recovery as a nation. Prior to the pandemic, we all knew that our mental health infrastructure was tenuous and now it's well over stretched. There wasn't enough work force to provide the mental health services even before the pandemic and we're revealing now the lack of diversity in the mental health workforce that's been highlighted with the pandemic. It's going to have limited capacity to appropriately care for those with the combined trauma from the COVID pandemic and racism, discrimination, racialized trauma that we're experiencing now.
Giselle Corbie Smith:
And to pivot towards our workforce, as we think about centering equity in our recovery efforts we need to focus on reinforcing primary care and our primary care workforce. We've seen the erosion of safety nets in our most needed and needy areas. We've seen a lot of deferred care of chronic conditions that are already known to providers and patients, like hypertension, diabetes, heart disease, and cancer as well as deferred care in terms of diagnosis of new sources of suffering in communities. We need to be thinking about creating a pipeline of health care workers that are appropriately trained to be able to care for individuals in a post-COVID pandemic. Many states and organizations have realized the power and expertise of community leaders that are providing that care. Community health workers, peer supports, contact tracers are being called to create a bridge between public health and our health care setting. Formally recognizing this expertise in creating pathways to become valued, permanent members of our health care workforce will be essential as we emerge from this crisis.
Giselle Corbie Smith:
And if you can move to the next slide.
Giselle Corbie Smith:
The third opportunity to ensure equity in a post-pandemic world is finding ways to reinvest in communities for recovery and resilience. The national and state level responses to the pandemic have revealed the fault lines between our public health emergency response system and our health care system. The appropriate emergency response of sheltering in place exacerbated and will continue to exacerbate chronic conditions. And these responses have put vulnerable patients who rely on our health care system at short term and long term increased risk for poor physical and mental health. As we rebuild in a post-COVID world, we need to focus on community resilience. Resilience in communities is a construct where we think about preventing, withstanding, and mitigating the stress of a community disaster or health incident like this pandemic. We need to work together to create an infrastructure so that communities can recover in a way that restores them to the sense of self sufficiency that's at least at the same level of health and social functioning after the incident.
Giselle Corbie Smith:
The next slide. Please.
Giselle Corbie Smith:
This diagram that the Rand and Robert Wood Johnson Foundation put together shows a framework to think about, community activities in a resilience framework, and to consider longterm recovery from disasters that leverage community strengths to manage other kinds of persistent and emergent threats such as severe weather and hazardous exposures, as well as how impacts of these events can be exacerbated by community vulnerability.
Giselle Corbie Smith:
The next slide, please.
Giselle Corbie Smith:
The community resilience model also allows us to see the critical role that health systems play as anchor institutions. How health care providers and health systems have an important role that can leverage the social and economic influence within communities that we serve. Reinvesting in communities to address these social drivers of health, like providing affordable housing and healthy food sources. Ensuring that the pipeline and pathways to our health care workforce, that we so desperately need in underserved areas, are actually coming from local community. How do we shore up that pathway and pipeline? By supporting the local entrepreneurs that can lead to a local supply chain. These are the all the opportunities for anchor institutions.
Giselle Corbie Smith:
The next slide.
Giselle Corbie Smith:
So as we end, I want to bring us back to this quote and prepare you for our audience participation. "There are years that ask questions and years that answer them."
Giselle Corbie Smith:
Can you move to the next slide?
Giselle Corbie Smith:
I want to offer you this idea of the 15% solution. These issues around health equity can seem enormous but what you need to remember is that 15% is always there for the taking. You can reveal the actions, however small, that anyone can do immediately. At a minimum we can create momentum and possibly make a big difference. A focus on the 15% of the solution that you can take reminds us that there's no reason to wait around feeling powerless or fearful. It allows us to focus on what's within our discretion instead of what we can't change. Each 15% solution adds to the understanding of what's possible. The idea that shifting a few grains of sand might trigger a landslide and change the whole landscape. So I'm going to ask you, since my time is up, I'm going to ask you to go ahead and chat in what you see as your 15% solution from your position of influence that would require no additional resources or authority. What's your 15% solution?
Giselle Corbie Smith:
The last slide.
Giselle Corbie Smith:
The questions about health inequalities have been asked for decades. What we've seen in the COVID pandemic is a wake up call for our nation. The reality is our country is only as healthy as those our system has relegated to the margins. And to be able to move forward to address health equity and ensure equity in a post-COVID world, we need to center the needs and interests of those that are on our margins. Our country will never be the same after this crisis. How we are going to answer in this time? We have opportunity now to ensure that no community, no individual is left behind as we emerge from this time. Thank you.
Kevin Larsen:
Thank you, Dr. Corbie Smith, that was terrific. We're going to move on to our next speaker, Leo Eisenstein. And after these two, then we're going to have a question and answer. So be thinking of questions for Dr. Corbie Smith and Dr. Eisenstein as Dr. Eisenstein speaks. So I will turn it over to Dr. Eisenstein. Happy to have you here and excited to hear about the work that you've done around algorithms in race correction. Thank you so much.
Leo Eisenstein:
Thanks, Dr. Larsen. And thank you, as well, to Dr. Corbie Smith for that excellent discussion of health equity and particularly, I really do appreciate the challenge to be able to look at the groundwater and to think about how to mobilize our own energy and resources in the fight for health justice.
Leo Eisenstein:
So today, I will give a short presentation on an article that I co-authored, which was published this past summer in the New England Journal of Medicine. My co-authors are Darshali Vyas and David Jones. I'll talk about the origins of the paper, some examples of our investigation, and I'll talk briefly about the response the paper has gotten and next steps.
Leo Eisenstein:
So it's titled, Hidden in Plain Sight- Reconsidering the Use of Race Correction in Clinical Algorithms. And as Dr. Larsen mentioned, I'm a second year medical resident at NYU and Bellevue Hospitals. I started medical school at Harvard in 2015 and this was just as the Black Lives Matter movement was starting to gain momentum. And in med school we were really galvanized by Black Lives Matter to look within our own institution and to seek out opportunities to promote racial justice. So following the lead of several Black classmates, we started a group called the Racial Justice Coalition and I was particularly involved with curriculum working group. And the motivating force for this group became this recurrent tension or even contradiction that we encountered in med school related to the concept of race.
Leo Eisenstein:
So on the one hand, we had our social science and geneticist faculty giving us the message loud and clear that race was a social construct and was not a reliable proxy for genetic difference. But then on the other hand, we learned from our clinical faculty that race was being used every single day in clinical medicine as exactly that, as a proxy or genetic difference. And as we delved deeper, we found that despite considerable advances in our understanding of race and genetics, physicians as a whole really still lack consensus on the meaning of race and so the result is this ongoing conflict between the latest insights from population genetics and the clinical implementation of race.
Leo Eisenstein:
So one of the most insidious manifestations of this tension is these diagnostic algorithms that adjust or quote/unquote, correct their outputs on the basis of a patient's race or ethnicity. So to orient you, I have given at the bottom of this slide as an example of how I'll see one of these race corrections in the electronic medical record of my current hospital. So I'm in the hospital reviewing my patients labs and a very common lab that we get is EGFR, which is an estimate of the patient's kidney function. And it shows up in my EMR as two values, and African American value and a non-African American value. And as a physician, I have the responsibility of determining which is the appropriate estimate for the patient in front of me. Now as you can see, the non-African American kidney function has been flagged as low. That's the 56. Lower than the 60 cutoff. And if it's low, then you know that requires further investigation while the African American estimate is registered as normal or below 60 and not requiring further investigation.
Leo Eisenstein:
And as physicians, we use these algorithms every day to individualize risk assessment and guide clinical decision. Our concern in the paper is that by embedding race into the basic data and decisions of health care, these algorithms propagate race based medicine. And the main concern we raise in our paper is that many of these race adjusted algorithms guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities.
Leo Eisenstein:
So to illustrate the potential dangers of these practices, we compiled in our paper a list of 11 such race adjusted algorithms in cardiology, cardio-thoracic surgery, nephrology, obstetrics, oncology, urology, endocrinology, and pulmonology. It's everywhere. And given these algorithms potential to perpetuate or even amplify race based health inequities, we felt that they merited thorough scrutiny.
Leo Eisenstein:
So the first example that I'll focus on is this one that we've already discussed a little bit, EGFR. And so, to give you just a bit of background, researchers have developed these equations that determine the estimated glomerular filtration rate, or EGFR, because it's hard to measure someone's kidney function directly so the developers found a more accessible measure called the serum creatinine level. And the EGFR algorithm takes this serum creatinine and converts it into an overall estimate of a patient's kidney function. And the algorithm results in, as I discussed, higher reported EGFR suggesting better kidney function for anyone who's identified as Black.
Leo Eisenstein:
Now, the algorithm developers justify these outcomes because there is this empiric finding of higher average serum creatinine concentrations among Black people than among white people with equivalent kidney function. So they saw a racial difference and thus decided it was appropriate, or even essential, to include race in their algorithm. What's crucial to note is that currently it's really unknown why this empiric finding exists. And initially, the explanations given for this finding included the notion that Black people have more muscle mass because creatinine is a direct byproduct of muscle mass and that was why there was higher serum creatinine. That's more of a historical point because at this point, no one is going to defend that extremely broad and problematic generalization that does exist in the literature. And analyses have formally cast doubt on that claim of muscle mass. So we now are stuck, in a way, with an empiric finding without a plausible causal mechanism and we're stuck figuring out how to navigate that.
Leo Eisenstein:
But currently the race corrected EGFR does remain the standard. And this is a problem, partly because Black people already have higher rates of end-stage kidney disease and death due to kidney failure than the overall population. So the potential consequence of this race adjustment is that it yields higher estimates of kidney function in Black patients. And if these are inaccurate, it might delay referral for specialist care or transplantation and lead to worse outcomes. And our position, basically, is that as long as uncertainty persists about the cause of racial differences in serum creatinine levels, we should favor practices that may alleviate health inequities over those that may exacerbate them.
Leo Eisenstein:
Now advocacy around this particular issue has gained a great deal of momentum. In 2017, we were successful with advocating with the Beth-Israel Deaconess Medical Center in Boston, change its reporting of EGFR and subsequently several hospitals across the country have followed suit, including Mass General, the Brigham in Boston, UCSF, University of Washington, and Vanderbilt University. And in fact, just recently, the National Kidney Foundation, the American Society of Nephrology have assembled a task force to study this issue and make formal recommendations, which we expect will come out in the next year.
Leo Eisenstein:
The other example that I'm going to provide is from the field of obstetrics and this tool is called the vaginal birth after c-section, or VBAC, algorithm. And this predicts the risk posed by a trail of labor for someone who's previously undergone c-section. This is an important tool because the health benefits of a successful vaginal deliveries are well known, including lower rates of surgical complications, faster recovery time, and fewer complications during subsequent pregnancies.
Leo Eisenstein:
The tool to assess someone's risk includes an adjustment factor both for African American race and Hispanic ethnicity and it predicts a lower likelihood of success for anyone identified in these categories. So people who are African American or identified as such, people who are Hispanic, are more likely to be steered away from a trial of vaginal labor.
Leo Eisenstein:
And one thing that's of note, is that the underlying study that produced this algorithm also found that other variables correlated with VBAC success and that includes things like marital status, and insurance type. But those variables were not incorporated into the algorithm but race was. This is concerning because non-white U.S. women continue to have higher rates of Cesarean section than white U.S. women. So the use of a calculator that lowers the estimate of VBAC success for people of color could exacerbate these disparities. This dynamic is particularly troubling because Black people already have higher rates of maternal mortality.
Leo Eisenstein:
So here, too, there has been a successful advocacy campaign and as you'll see on the right side of the slide, the developers of the algorithm are now developing a version without the race and ethnicity adjustment.
Leo Eisenstein:
So how did we get here? How did the researchers arrive at these race corrections and what do they say about the purported racial differences? Some algorithm developers offer no explanation at all of why racial or ethnic differences might exist. Others offer rationales but when these traced to their origins they lead to outdated, suspect racial science or to biased data.
Leo Eisenstein:
But in all the cases, we wanted to really emphasize that the researchers followed a defensible empirical logic. The examined large data sets that looked at clinical outcomes with patient characteristics and they performed regression analyses to identify which patient factors correlated significantly with relevant clinical outcomes. It's a very non-controversial strategy. And minority patients routinely have different health outcomes from white patients. So race and ethnicity often correlated with the outcome of interest.
Leo Eisenstein:
And then the researchers decided it was appropriate or even essential to adjust for race in their model. This, to us, is part of the problem. If race does appear to correlate with clinical outcomes, does that justify its inclusion in diagnostic or predictive tools? So, the relationship between race and health [crosstalk 00:49:03]. What's that?
Kevin Larsen:
We're nearly at time. Can we get you to summarize?
Leo Eisenstein:
Yeah. Yeah. So, we feel that given the complexity of the relationship between race and health, we feel that it's insufficient to translate a data signal into a race adjustment without determining what race might represent in the particular context. And particularly, most importantly, possibly, that racial differences found in large data sets most likely often reflect effects of racism. That is, the experience of being Black in America rather than being Black itself. And in those cases, race adjustment would do nothing to address the cause of the disparity. And instead, these adjustments deter clinicians from offering clinical services to certain patients, they risk taking inequity into this system.
Leo Eisenstein:
The last point that I'll make is that there's been a lot of momentum and there's been a lot of, sort of, interest at the federal level on these questions and while the advocacy momentum has been exciting, I want to end with an attempt to put this in perspective. And almost a bit of a warning. Because I think it's tempting to see the race correction issue as low-hanging fruit or possibly a technical quick fix that above all feels manageable and concrete rather than daunting and abstract as larger structural issues sometimes feel. But for perspective, the issued clinical algorithms only concerns patients who actually make it to the clinic in the first place.
Leo Eisenstein:
So, I want to try to keep in mind what's a larger driver of racial injustice: these algorithms or the inadequate access to care that racial minorities experience in our market-based health care model that fails to ensure health care as a human right. So as physicians and others in the health care system, I think it's good to recognize what is directly within our sphere of agency, like these algorithms but it's also crucial to reach for the higher hanging fruit, which is the groundwater, the social, political, and structural factors that cause such profound harm and perpetuate racial inequities.
Kevin Larsen:
Thank you so much to Leo and his research collaborators, excuse me. I would like now to introduce Aric Coffman, who is a fellow physician here at Optum. He is at OptumCare and Aric will be a moderator for our panel discussion that comes after this, so we will ask you to please join that. But he, at this time, will also help moderate a chat, a Q and A. Aric, are you there?
Aric Coffman:
Yeah, thanks, Kevin, for the introduction. Great to be here and really appreciate the first two speakers, just fantastic work and very, very inspiring. Leo, I'd like to go first to you, if I could, in a question, and maybe you could help me think through, I'm a front line clinician, at the point of care, and there's a part in the paper that talks through allowing that clinician to discern whether the correction to exacerbate or relieve inequities. And so, I'm curious, talk me through how you would advise a clinician at the point of care as they're thinking through the use of these measurements in their clinical practice, today, before we get to some of the answers that the teams are going to searching for over the coming months and years?
Leo Eisenstein:
Yeah, I think that's a really important part. It's a concern that's been raised to us before and I do think that a lot of the onus of this will be on the professional medical societies and the original developers of these algorithms to go back to the evidence and reassess because often times front line providers are too busy to do that ground work. But we do still maintain that front line providers can be, sort of, thoughtful evaluators of our tools and stay critical of the tools that we're using.
Leo Eisenstein:
And so, if I can, am I able to go just to this slide? This is the slide that does sort of offer our framework for how to evaluate. And I think that these questions can sort of spiral out of control to be overwhelming evidence reviews. But I think that the last one that you point out is the key one that I would want front line providers to take away. To ask yourself, does this tool that I'm using seem to be, given a patient in front of me, for example, a Black patient in front of me who's experiencing at baseline, likely a lot of health and other structural inequities, is this tool that I'm using protective for them or is it putting them at more risk? Either through directing attention or resources away from their care or assuming that they have a normal value when in fact there might be a fuller picture to assess.
Aric Coffman:
Thank you so much. Dr. Larsen, do you want to go with a question now for Dr. Corbie Smith?
Kevin Larsen:
Sure. Yes. Yeah. Giselle, you work extensively in rural communities in North Carolina. What are some of the unique strengths and challenges that you see in equity and health in those communities?
Giselle Corbie Smith:
Yeah, so going back to the participant who challenged me, it really did require us to rethink our intervention, to really build on the strengths in that rural African American community. What we know is that in rural communities that the kinship ties are very strong, that bonding social capital is a critical strength. In this time, we're seeing that people are finding different ways to connect with each other. And I see that as one of the key strengths. The opportunities there are really to build on that fabric, to be able to create those bridging social capital, being able to people like me, who live in Chapel Hill, an hour and a half away from the community that I work with. So that, in the setting of disaster I can be able to provide, sort of, all the sort of support that is available within my network and create that bridge to their network.
Giselle Corbie Smith:
So I think it's been exciting and I'm a city girl, I grew up in New York City, and yet have come to really love the work that we've been able to do together in rural North Carolina. So, yup, that's what I would see as the strength as well as the opportunities there.
Kevin Larsen:
Thank you.
Aric Coffman:
Great. And Giselle, there's also been a ton of focus on championing diversity and inclusion programs as one part of the path to equity. How much of a focus should that be and can you help us understand the differences there?
Giselle Corbie Smith:
Yeah, thank you, Aric, for that question. So, I do think, obviously, diversity is going to be important, not only because I'm a Black female physician, I'm not totally self-serving, but because what we know is that when we have diversity of perspectives, whether that looks like that is due to our social identities or any other ways that we're diverse, our disciplinary focus, our inner professional focus, our geographic identities, that all of those lead us to better answers to complex questions. And certainly this is a complex question.
Giselle Corbie Smith:
However, diversity is not the same as health equity. Right? Diversity is important but not sufficient for us to get to health equity. As illustrated by the same story that I just referred to, even as a woman of color in this space doing health equity work, I've been trained in an environment and a system that has a particular perspective that I internalize. And in my early work started, incorporated into my research. And so really interrogating the systems that we're in, the values, practices, norms, and policies and how that can be shaped and reoriented towards equity is basically how we design in this systems approach to equity.
Aric Coffman:
Okay. Thank you so much.
Kevin Larsen:
Thank you all very much. We are out of time and need to move on to the panel discussion portion of this conversation. So, if we were here in the room we would all give you big round of applause but thank you, thank you again. For those who want to ask some questions, Dr. Corbie Smith will be part of our panel discussion Q and A. So we're going to move to the second part of the program. We'd ask all the audience members to click on the join part two link within the call to action widget, on the top right hand of your audience console, and that should take you to the second portion of the event. We'll ask you all to join that now and we will be taking a short break and then we'll be starting back in again in about 10 minutes. Thank you very much. Excuse me, in five minutes. We'll be starting again at five after.
Kevin Larsen:
Hi, it's Dr. Kevin Larsen, welcome to part two of today's webinar, designing in health equity to make our system work better for everyone. I apologize that we're starting a little bit late. We are still getting a couple of our panelists onto the platform. So there's some work behind the scenes to get the panelists live with their cameras. I'm your host. Our moderator today will be Dr. Aric Coffman and he is the vice president for OptumCare in the Pacific Northwest. Aric, I'll turn it over to you to introduce our panelists.
Aric Coffman:
Great, thank you so much Kevin, and thanks to everyone who joined the first session. It was a fantastic session, and we're excited about this one as well. In this session, we're going to hear from four additional thought leaders with their perspectives and will touch on different parts of the health system, as well as our communities. Each speaker will spend six or so minutes presenting their thoughts, and then we'll follow up with a question and answer session. Today I'll be introducing first, Dr. Ana Fuentavilla, the CMO for Optum Population Health Services, and she'll be kicking off with the first presentation and she'll be followed by a Atum then Elena and then Chyke. We're really excited about the presentation. So let's go ahead and get started, Anna.
Ana Fuentavilla:
Thank you so much Aric, I am one of the people having technical difficulties, so I'm still not on camera and I can't advance slides. So if I could ask you to advance the slides for me, Aric, I appreciate it. And I appreciate the opportunity to join my seen fellow panelists in a very important discussion and where I get to share with you, the actions that we're taking at UnitedHealth Group and Optum to design in health equity, into everything that we do. And if you'll head over to slide four for us Aric, that'd be great. We really do, as Dr. Corbie Smith was mentioning during her excellent presentation, find ourselves in this unprecedented health crisis that requires us to take action to really ensure timely, compassionate, and equitable healthcare for all.
Ana Fuentavilla:
And we really do believe at Optum and UnitedHealth Group that advancing health equity really helps make healthcare better for everyone that we are privileged to serve. So it's really a top concern for us and a focus at UnitedHealth Group. And I would say it really is fundamental to our belief and Dr. Corbie Smith mentioned those words that we leave no community behind. So no matter race, gender, ethnicity, sexual orientation, age, whether you're living with a disability and what your ZIP code is, or your educational level, we believe we really have to be deliberate about leaving no community behind. So I'm going to share with you our progress towards equity at UnitedHealth Group and Optum, and I'll start with our internal efforts. And I'll start by saying that for years, we have been working with some of the partners on this panel to really be intentional about improving health equity for the populations that we serve.
Ana Fuentavilla:
But we have a renewed commitment that I wanted to share. Some of our internal work will be driven by this and that is to advance inclusion, diversity and health equity through some deliberate steps. And the first is, looking inside of the UnitedHealth Group, where we are intentionally making sure that we have a diverse workforce at every level that is reflective of the populations that we serve across America. And that means frontline workers to entry level employees, to our highest level of leadership. We also are committed to continue to provide fair and equitable pay to our employees. We're committed to operate without bias, and that is work underway, of making sure that data and analytics and processes are not biased. And that if we identify bias that we quickly turn that around and remove it. We continue commitment to enable a diverse workforce for the future, for the 21st century.
Ana Fuentavilla:
And Dr. Rios and I have been partnered on this for some time through an initiative I'll tell you about in a minute. So that is our North star and our commitment to this important equity movement forward for a UnitedHealth Group. So let me share with you a few examples of the actions that we're taking toward this commitment. And the first is our competency training, cultural competency training and unconscious bias training, not just for our staff across our enterprise, but we also are sharing that with[inaudible 00:04:41]. In addition we have deployed guidelines for the responsible use of emerging analytics and artificial intelligence to be sure that we mitigate bias and that we actually point analytics and data to create greater equity intentionally.
Ana Fuentavilla:
Another commitment that we've made is actually encouraging and really challenging our employees across our businesses to hardwire equity into all of our business models and programs. And one of the teams I wanted to highlight is within OptumInsight, where they challenged their staff with a do good now health equity challenge, and the first team to win in OptumInsight in this awesome challenge was the team that was focused on unconscious bias. And they developed a four part approach where they were really working through community partnerships, provided training on bias, member advocacy materials, and created a bias response team to help patients or members. And it was a great way to make it fun and allow employees to really drive health equity into everything that we do. Another example of important internal work focused at diversity inclusion and health equity is our social responsibility commitment. We have a leadership team that really encourages that our employees volunteer within their communities, volunteer to help in desperate communities, their time and talent.
Ana Fuentavilla:
And we provide time and support for some of that. One example of that is the work that I was able to do two weeks at the beginning of June on the Navajo nation, where I served on the front line, serving Navajo people and families with COVID exposures and infections. That's one example. Another important work that our social responsibility commitment led to, was the deployment of an initiative at the beginning of the COVID epidemic called stop COVID initiative, where we pointed our talent, our resources towards the hardest hit communities like Los Angeles or new Orleans and Philadelphia, and provided communities that were hardest hit with testing, and food supplies, and COVID related supplies to protect families in the most need. So those are some examples of our strong commitment towards social responsibility as an enterprise.
Ana Fuentavilla:
And the last thing I'll mention is our Equity Advancement Board. This is a team that will lead together across our enterprise, 16 diverse leaders from UnitedHealth Group, UnitedHealthcare and Optum that are going to really drive and accelerate our progress and ensure that we operate with equity and bias free, and all aspects of our organizations, really examining not just our diverse workforce, but processes and systems to avoid bias and reach equity. So those are some examples of our internal work. If you move to the next slide for me, please, Aric. We've got a lot of effort externally and we've made a lot of progress. We really have mobilized and leveraged our business assets, capabilities and scale to further equity with examples across Optum advisory board and their research, Optum labs and their data analytics, as well as OptumInsight. The work that United Health Foundation has done with America's Health Rankings and our partners there. Those are some examples of business areas that are really working to advance equity, but we feel that the most important part, not just looking at our own programs is really developing and working with key partners both locally and nationally.
Ana Fuentavilla:
So let me share with you... Well, first of all, we're looking and always looking for those partnership opportunities to advance equity, but let me give you some examples of current work, and I'll start with the area of maternal mortality where women of color are losing their life during childbirth or surrounding childbirth four times more often than white women in America today. And so for the last several years often and the UnitedHealth Group have been partnered with CMS, with the CDC, with Health and Human Services, with National Healthy Start, with March For Moms and with several local healthcare systems to save lives across our women of color communities and examples of the work in this area have been local grants provided for community outgroups, outreach, excuse me, work with Morehouse School of Medicine on racial bias training, work with Health and Human services to develop a safety checklist for hospitals and advocacy with the joint commission that really led to the joint commission requiring that all your hospitals implement safety projects around hemorrhage and hypertension around delivery.
Ana Fuentavilla:
We've also recently deployed projects around hypertension and Intimate Partner Violence that we're very excited about that partnership in the Northeast. Other examples of key partnerships, again with Morehouse School of Medicine is we are looking at the effect of COVID in individuals living with sickle cell trait, which is very prevalent in the African American community. We've partnered with the Yale School of Medicine, looking at racial disparities in the use of ACE inhibitors in a clinical virtual trial, which we believe is the first of its type. We've done some really important work with Boston Scientific, Medtronic and University of Minnesota around the pandemic, in the development and deployment of light ventilators to really respond to the inpatient need for ventilation services. And I've got many more, but I'll stop with one more example, which is partnerships with local health systems, and specifically I'll call out John Muir Health in the California area where, as you remember, the California market was one of the first States to be really hit hard by the pandemic and continued to be throughout the summer.
Ana Fuentavilla:
Well, we were able to partner and accelerate the tele-health capability for John Muir Health in virtual visit capabilities to really help them not through that initial surge, but through the remainder of the spikes and surges they had through the summer. So those are some key examples of what we think are critical partnerships that will make this sustainable for the future to really create health equity. A couple more things I'll call out, and that is the partnership around creating a diverse workforce for the 21st century. And I'll tell you, we're very proud of our Diverse Scholars Program at UnitedHealth Group. One of our partners is Dr. Elena Rios, who's one of our fellow panelists. This program has been in effect for over 11 years. We have sponsored hundreds of diverse scholars into the health professions and we are committing to by 2025, increasing the number of college students in the Diverse Scholars Initiative, and really actually launching a new program to help students as early as middle school to pursue interests in the STEM fields or the health professions.
Ana Fuentavilla:
And then lastly, I'll mention we are very committed and in a very strong relationship with INROADS internship organization where we encourage our own staff team members at all levels to serve as mentors, sponsors for promising talent. And we believe that these two initiatives are really key to developing a diverse workforce for the 21st century, which is an important part of health equity[crosstalk 00:12:32]
Aric Coffman:
[inaudible 00:12:32] Thank you so much
Ana Fuentavilla:
[crosstalk 00:12:32] and I return it back to you Aric.
Aric Coffman:
Great, thank you so much, and I think we're gonna shift now to Elena Rios, who's going to speak to us, I think, on some things around family, Elena.
Elena Rios:
Yes, you can go[inaudible 00:12:57] I guess I advance the slides here. I think what's really important about Latino health and the importance of reaching health equity among our underserved populations, or as was talked about earlier, marginalized patients is that we really need more trust. We need to build trust whether it's for research or prevention or health services. So these are just some of the items I think that are important to consider as we design in for the future, with the COVID-19 pandemic all around us. First we really do need more education and it is about prevention education for family wellbeing. And that means we have to really think about the digital divide that exists and having technology that is usable, or that is realistic, that is affordable.
Elena Rios:
Many Latinos have cell phones, but may not have computers. So we need to think about that in healthcare delivery for home care, especially in monitoring of our patients. The second thing is we need a real thinking about the affordability of comprehensive insurance reform, and that means everything from having a public option subsidies for the insured population, having to really improve upon our employer insurance problem, not problem, but basis for insurance. As many, many people lose their employment, they are going to be losing their employer based insurance which is something that a lot of families have always known. And they need to be told how to get into the Exchange or Medicaid or Cobra, et cetera. And then the expansion of Medicaid, I think, is something that we really do need as a country to think about.
Elena Rios:
How do we make that happen in the States that have been politically saying no to the Medicaid expansion? It just makes a lot of sense. Medicaid is now the biggest insurance program in our country. And then lastly, just to make things I think more comprehensive, we need mental health benefits, more so than ever before. And then we have to think about climate change. Climate change for the future, for our children, for grandchildren. I think that is something that our families are starting to realize more as we have more wildfires in the West and the hurricanes in the East et cetera. And then of course, there's the importance of relating our vaccine uptake especially for adults, which we know are the worst off when it comes to the COVID pandemic.
Elena Rios:
That we have to increase the flu vaccines and at the National Hispanic Medical Association, we have been involved with campaigns for several years with CDC and ASTHO with the office of minority health, giving vouchers to some drug pharmacies like Walgreens way back when H1N1 happened and more recently with some of our partners like Santa Fe and Anthem. And I think it's just very important that we start educating people about why you take a vaccine and the importance of vaccines and other medications. And then we have to build our public health infrastructure. And I think the trust in our communities... When I grew up, we had public health clinics and we had actual health delivery through the clinics, not just what's become a public health surveillance system and database system.
Elena Rios:
And then lastly, innovation, Spanish language, comprehensive diabetes, hypertension, home health packages that get delivered to the home. And then the second thing I wanted to mention was, as Anna mentioned, we are very grateful to the United Healthcare Foundation's support for a Diverse Scholars Program, which has really been a mentoring program and a scholarship program for students in health professional schools. The different groups that get the funding target different levels of students. We believe in targeting students who are already in those health professional schools, nursing, dentistry, public health, medical school. This year we're adding physician assistant programs as well as pharmacy school. And I think what's important to us is that there are very few Hispanic students that make it into higher education and then into graduate school, which all these health professional schools are considered. And it's important to support them within our family of the National Hispanic Medical Association and our foundation to be able to mentor them.
Elena Rios:
And what I have here is we have a grant from the office of minority health, where we're actually doing a research study on mentoring of college level students who are very interested in health equity, and they're not all Hispanic, but the majority are. And just to share with you some of the contributing factors that we put into the proposals, that they don't have role models, they don't have peer support or family support, and they come from low income, don't know anything about financing higher education. And then you see that they have... Our strategies really are to look at personal development, academic development, and financing on some of the measures that we would look at [crosstalk 00:18:44] Okay, I'm going to wrap up here. I think what's important to realize that at each step of the individual, the Hispanic population and the professionals at each level, there are measures that we can actually show that improve with mentoring.
Elena Rios:
And I'll just end with I think some of the value of having mentoring, is having individual needs assessment but also bringing together a group vision that it is important to give back and to go into primary care, or to go into community based research, or go into academic careers with an eye towards leadership and with more leaders that have the same vision that we can mentor. I think that, that's how we're going to have a more equitable healthcare system, with leadership through our Hispanic and African American, native American to professionals for the future. And they are very interested in doing so, thank you.
Aric Coffman:
Thank you Elena, I appreciate it. We're now going to move to Chyke. Go ahead Chyke, you might need to unmute.
Chyke Doubeni:
Yeah, thank you. Well, thank you for inviting me to be part of this panel. Is quite an honor to be here, to share with you and learn as well as many speakers have gone before me. I am privileged to be the inaugural director of the Mayo Centre for Health Equity and Community Engagement Research. And also I should share that I'm the director of National Center for Integrated Behavioral Health in primary care supported by HRSA, that advances the models of training in IBH in primary care. What I want to share with you is, in some ways I hope bringing together some of these streams of conversations. I'm going to walk through this slide and hopefully get to the next one to get us some time back. And basically in essence we talk about inequities, so health disparities, but thinking about it from an equity lens. These are systems and structures that are created in place, and have been perpetuated over time, but more importantly, they affect the care continuum.
Chyke Doubeni:
And I'm going to talk a little bit about a care continuum, and then in a section between that the social and behavioral factors that affects there were continuum care, which leads to unfortunately inequities and disparities and all of the outcomes. And I must say that this is personal to me as a black man oppressed, one of the highest risk of dying, just about anything you think about, but also many times you get that same soap being at target though targeted. So is very personal to me. The first piece of this is all mostly about health professions education, I know Giselle has covered a lot on this and many have covered I'm not going to go into the details of it. What I do want to emphasize is the importance of institutional culture and the design of the training environment that informs training. And why is this important? Because a diverse workforce, as we know is critical to health equity.
Chyke Doubeni:
Now, If you go forward a little bit from this, this design and creates a structural barriers and these avoidable variations in the quality of care, which leads to these gaps in the continuum of care. So as many of you know, I am a member of the U.S. Preventive Services Task Force. We're fortunate to now have created a racism task force within the U.S. Preventive Services Task Force to deal with many of these issues, and to the point it's about racism, not race. And how do we deal with this in the context of progression? From the position of Optum, I put this predictive analytics because it's important because that's how intuitively we as clinicians identify those who are eligible for screening or any service to clinical cirrhosis, then how to receive the services, then keep receiving it at the right time and right pace. But more importantly as I'll show you, is that the fault lines that occur through this continuum of care at multiple steps contribute to disparities that we need to address.
Chyke Doubeni:
It's not just one thing that we need to fix. It's multiple things and it's a system's change that is needed to do so. And unfortunately, with the social factors that affects communities of color, these become insurmountable barriers. Sometimes I look at it as a glass wall, you can see what's in front of you. You want to get it, but you can't because of the barriers that exist. Now, if you think about the broader picture of this, Data is all, that's the most important because without data, we can't really assess quality. It's all kidding in insights. That's really important. And Optum is still in a good position to fix this. And performance measure is so important because clinicians respond to these policies, incentives, resource allocation, social injustice, all of this, almost like a top layer affects the delivery of care and receipt of care.
Chyke Doubeni:
Now, what is also very important is community integration and engagement because without a community involvement oftentimes these things don't get[inaudible 00:24:04] and mistrust is magnified, right? So let me spend just a few minutes then I close here. In this slide, you see, outlined processes of care regarding colorectal cancer screening. This is the study we performance that show that each of these process falls leads to consequential outcomes. One, for instance, they don't get screened. That leads to its own outcome. There is still the differences in this case control study. And what you see that's most important here is this. And what I want to highlight is this, what we found here is that someone gets screened. This is fecal occult blood test. The test is positive. Many patients do not get diagnostic testing. And that leads to very high risk of death.
Chyke Doubeni:
And so to design healthcare well, we have to understand all of these steps in the care process, identify and fix them. Now, this is one of the scenario. I wouldn't go into it, but the findings are stated. What we also find is that when the quality of care is good in a [inaudible 00:25:08] environment, you also find those disparities, which means people are being treated differently [inaudible 00:25:13]
Aric Coffman:
[inaudible 00:25:13] A call difficulty there.
Kevin Larsen:
Chyke, are you back with us?
Chyke Doubeni:
I am back, yes.[crosstalk 00:25:45] So thank you. I am done.
Kevin Larsen:
Wonderful, this is Kevin, unfortunately Atum, our other presenter has not been able to successfully connect. So, but we are happy to have Ana on video now. We will move into the question and answers. We have a few prepared questions. We'll have again, invite Dr. Corbie Smith to be back on with us. I would please ask you to send some of your questions in, if you have questions for this terrific panel. Aric, do you want to start?
Aric Coffman:
Yeah, sure, I would love to hear from the panelists and thank you so much for your presentations and work again. It's very, one, inspiring and two, instructive on some of the things that we need to be thinking about, could one of you take on the question and it could be more than one, Technology is becoming a bigger part of our everyday lives and what are some of the things that we need to address with technology to prevent widening of the existing gap with health equity and potentially even narrow the gap? How would that work?
Giselle Corbie Smith:
Well, I'll just underscore... Thanks Aric for that question, I would just underscore that we have this opportunity now, a window around broadband access. And certainly it's one that we're trying to push through in our state to ensure broadband is accessible and affordable to every person in North Carolina. I believe that, that would not only address the issues around access to care for at least some of the issues around access to care, but it actually addresses other equity issues. It addresses the educational equity issues that we're seeing in such stark relief now with our children and even college students that are not enrolling this semester because they don't have regular and reliable and affordable access to broadband internet.
Giselle Corbie Smith:
It would potentially address and hopefully mitigate some of the access issues for entrepreneurs in rural communities where we're seeing sort of the aging of the workforce and shrinking opportunities for... Well, also on top of that, the social issues of over policing in minority communities that might make it difficult for people to... If they have to check a box they've been involved with the criminal justice system. This allows them to have an online presence, allows entrepreneurial efforts, allow access to this knowledge economy that we now have as opposed to a labor economy that we're evolving from. And so for me, I would suggest that access to broadband would be one of the major policy advances that we could actually have in our country and certainly locally, geographically.
Aric Coffman:
Thank you, do we have any other thoughts on that [inaudible 00:29:03]
Elena Rios:
Yeah, I have one... Dr. Rios here I think telemedicine and health monitoring of our patients is something that needs a national guidance. The laws right now for licensing of businesses and telemedicine are really state by state and that whole interoperability focus of the office of the national coordinator, HHS was to create a movement to get to that, but it hasn't happened. I think with COVID-19, we're going to see much more of policies moving forward. I think telemedicine is going to be very important. We have robotics, we have project ECHO in our rural communities, lots of opportunities for telemedicine or telehealth.
Chyke Doubeni:
Aric, [inaudible 00:30:07], can you hear me?
Aric Coffman:
Yeah.
Chyke Doubeni:
So I agree telehealth and broadband access to key SMR for [inaudible 00:30:16]American partners that highlight the importance of broadband into a community. It's not surprising. But one of the other things that I want to emphasize is we're leveraging a towards technology use in healthcare. And as Giselle pointed out, this is a challenging time for many in our communities. So one of the important area is in community engagement,[inaudible 00:30:45]So I don't believe our community is actually afraid of [inaudible 00:30:53]technology, but they are dominating engaged in a way that allows them to leverage this in an effective way. I can tell you early in the pandemic I was watching my wife, [inaudible 00:31:03]primary care physicians. And because I have more of an administrative role, I have a privilege just watching her and the challenge that it had, over time, this got more used to it.
Chyke Doubeni:
But another important thing here is access to care. As though we've talked about the Optum algorithms and all the potential that we have and using digital technology, to leverage and understand health and promote health. We cannot use though if we don't have enough data input from our underserved population and that is critically important. So I think it's a multifaceted approach that we have to take. We're thinking about leveraging technology for RPM, Remote Patient Monitoring, all of those things around technology and [inaudible 00:31:48]
Aric Coffman:
Great, Thank you for that.
Ana Fuentavilla:
Ana Fuentavilla, I'll add one more comment, really agree with all of the other speakers and their reflections. I would add to the last, which is tying back as the importance of broadband with telehealth services to expand access to care in a way that's trusted by the individual community. So I think there has to be a translation either with local trusted partners, but also in a way that it's culturally appropriate for that community, whether it's the native American community, Latino community or black community. So I think that's part of what we haven't figured out. It's not just about language, but it's also about will they use it? Will they trust it? Who can help them with it? All of those things.
Kevin Larsen:
This is Kevin, I've got a question. A number of you have talked about racism and that's, that's actually a word and a topic we don't often actually say out loud, there is racism in our country and racism in the system. What can we do? What should we do to really address racism as an issue?
Chyke Doubeni:
I can start. But I thought that Giselle made a wonderful job of talking about how we address it. To my mind, I'm not sure there is a right or wrong answer or right or wrong approach, but what we know is important is this, I think we have to first of all recognize the excess and know that's a problem. The second and most important thing that I believe is to be intentional. I'm a black man in leadership positions in academia, and I can tell you, I've seen it all. And the other piece that's also important, so it's not about inclusivity, right? So inclusivity seems like really nice words, but what's also important is that people should be at the table because if you're not at the table, not only don't you have the ability to change the perceptions of people, right?
Chyke Doubeni:
So if you go back to kind of plant experiments on how people sort of ingrained this idea that we are inferior. So we behave inferior, or they look at us as inferior, all of those things can be changed if we're intentional, right? Recognize the problem and make sure that the diversity and inclusivity in a leadership, not just having people who look black, but also people who are in leadership that actually are from diverse groups, because then it brings the perspective, but also begin to help the organization change culturally. That when people see those diversity on top, they'll say "Oh, I can be there." It's really empowering in my view to have that diversity and inclusivity.
Giselle Corbie Smith:
Yeah, I would thank you for that. And I would add naming it as has already been said, I think being willing to use the term racism and to be able to call it for what it is, is critically important. It starts the dialogue, the willingness to be uncomfortable by saying it there's no comfort in the growth zone and no growth in the comfort zone. And so you have to be willing to be uncomfortable. And because that's where the change happens. That's the leading edge of change. I think the other thing is once that's been named it starts to, again, reframe, how can we have our organizations or systems and organizations adopt an anti-racist analysis Ibram X. Kendi's book, How to be an Anti-racist, is a phenomenal workbook really about how to think about an anti racist, not being a racist is not enough to be able to address racism.
Giselle Corbie Smith:
You have to be willing to be anti-racist, to be able to look at... Our young colleague Leo, so pointedly points out, you have to be willing to look at the outcome you want and identify the path to get there. And if what we're doing is creating... The systems that we have are exquisitely designed to give us the outcomes that we are getting. There's no mistake in the system. We have to decide we want a different outcome and design in or reverse engineer our systems to create what we need and what we want, what our patients need more.
Aric Coffman:
Great, thank you for that question. Any other comments from the panelists?
Chyke Doubeni:
Mayo clinic, as I shared, maybe not in the rush of the presentation, invested a hundred million dollars, about 10 years to address issues of equity, diversity, and inclusivity, and that is across all the mission areas of research, education, and efficiency. One of the things that I would probably applaud Mayo for doing this is that we're the people who are actually tasked with implementing this, not the leaders. So the leaders meaning the CEO, the board of governors, [inaudible 00:37:23]hospitals, and what we call the chief leaders ask the leaders.
Chyke Doubeni:
And that's important because I think it sends the message that the system takes us seriously. It's going to be uncomfortable. And this is going to be a very uncomfortable thing. We've also launched what was called everybody in campaign. Everybody in campaign is basically what it is. That everybody stand and we're going to talk about it and we're going to still feel uncomfortable about it. Mayo did something else that's symbolic. We closed the doors to the former building for those of you who know the former building, we closed the doors. They may not mention I stood outside and re-opened them to an Anti-racist new Mayo. That's a lot to pick on, wish us good luck, right? And to Giselle's point, the symbolism is important but outcomes are actually what are more important, right?
Aric Coffman:
Thank you, we have a question from the audience. Oh, great, we have a question from the audience. I think Dr. Corbie Smith, you mentioned it over policing and this question asked if you could define over policing and explain how it impacts health inequalities.
Giselle Corbie Smith:
That's a great question. And so I'll give you a couple of examples. There's been a recent push to recognize police violence as a public health issue. And I think if define a public health issue as one that, where there's been unacceptable morbidity and mortality from a condition, then I would suggest that this is in fact, a public health issue. And the over-policing, over surveillance of black and brown communities for any of us that have driven while black or brown and understand what it means to be pulled over for no reason, targeted for no reason, the immediate trauma of that and the vicarious trauma in families, I think is a critical issue. However, the other thing that we're finding now in the COVID-19 pandemic is that the transitions and interactions with the criminal justice system by being arrested, put in jail, even released, being arrested, put in jail, tried and be incarcerated.
Giselle Corbie Smith:
That cycle of coming in and out of communities has led to outsized the risk of COVID-19 and coronavirus infection in communities that are overpoliced because individuals in those communities are more likely to have interactions with the criminal justice system. And we know that those congregate settings I've put everyone, not just the individuals that are incarcerated but also those people that work in those settings at increased risk for coronavirus infection. And in fact, some of the first sort of blips above the radar were amongst those people that worked in the criminal justice system. And they're increasing rates of Corona virus that were as sort of the Canary in the coal mine, to be able to understand that we had this new wave coming in our criminal justice system.
Giselle Corbie Smith:
So that's just one example. You know our colleagues like Emily Wang at Yale and Laura Brinkley-Rubinstein at UNC, David Rosen at UNC have been able to demonstrate the increase in chronic morbidity and mortality of individuals that are in an experienced the criminal justice system. There's so many ways that over policing can lead to increased morbidity and mortality in black and brown communities.
Aric Coffman:
Another question from the audience, Kevin, if you don't mind, I'll go ahead and tee this one up. This one says, what guidance can you give researchers that want to study the effects of inequalities and racism in large data sets like Optum's to identify opportunities for systemic change i.e. stratifying by race is not enough and may even lead to reinforcing race as a driver of outcomes.
Chyke Doubeni:
I mean, that's a loaded question, but maybe taking that step back in minutes is I just want to also say that keeping in mind that a black person who has a clean record is less likely to be employed than a white person with a criminal record. And so if you think about that first and think about a black man who has been arrested because of over policing, whether it was right or wrong you were in trouble, right? And so you now have to greater involvement to recidivism that leads to adverse health outcome, if anybody doubts the effects of low educational status, low income status, and the relationship within those and health, the one single thing that is the strongest of all, I'm not sure that I have a good answer to that question except to say that I think we have to look at that data with some skepticism, just because we don't know with certainty about what those things mean.
Chyke Doubeni:
But what they can tell us is to be able to look at data that actually identifies racial groups, social economic groups, geographic locations, because of desegregating data is really important for us understand them. Now I would encourage and this is selfishly, I will make a pitch, but the fact that we have to look at the continuum of care is not just about looking at someone, got a service, yes or no, what is a quality of this service?
Chyke Doubeni:
And let me give you an example, a colleague of mine and we did a paper that was published in new England journal of medicine. And of course it is these that I'm most familiar with, but which black people and native Americans that probably highest risk colorectal cancer, what is the price? We did a study that essentially showed that and many of you know this, that if you get your care from someone who has lower than normal detection rates, meaning the lower quality of screening, right? Your risk of colorectal cancer, and dying from it is higher for a disease that is preventable. That's what explains product variation, even the higher quality care.
Chyke Doubeni:
So I think looking more deeply into the process of care, not just saying yes, no, what is really the quality of care you get within those settings is important. You can get at it with discrete data, but I think it's important to pair this with more qualitative data that allows you to take a deeper dive in it. And that to me is the most important thing. Don't just look at the numbers because numbers can tell you any story you want to tell, you have to look more deeply than that.
Elena Rios:
One of the things I would add is to look at data that describes the asset model in our communities. And again, that was the focus of why we have to look at social supports and family, too often we're looking at the negative aspects. But I do think we need to start thinking about how to create that data into the racism picture of might be from customer satisfaction, for example, or a patient satisfaction. What is it that drives them back to go to a doctor or a nurse or clinic. And there has been studies about black and Latino doctors and dentists often see black and Latino patients. Is it just because they're going back to their home cities? Or is it because they naturally attract them? What is it about that attractiveness? What is it that happens? Anyway, there's a lot to be learned about the asset model, positive side.
Chyke Doubeni:
I don't want to take a negative tone to this but it's again a pet peeve of mine. And I want to also step back for just a minute. Maybe you can get this with often lab data. We know that a lot of people serve populations, get their care from impoverished communities, improper setting, federally qualified health centers, right? And in my mind, if we're going to change the outcome, it's going to change the future. We have to invest in those communities. We see those assets on how do we improve the care. And one of the most important things that I believe we can do is that people can and should get the care they deserve wherever they get the healthcare. And that has to be a lens through which we look at this because if we only invest in sort of in just the Mayos and the UHCs and PANs, we'll never get there. Majority of people we want to lift up in this process, get their care from this settings, in which resources are really scarce. Look at Alaska for instance, look at all black people, it's really hard to get care.
Chyke Doubeni:
So I think we have to look and see, where do we get a more holistic data? How can you invest to get a better sense of the experience? If they only get care, but they don't people who have insurance, they're missing a good source. The large source of people who don't have access to that. So you're looking at a real picture, but you're looking at a picture that is somewhat tilted towards those who have perhaps a little bit more resources at their disposal.
Aric Coffman:
Thank you for going there, very much. And I think Kevin we're now at time, I want to thank all of the panelists and our speakers and our other speaker who's not here now, this has really been fabulous and rich in dialogue, and it just seems like we ran out of time. We have so much more to do, and so many more things to discuss, but I just want to express my thanks for each one of you and your contributions today. Thank you.
Kevin Larsen:
Thank you and I want to thank a to Atum Azzahir here who unfortunately were unable to get her connected. But I'll put a plug in. She is the CEO and founder of a terrific organization called the Cultural Wellness Center in Minneapolis, that really brings together the community assets and works at this place of strength from the community and the strength in culture and the strength and wisdom of the culture. And how does the community work at using those assets and letting them grow and flourish and reaches into healthcare as opposed to healthcare reaches into the community. So hopefully we'll get a chance to have her speak in a future time, her slides will be included in these presentations. Again, thank you so much for the group that was here.
Kevin Larsen:
This was a terrific conversation. We'd like you all to please complete a brief survey by clicking on the survey widget at the bottom of your audience consul. And we really hope that you'll come and join us for the next four webinars and our connect 2020 mini series over the next two months. The next webinar is entitled integrating behavioral health to the quadruple aim that will take place on November 4th, the day after the election. We hope to see you all there and thank you again.
Action plans for social justice
Addressing health inequities demands a multi-faceted approach. Learn about multiple solutions, including embedding health equity into organizational culture, enhancing training and mentoring opportunities, and improving accessibility to preventative services.
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Towards whole health and integrated care
Most individuals with mental health disorders do not get the formal treatment they need. This session offers ideas for closing the gap in behavioral health care, including implementing an integrated approach and utilizing measurement-based care.
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Kevin Larsen (00:00:02):
Hello, I'm Kevin Larson. Welcome to connections 2020. This is Optum labs research and technology forum, virtual session. And today our virtual session is integrating behavioral health to drive the quadruple aim. We're very excited to have a series of prestigious panelists from across the country and some from within optimum United. Um, I'm pleased to be co-hosting this with, with, um, uh, dr. Robinson Biel from Rhonda Robinson Beal from United health group. And, uh, this session will be split into two portions today. The first portion will be a series of keynote discussions with the Q and a, and at the end of the hour, we will transition to a panel discussion with much shorter introductions in a more robust conversation with you as the audience. Um, the, just a quick highlight about who we are at Optum labs. We are a research health services research and innovation group is that as part of United health group, we partner with a lot of internal and external organizations to drive, um, new scientific discovery and new innovation using our data, uh, as a feedback mechanism into healthcare in general, uh, with a goal of new discovery and publication in the scientific literature, here's a list of many of our partners.
Kevin Larsen (00:01:37):
You can see their government, uh, academic organizations, groups like ARP, and MCQA, there are overall five sessions in the, this series of connections, 2020. Uh, we had our first session a couple of weeks ago. It will be soon be available for you to look at, um, uh, as a video that was a terrific session in designing health equity to make the health system work better for everyone today's integrating behavioral health to drive the quadruple aim. Uh, next we'll have the, uh, virtual ideas exchange coming up, uh, in the week. This is a abstract meeting to highlight some of the best research that's come out of our collaborative in the last year, the following week, we will have living better through health in the home. This is a really tiny in this COVID age of everyone working remotely and all sorts of telemedicine, home monitoring, et cetera. And finally, we'll be presenting a session on chronic kidney disease, innovation and the polychronic population. Uh, in the first week of December, we welcome you to all of these sessions.
Kevin Larsen (00:02:47):
Here are a few reminders. Uh, you can expand the slide area by clicking the maximize icon on the top, right of the slide, or by dragging the bottom corner of the slide. Um, there is a Q and a widget on the side to submit questions. You can also click the help widget for technical support, and you will, you will have, um, response in the chat. As I mentioned, our webinars in two parts, uh, there will be a little loading widget on the top of the screen that says, go to part two now for you to join the second part of our program at that time. Um, we can only have a certain number of presenters, uh, live. And so we have this in two chunks, so we can have two sets of presenters, but please, uh, join the second session so that you can be there and participate in both parts of this conversation. Uh, today's speakers. Um, we're really happy to have, you're going to unit sir, from the university of Washington, Harold Pincus from Columbia university, uh, and Rena Pandy from the able to, um, uh, application you're at Optum. And with that, I will turn it over to you again, to talk about integrating behavioral health care, to drive the quadrupling
Jurgen Unutzer (00:04:09):
Good morning, everybody, or good afternoon, depending on where you're at. Uh, it's still morning here on the West coast. Um, my name is [inaudible]. I'm a psychiatrist and health services researcher. Uh, I chair the department of psychiatry here at the university of Washington and just a little disclosure. I do, uh, grant and contract funded, uh, research, uh, on this concept of integrating, uh, mental health, behavioral health and the rest of the healthcare system. Uh, I don't do any paid work for a pharmaceutical or device manufacturers. Uh, just a little context for my comments. Uh, uh, I w uh, I shared the only academic psychiatry department in a school of medicine, uh, peer in the Pacific Northwest, uh, where we, uh, are the only, uh, school of medicine for a five state region that covers about 27% of the us landmass. So the States of Washington, Alaska, and Wyoming, Idaho, and Montana.
Jurgen Unutzer (00:05:12):
Uh, and I say that because, uh, that's the context in which we, uh, you know, two decades ago started to say, uh, why should we be integrating behavioral health services? And the reason, uh, you know, get a pretty clear, uh, in my next couple of slides here, but before I do that, just a really brief recap on, uh, the challenge we're all up against. So mental health and substance use problems are huge drivers of health-related disability. About 25% of all health related disability are caused by mental health or substance use conditions. That's five times more health-related disability than diabetes or heart disease. That's 15 times more disability than is caused cancer. Uh, and a main reason for that big difference is not that those aren't really, uh, important, uh, and disabling conditions. The main difference has to do with, uh, the age at which you develop the problem.
Jurgen Unutzer (00:06:11):
So most people who live with a serious mental health problem, uh, 50% of them will have presented with symptoms by the time, uh, were, uh, 14 or 15 years old by the time we're 27 years old. Uh, uh, the vast majority of us will have presented for the first time, uh, with the, uh, mental health or substance use condition. And that's very different, uh, from, uh, you know, heart disease and cancer, where you present with that in your sixties, seventies, maybe in your eighties. And so the cumulative burden over a lifetime is enormous. Uh, also very expensive employers, uh, feel this in, uh, the way of absenteeism and presenteeism, uh, and very high healthcare costs that are associated with mental health and substance use conditions for governments that costs are in things like, uh, homelessness involvement with the criminal justice system, uh, and, and things like that.
Jurgen Unutzer (00:07:07):
Uh, for those of us living with these conditions, you know, uh, we have, uh, you know, we experienced tremendous reductions in our life expectancy, a person living with a serious mental illness in this country, uh, has a life expectancy reduced almost 25 years, uh, and at its worst, uh, these are huge drivers of things like suicide or things like drug addiction. We have now in this country, uh, suicide every 13 minutes, and somebody dies from a drug overdose every eight minutes. So this is not a small thing. This is an enormous problem that comes at individuals that families and employers, that's the reason we really need to think about, uh, what are we doing, uh, for this a little bit of a epidemiology here. So if on this slide, all these little people on the slide, or let's say they're all the people living in the United States with a mental health or substance use condition, or let's say you're a large employer.
Jurgen Unutzer (00:08:05):
These are all the people in your workforce who have a diagnosable mental health or substance use condition. How many of those people do you think, uh, will see a psychiatrist, somebody like me, a doctor, trained to treat people with mental health conditions in the next 12 months, or the answer is about one out of 10, 12% of people who live with a diagnosable mental health condition will see a psychiatrist, uh, in the next 12 months. So that's not so hot, but now you might say there's a lot more reading people with mental health problems. And in psychiatry, there are psychologists, there's masters level counselors. There is all manner of therapists. If we take everybody, who's got any kind of professional training to help somebody with a mental health condition, a one out of five people who live with a diagnosable disorder, we'll see somebody for at least one session, uh, to, uh, help them, uh, with a mental health condition, one out of five.
Jurgen Unutzer (00:09:01):
Now, if you thought back to what I said about diabetes and heart disease and cancer, what if we had to say that one out of five people who live with cancer, who live with serious heart disease, get to see a cancer doctor or somebody who knows about heart disease in the next 12 months, we find that totally unacceptable, but that's the reality. That really is where we are in the area of behavioral health care. Now, the good news is, uh, uh, not everybody sees a specialist, but about 40% of people who have a diagnosable mental health condition will tell you that they got help from their primary care doctor. They got some form of treatment from their primary care doctor in the last 12 months, but that still leaves about a well over half of all the people who have a need for care, uh, really getting no formal healthcare whatsoever.
Jurgen Unutzer (00:09:50):
So we have problems with access to care, uh, and, uh, these things are aggravated by the fact that, uh, 50% of, uh, practicing psychiatrists don't accept any form of health insurance, they're cash only practices. So they're really out of the market for, uh, insured patients. Uh, we have, even in the people who do have insurance, uh, there is plenty of evidence that we have serious challenges as even with good commercial health insurance, uh, with adequate networks in many parts of the country. And even if you do have insurance, it can take a month, uh, to see a psychiatrist. So if somebody is struggling with a really serious mental health or substance use condition waiting a month to see somebody is pretty, pretty difficult. Uh, and, uh, if you ask our primary care colleagues, they will tell us every day, uh, that, uh, uh, psychiatry and mental health services for their patients are the number one access problem that they experience.
Jurgen Unutzer (00:10:46):
Uh, this is my only, uh, there's one of two cartoons here. This one says that we couldn't get a psychiatrist, but perhaps you'd like to talk about your skin, dr. Perry here is that dermatologist. And I hope I didn't offend anybody with that comment, but it is really quite costly and that, uh, we have access to all manner of medical specialists, but we do not have good access in many of our, uh, you know, geographic areas in this country, uh, to psychiatry when we need it. Uh, the other concerns are not with access, but with quality of care. Uh, so what we see, uh, and this has changed over the 25 30 years that I've been in this business. Uh, we now see, uh, very common that a person walks into a primary care doctor's office, but the mental health or substance use problem, maybe anxiety, maybe depression, maybe something more serious.
Jurgen Unutzer (00:11:37):
And they'll walk out with the prescription, usually for an anti-depressant medication. About 30 million Americans will get a prescription for an antidepressant medication the typical year. But if you follow those people out six months or a year, only about 20% of them will have significant improvement in their care. Very few will get effective psychotherapy if you're having a substance use problem, only about one in 10 will get what looks like evidence-based treatment. Uh, and, uh, that is the other challenge we have, we have access challenges and we have quality challenges. And together that means there is very, very few people who have, uh, perfectly a diagnosable treatable, mental health and addiction problems who really don't get the care. Part of the problem is we have an enormous shortage of mental health professionals in this country. This is data, uh, from the federal government, uh, and it basically is telling us that every single state and some of them are worse than others, uh, you know, is struggling with huge mental health care professional, uh, shortages, uh, in our state here in Washington, uh, you know, to make this a little bit more concrete, we have 39 counties bought half of these counties don't even have a single psychiatrist or psychologist or clinical social worker, nobody who has any form of training, uh, in treating somebody with a mental health condition.
Jurgen Unutzer (00:12:58):
Uh, you know, they are people who are in the business of recruiting. Physicians have realized this, this is data from merit Hawkins, one of the larger physician recruitment companies, uh, and, uh, 10 years ago, psychiatry was sort of near the bottom of what they were searching for when they needed to find a position for somebody, uh, by 2017 that had really changed. So now it's, you know, at the very top of what the demand is, what people are looking for, and it's very hard to hire, uh, in many parts of the country, a good mental health professional. So, uh, so far, all I've done is tell you a whole bunch of challenges. So I'm gonna switch gears a little bit and talk a little bit about what did we do to close this huge gap we have between what people need and what we can actually do.
Jurgen Unutzer (00:13:46):
So the first strategy would be to just say, we just need more mental health professionals. So how do we train more mental health professionals? And in, in this business, it's also a challenge of how do you retain people doing this work. Doctors tend to stick with what they do. They're, well-paid, they're well-respected, but we have many, many people in the behavioral health professions, uh, masters level providers. Uh, it's very hard to retain them. It's a little bit like trying to retain good public school teachers. It's a tough job. It doesn't pay all that well. And people burn out and say, I can't do this forever. So we have a huge blow up a huge production training problem, but we also have a pretty significant retention problem in this field. Uh, the other strategy is we might say, we got to take all of the people.
Jurgen Unutzer (00:14:31):
We can get to become mental health professionals, but we're probably still going to be short. So what else can we do? And the other strategy would be, is there something that we could do where we are not working harder, but we're working smarter. And there is a couple of ways to do that. And I'll call out a few of them just very briefly here. The first one is, uh, using technology to make us a little bit more portable. And I'll say just a word about that in a minute. So that's things like tele health, mobile health, uh, M health and so on. Uh, the second strategy would be to say, what about those 40% of primary care providers who are helping somebody with a mental health problem, but they're having a hard time doing it really well. What if we partnered in a much more systematic, organized way?
Jurgen Unutzer (00:15:15):
Uh, and, uh, that's an approach that's often called integrated care or collaborative care, and that's a good strategy. And I'll say a few things about that. And then the final strategy is, uh, could we work a little bit further upstream? Do we really have to wait until somebody is, you know, uh, psychotic, uh, on a gurney in a, an emergency department, that's a person who is sort of the mental health equivalent in my mind of a late stage stage four cancer. There is many, many things, many opportunities we have missed, uh, you know, uh, you know, helping somebody earlier, uh, before it gets that bad. Uh, and so the earliest we could do, uh, in my mind is we have built in our state here or really wonderful program that focuses on perinatal mental health and supporting, uh, young women and young families around the time of childbirth, uh, around mental health and substance use conditions.
Jurgen Unutzer (00:16:07):
And it turns out that kind of very early investment is actually a really, really smart thing to do for a lot of reasons. So just a one slide on technology, uh, you know, uh, even before the pandemic, uh, we were an organization that had invested a lot of resources in this, and that's in part because we're in this geography, uh, where we're serving a five state region that many, many counties and even large parts of States really don't have access to specialty mental health care. So, uh, even twenty-five years ago, uh, you know, we were able to do telehealth, uh, tele-psychiatry visits into rural primary care practices in States like Montana and Idaho and Alaska that was feasible twenty-five years ago. It's still a very feasible thing to do now. And I think with the pandemic, we've all learned loads about, uh, how easy it really is, uh, to put a mental health professional into pretty much anywhere where you have internet access, uh, the other strategies involved, uh, you know, partnering, uh, people with technology.
Jurgen Unutzer (00:17:11):
Uh, and I don't have enough time to really give some great examples of that, but there's lots of, lots of opportunity in that area. Uh, the next, uh, strategy might be to say, what is it that we as mental health professionals can do to help those 40% of patients who are actually cared for by their primary care providers, but maybe not doing all that? Well, this is one example of how to do that. So, uh, in our state here in Washington, we operate a 24 seven, uh, psychiatry consult line, any prescribing provider in our state, they could be in a primary care practice. They could be working in a jail, they could be working, uh, in a community hospital that doesn't have psychiatry in an emergency department. Uh, they can call 24 seven and they'll get a psychiatrist here at our shop. We have a team of 30 people who staff this line, uh, and they'll talk to us about the patient if need be.
Jurgen Unutzer (00:18:04):
We can actually see the patient, uh, using tele-health and we'll give them a real time, uh, consultation on what to do with a challenging case. That's been, uh, you know, really rewarding, uh, for those of us doing the work. And it's also been, I think, a pretty nice solution for some of the, uh, you know, access problems, uh, in our state. Uh, one step up from that would be something like the collaborative care model. So we're not just answering phone calls in that model. What we do is we actually train a behavioral health professional in a primary care practice. Sometimes it's a nurse, it could be a social worker, it could be another master's trained behavioral health provider, and they work alongside a primary care doctor, and they take care of a panel of patients in primary care who have common mental health problems, things like depression or anxiety, or a substance use problem.
Jurgen Unutzer (00:18:53):
Uh, and, uh, we use, uh, structured measurement. Every time we see a patient, we actually see is the patient improving. Uh, we train the staff in those clinics in brief evidence-based, uh, psychotherapy interventions. We track everybody on a population registry, uh, and we have a psychiatrist who once a week, we'll meet with the team in primary care and go over every single patient that's being treated to see if there's something that needs to be done to improve their care. We've tested this, uh, and it turns out in a randomized controlled trial, it's much more effective to you, this kind of an approach than to do what we normally do in primary care. We've also looked at the cost effectiveness of this approach. This is an article that ran in the wall street journal, and it basically sort of made the point that for every dollar we spent on this type of collaborative care, we saw six and a half dollars in reduction in total healthcare costs in overall healthcare costs over the next four years.
Jurgen Unutzer (00:19:50):
So this is a good thing from an ROI perspective. Uh, we have rolled this kind of an approach, this kind of a collaborative peer program out in some 20 clinics and our academic health care system has a collaborative care team like this onsite. We've built a training program around this. Uh, we have published on this, uh, we've worked with CMS a couple of years back to put in place a set of really nice collaborative care billing codes that make it possible for primary care practices to put these kinds of programs in place. Uh, and, uh, we have, uh, partner with a couple of other organizations. This is one study from the Mayo clinic where they studied 7,000 of their own patients. And they looked at, uh, how long it took for a typical depressed patients to go to remission from depression before they put in place a collaborative peer program. And afterwards, uh, so this is a large study, 7,000 patients. I wasn't involved in this. This is a study that they've shared with us. And what they found is that, uh, for putting in place a collaborative care, um, male clinic patients in their clinics, it took an average of 614 days until they saw remission of depression after they put the program in place that went back to 86 days. Uh, one more example.
Kevin Larsen (00:21:13):
[inaudible] can we, can we get you to wrap up? We want to be sure we get to all the speakers here.
Jurgen Unutzer (00:21:17):
Yep. Last, last, last two slides. Uh, we implemented a program like this for a high risk moms in our County, and we saw dramatic reductions in depression improvements. Uh, and we have a similar program that are now being offered statewide. So these are just examples of ways of trying to bring behavioral health services into settings, where you might not normally see them.
Kevin Larsen (00:21:41):
Okay. Thank you very much. Um, and with that, I'd like to turn it over to dr. Harold Pincus, who is out of the Columbia university and a, a long time collaborator. Happy to have you here, Harold, I'll turn it over to you.
Harold Pincus (00:21:55):
Thank you so much. And I'm delighted to follow up, uh, from what you're going to have been talking about and talk about some of the issues about, uh, integrating behavioral health in general health care from a broader policy and systems perspective. And so I'm going to be talking about are questions, like why is the behavioral health general health interface important? Uh, why is it, uh, uh, what are some of the key barriers in terms of why we're not addressing some of the issues that you're going to just talking about, who are the integrators that are actually responsible for conducting the integration and what is it that they're integrating to talk a bit about how these things are addressed from the point of view of a clinical strategy of measurement based care, to talk about the policy concept of shared accountability, and then to think about how you actually make people accountable by developing a way to, uh, uh, quality to measure the quality and integration capacity at multiple levels.
Harold Pincus (00:22:58):
So, uh, so you're going to talk a lot about the impact of behavioral health comorbidities, uh, on people in, in terms of people who have severe mental illnesses, as well as people have more mild to moderate illnesses that are often seen in primary care. And this just sort of builds on that and shows the additive effects of having a co-morbidity for mental illness. And, uh, and if you add on top, if you compare that to having a co-morbidity of substance abuse, and then the additive effects of having both of those comorbidities, um, across some very other, a number of other common, uh, medical conditions, such as asthma congestive, heart failure, coronary heart disease, diabetes, and hypertension. But I think it's all of a sudden to think, uh, to think beyond the sort, the issues of the global disease burden of mental health and the impact on disability and costs also think about it from a very clinical perspective.
Harold Pincus (00:23:53):
So think for a moment about a 60 year old woman with diabetes, congestive heart failure and depression, oftentimes that course of the clinical course of somebody like that is to have frequent hospitalizations and rehospitalizations have problems with self management and adherence, which are necessary for treating their chronic medical conditions. And the woman often becomes an early candidate for long-term care or a 25 year old HIV positive female IB drug abuser, who has PTSD here. You might see somebody who has frequent emergency department visits, uh, failure to adhere to her medication regimens for, um, uh, for HIV. And again, increased medical costs, um, or a 35 year old man with schizophrenia, diabetes, and tobacco dependence. It is Murdoch as you're going to send, you can keep that kind of individual can expect to have a 25 year shortened lifespan with increased medical costs over the course of their, of their life.
Harold Pincus (00:24:50):
Um, so these are real clinical issues that we have to figure out how to deal with that really requires some way of integrating care. And the problem is that we have a lot of difficulty with addressing these from historical stigma and conceptual and practice level kind of issue. So, number one is we're not really clear about who is responsible for what, when people have these complex co-morbidities, um, how do we actually make integration happen and then dealing with the longstanding mind, body dualism and stigma that's attached to mental health and substance abuse, going back to Hippocrates and Descartes to how we've set up, uh, over the past hundred years or so are very fragmented, uh, S uh, uh, healthcare system, um, going to the present day where when you're trying to think about how do we integrate things from a, uh, an informatics and an it perspective, how do we actually integrate, um, behavioral health and general health, uh, data, which is also a major challenge.
Harold Pincus (00:25:49):
So this fragmentation is really, you know, you think about it. Like, sometimes I like to, like in the healthcare system is sort of, uh, in terms of thinking about agriculture. Now, we'd like to think of the family. Farm is kind of a nice place where everybody works together, collaboratively, everything's nearby, and, um, easy to get to. Um, that's not the case and just like, uh, agriculture, the healthcare system has become much more industrialized. So you have the, the silos of general health, mental health, and substance abuse, and with mental health and substance use often dirty segmented, um, in and of themselves. And then when you add issues around social determinants of health, you know, things like, um, uh, social services, criminal justice issues, um, nutrition needs, transportation needs, um, educational needs for kids and adolescents. Um, those are often key issues and addressing some of these healthcare concerns, but again, these are off, they're not integrated.
Harold Pincus (00:26:45):
Um, and part of the problem is when you think about, um, any given individual and who has these kinds of co-morbidities, um, where do we slice this rectangle between the responsibilities of the primary care provider and the behavioral health specialist? We often don't, uh, aren't very clear about that with individual patients. And we certainly have not been very clear about that in terms of policy and practice. In most cases, there's very few agreements around how we actually operationalize these shared, uh, expectations across these two domains. Um, if you look at how providers are connected and you're going to alluded to this as well, now, there's different ways of framing the relationships between behavioral health providers and primary care general health providers, um, ranging from sort of autonomous care on one side or the other, or parallel play, um, up to a very simple referral and no real connection to various levels of more intense collection connections up to integrated teams.
Harold Pincus (00:27:48):
Um, for the most part, most of the action that goes on in terms of managing people with comorbidities, is that at the bottom of this slide, um, not at the top of the slide, um, and that's part of the problem. We don't have a clear expectation, uh, for people to use things like the collaborative care model that you're gonna describe. Uh, we don't really have the accountabilities and the incentives in place to move the needle. And that's part of the problem. We don't have clarity back who are the integrators and it, when we talk about integrators, think about it from the point of view who has responsibility and accountability for individuals different types. So if you think about it, there's two different categories and people have approached integration from one is thinking about how do we integrate behavioral health care into primary care for people with, uh, typical primary care conditions, um, hypertension, diabetes, and so forth, um, who have mild to moderate behavioral health conditions, such as anxiety disorders, depressive disorders.
Harold Pincus (00:28:48):
Um, on the other hand, we also have the problem with people with severe mental illnesses, uh, schizophrenia, bipolar disorder, uh, substance dependence, who often don't have access to primary care and preventive care or care for the chronic, uh, general medical co-morbidities they might have, um, how do we integrate care for them integrate primary preventive care for them into their behavioral health specialty care settings? I mean, the thing about it from an individual level, as well as at a population level, in terms of organizations that are responsible at a population level, and that we need to think about how do we integrate it for what, um, who's doing, what for whom, um, both care in terms of making sure that, um, the individual is, is being, is getting resources across all those silos that I mentioned, if they need it, um, how do we assimilate data across those silos in a way that's usable for clinicians as well as for accountability, and then how do we hold people accountable?
Harold Pincus (00:29:48):
Um, both in terms of developing performance metrics and also adequate incentives, whether they be financial incentives or other types of incentives. Um, these are all key challenges in thinking about how we integrate care. Um, a key principle in terms of integrating care is applying measurement based care. And I think this notion is that, um, basically treating behavioral health conditions is not unlike treating other chronic conditions. Um, and you need to apply this, these strategies to, to do it. And whether it's diabetes and hemoglobin A1C, or the PHQ nine for depression, or the Vanderbilt assessment scales for kids that you need to systematically approach apply appropriate clinical measures in a longitudinal way. And that you're assuring consistent longitudinal assess assessment that basically boils down to having ruthless followup or care management for people. So you don't let them fall through the cracks. And then you're not just measuring the clinical status of people, uh, for measurement's sake, you're actually doing this as part of an action oriented menu of evidence-based options. And if people aren't getting better, you do something, uh, you add something to it out of a venue of evidence-based, uh, options, so-called, uh, treatment intensification, or step care models. And to do this, you need to have a practice-based infrastructure that allows you to track people effectively, uh, within information technology and registry capacity, so that people can be tracked that you can have adequate care management and people don't fall through the cracks. And then you have to build relationships among those silos that I described earlier.
Harold Pincus (00:31:27):
Um, one
Harold Pincus (00:31:27):
Key issue is when you get to the point of accountability is how do you actually make these diverse silos or parts of the, uh, uh, or parts of the healthcare system mutually accountable for integrating what they're doing, and basically think of it in terms of shared accountability. Um, and to make it simple as if I'm a psychiatrist, I'm treating somebody with schizophrenia and diabetes, I'm accountable for their outcomes for both schizophrenia and for diabetes, and my colleague, the endocrinologist, or a PCP or a diabetologist who's treating them primarily for the diabetes is also equally accountable for their outcomes for both diabetes and for schizophrenia, which means we have to talk to each other. Uh, and I think that's what you need to do, and to make this concrete in terms of, uh, both, uh, how we operate in clinical care, but also in terms of applying it in terms of the relationship between the med surge health plan and the behavioral health carve out, um, and to do this in terms of the training and development of our workforce as well, and to also develop this kind of accountability process, you need to adequate quality measurement capacity so that you can hold people accountable with their performance.
Harold Pincus (00:32:45):
Um, and there are different approaches to do that. And I'm not going to go through all of this, but to say, basically you need to put together leadership across the different domains and all the different silos. You need to start by standardizing practice elements in many of the behavioral health interventions, and way in which we assess people are not, uh, integrated into it infrastructure, which is a key piece of this. You need to assemble these practice elements into guidelines, across mental health, substance use, and general healthcare. Then you need to operationalize those evidence-based guidelines, it's ventures, numerators, and denominators. That's also, um, used for improvement as well as for accountability. And then you actually have to train providers and organizations to use those measures, to improve care, and then do this in a way that continuously, uh, provides evidence for how to improve the system.
Harold Pincus (00:33:40):
Um, we've actually developed, and I can talk to it in the chat afterwards, um, a number of ways by which one can develop different measure measurement concepts, um, to apply this kind of quality measurement approach, and to do this at multiple levels at the patient level, at the provider level, at the practice or delivery system level at the health plan level at the purchaser level, whether it be private purchase purchasers employers, or public, uh, public purchasers, Medicare, Medicaid, and finally at a population or policy level. Um, actually I have a list of 15 different PS if we really want to get the technical. Um, and so let me just stop there and just say that basically the bottom line is we have to eliminate this mind, body duality, and really think coherently and, and from an integrated care perspective at a practice level and also at a policy level. And so I'll stop there and I guess, turn it over to Rena.
Kevin Larsen (00:34:40):
Thank you so much, Harold. Um, I think we need to have psychiatrists all the time. You guys have been fantastic about, uh, staying on time, really excited about our, our conversation afterwards, uh, with that, I'll turn it over to Rena Pandy, who is the CML for able to
Reena Pande (00:34:56):
Kevin thanks. And it's a absolute pleasure to follow Yurgen and Harold, um, uh, w we're we're well-represented in terms of our academic institutions. So we've got West coast, Seattle, New York and Boston, which is from where I inhale. Um, but I am, uh, I'm the odd ball of the group because I'm not a psychiatrist. I'm actually a cardiologist by background and spent a lot of years in academic medicine, um, and came to this work from the other angle, which is that I saw amongst my patients, how common behavioral health, common co-morbidities were and how to be blunt poorly, we address them and how impactful they were. So it's been a pleasure to do this work at able to now this past seven years. And, um, I'm going to tell you a little about our work, which is an example of, um, the kinds of things that you're going to inherit mentioned in both of their talks, but, and you guys set such a great context.
Reena Pande (00:35:46):
I just wanted to add a couple more layers of context before I jump into able to work specifically. One is that, um, the, all of the stats you heard represent, you know, many years of experience, but this last year has added another layer of complexity to the behavioral health challenges that many, many face. And so just a reminder that it was challenged before today and 2020 has layered in COVID and the mental health crisis that we're facing as a result of the pandemic. So many adults, so many more adults reporting. Now that mental health has been negatively impacted. You know, we used to say one in five, then we went to one in four, and now lately that number is changing to one in three adults reporting that reporting symptoms of anxiety and depression, um, and a lot more, uh, substance abuse as well as substance misuse.
Reena Pande (00:36:38):
So it's a challenge. And I think a lot of people are worried that while things are worse today, there may be a long tail of mental health challenges that follow. So just wanted to mention that, um, the other points that are sort of interesting are, um, and to really follow on, on Juergen and Harold's comments is just this tremendous change in the way people, patients, consumers are thinking about mental health and the support that they might seek. The top line of this curve is something that we've been tracking for a while. Um, you know, you can see this tremendous rise in people searching in Google for mental health services near me. And we actually were looking in the pandemic and we saw that downturn, um, at the far right there in twin between 2019, 2020. And we're surprised. And then, um, it was super interesting to discover this shift in obviously people not seeking mental health services near me because they can't physically go anywhere.
Reena Pande (00:37:36):
But the rise in this search for virtual mental health, um, in, in Google searches and just a really interesting lens on how people are thinking about getting the mental health support they need. Um, I'll add another layer of complexity here, which is that, uh, finally I think the world has come around to what Harold and Juergen, you guys have known a really, really long time, which is that mental health matters. Yes, it does. It's the siloing of mental health is a significant challenge that having mental health disorders, alongside physical health conditions, significantly impacts outcomes and total cost of care. And we have to do something about it. Um, and people are doing something about it, which is great. Um, as you can see on the very top, a significant amount of investment dollars are being poured into mental health and it's led to a plethora of solutions.
Reena Pande (00:38:29):
Um, but at the, at the same time that, um, it's a great thing that there are all these solutions, this complexity has created confusion in the market. Um, and while payers and providers and consumers are now eager to address mental health, that kind of knee jerk has been, um, which solutions shall we choose. And I think some of the lessons and training we're kind of trying to provide to our partners is it's not one thing. Mental health is not one thing. There's, it's complex patients. It's a heterogeneous population of patients, and we need to be putting together a solution set to really meet the needs of patients. So this complexity is great, but on the other hand, it has posed challenges and, and that competition is really maturing. Um, and the outset, I think a lot of the focus has been on access. How do we get more behavioral health solutions to people?
Reena Pande (00:39:16):
Great, a problem we do need to solve, but increasingly, and it's a good thing. You know, the shift has been towards ensuring access to quality. Um, Harold, I know this and you're into this is, uh, a love of both of yours is to ensure not just getting patients access to care, but ensuring that care is being delivered with, um, adherence to evidence-based guidelines and practices and, and with quality. And it's because we have to shift towards focus on outcomes and measurement based care, not only for our patients, but for our partners, um, and ensuring that we're seeing the kinds of return on investment that you're gonna mentioned collaborative care and addressing behavioral health care can actually demonstrate. Um, uh, so, so with that, let me tell you a little bit about our work at able to, um, we try to adhere to all of those pillars, the philosophy that I shared on the last slide, making sure patients are getting easy access to high quality care that demonstrates outcomes and, um, value really perfectly in keeping with the triple aim and the goal of integrating behavioral health to achieve that triple aim.
Reena Pande (00:40:19):
So we're an organization of providers that our core we've been delivering care to patients with here will health challenges for the last decade. Um, we do that through a national network of our own community of mental health providers, largely licensed clinical social workers, psychologists, um, uh, who are delivering at the core cognitive behavioral therapy and other best practices. Evidence-based behavioral health interventions. We do that across the nation in all 50 States. And we are now available to about twenty-five million covered lives through our partnerships with pairs largely and a few employers, but largely through our payer partners. Um, and there are a couple of logos at the bottom, which the clinicians in the, um, a plan folks who are listening in will, will recognize, I mean, so much of mental health, um, solutions out there now are, um, I don't want to, I don't want to dismiss cause there's so much good stuff, but I would just say, I think people need to recognize that we have to innovate, but in a context of the, uh, the complexity and the messiness of healthcare, and there are reasons why organizations like IRAK and insecure and high trust and why HIPAA, for example, existing, we have to make sure we're adhering to the guidelines that they lay out for us as we innovate.
Reena Pande (00:41:40):
Um, for us, it's been core to ensure we're balancing tech and people. Uh, that's been a principle of ours from the get go. Um, there's so many great things that technology can do, but at the same time, there is a value in that human connection. And many of us are clinicians. There's, there's, there's a beauty in that connection that we can't lose, but if we can really find the best of technology and the best of people and marry them together, boy, are we talking now? So let me tell you a little bit about our solutions, which kind of a full along this spectrum of digital predominantly on the left side and human predominantly, but digital or tech supported on the right side. These are the examples of the kinds of patients that we might treat. So Nancy on the far left might be someone with mild depression.
Reena Pande (00:42:27):
Who's busy and has no interest in, you know, logging in to see a therapist, but is savvy digitally, and might be interested in engaging in a digital tool. And as a level of complexity that is acceptable for a digital solution, um, she might be someone who would use our digital plus solution, which is cognitive behavioral therapy, really baked into an app, um, where all the lessons and the tools and the homework and the activities that are core to CBT or, uh, available through technology, but behind the scenes, she would have a coach who would work with her by phone or by video or through text or chatter, whichever way she chooses to help support her, um, her adherence to the, to the app and ensure that she's seeing the benefits she, she should, it's being not a licensed professional. One step over to the right would be, um, uh, Jean who might have more of moderate depression, um, maybe coexistent anxiety, maybe addressing a recent life event, um, like a change in her job situation or a family situation to us therapy plus would be super for her.
Reena Pande (00:43:32):
That would be a weekly sessions with a licensed clinician to who would deliver cognitive behavioral therapy. Um, and she would have digital tools to compliment and integrate with that human clinical experience on the far right. Fred would be a great example of someone who would be perfect for therapy 60, um, someone with depression, but also with physical health. Co-morbidity, there'd be three sixties program we've been delivering for years and years and years. Um, really the content is integrated. So this is integration at the level of the patient care. Um, and the, in terms of the content that's being delivered. So his treatment would re literally weave in concepts about how to think about his depression in the context of his diabetes and vice versa. And that would be a, again, a human condition, licensed clinician, married with a human coach, um, delivering care virtually through phone, a video and supported by our technology platform.
Reena Pande (00:44:30):
Let me share a few more before we get to the end here. Um, this just gives you a sense of the rigor with which we deliver our care. Uh, some of the things that you are gonna inherit when we're mentioning it's all protocols, our conditions are highly trained. We supervise them to ensure they're delivering care with high quality. Um, and we are adds that level of academic rigor that you've heard in the prior prior talks, um, to make sure that we're delivering the care that the evidence-based, uh, suggest we should. This is I won't go into this in detail, but this gives you some sense of the complexity of the care we deliver. Uh, and the protocol nature of the care we deliver in this kind of program that Fred would see. Um, and all of this is supervised and, uh, overseen by senior clinicians to make sure that they're delivering care.
Reena Pande (00:45:17):
And lastly, um, just at the end here, we heard of the term measurement based care, which we strictly adhere to, um, with great pride that we can say that we're measuring outcomes and that we can improve patient outcomes from a behavioral health lens and medical health lens work productivity lens. And just hidden down here is this point about keeping people out of the hospital, um, that we've done some studies with thousands of patients going through our programs compared to propensity match control patients. Um, and we see that this reduction in hospital utilization translates to a return on investment from a medical cost offset vantage point, uh, and a reduction in costs to the tune of about $4,800 per patient going. So lastly, I'll just make two comments. One is that COVID made telemedicine mainstream, and I think especially in behavioral health, it's, it's here to stay.
Reena Pande (00:46:13):
And that, um, finally, it'll be interesting to see what other changes COVID brought that, uh, impacted behavioral health positively and to see whether whether they last so that we can make it simple to get patients access to the care they deserve. Um, we can see the kind of outcomes that are possible, and we can continue to look deliver care with very high quality as we seek to integrate how behavioral health to truly achieve the triple aim. So thank you guys. Um, pleasure, pleasure. Having the opportunity to share a little bit of the able to story with you today.
Kevin Larsen (00:46:50):
Thank you, Rena. That was terrific. And I want to now introduce dr. Rhonda Robinson, who is the chief medical officer for behavioral health here at United health group and, uh, dr. Robinson Beale, we'll ask some questions and we will also have a Q and a portion. And if you have any questions that you would like to submit, please enter those into the chat box and I will, um, uh, be monitoring that chat box. And we'll augment dr. Um, uh, questions with those questions for you as well.
Reena Pande (00:47:26):
Thank you, Kevin, and thank you to your again and
Rhonda Robinson Beale (00:47:30):
Heroed and Rina, what a great presentation and really a very comprehensive look and on the whole topic of integrated behavioral health, uh, I have a series of questions that we talked about this all of you to some degree in our, addressing it in different ways, the supply of mental health practitioners being low. And I want to raise that because I think you brought some very interesting points, um, about particular Juergen in terms of how you set this up in a practice, um, the use or the role of psychiatrist versus social workers versus caseworkers Harold, from the standpoint of you have measurement based care as being a way of measuring the effectiveness of the various providers across the way, and Rena given the process that you haven't placed with able to the use of social workers and psychologists, um, as the delivers of healthcare for the medical behavioral population. So tell me how you would see addressing the supply or the lack of supply of mental health practitioners through the various approaches that you've taken.
Rhonda Robinson Beale (00:48:55):
Rena, can we start with you? Cause I think you have a barrier. Sure. I wasn't sure which one of us should start, should start first happy to start the conversation. So it's an interesting question. I think, um, you know, we've, uh, to date not had an issue with ensuring that we have a supply of conditions to deliver our care. Um, but we'll have to see how that plays out over the next several years as more and more need increases. I'll just say, I think we should be smart. Um, all of us was using the right clinicians to deliver the right care. So, um, you know, in medicine we talk about kind of practicing to the top of your license, right? So I think ensuring that, um, we use, we use social workers in the right way, psychologist in the right way, psychiatrist in the right way to compliment one another, um, will, will be key to ensure we're using the supply optimally.
Harold Pincus (00:49:53):
I was going to add to what we're saying. Go ahead. I'm sorry. Oh yes. I agree. It's Rena. And trying to, trying to put together sort of a team in a way that's addressing, uh, each addressing issues at a clinical level, from their own special, special approaches that are unique, trying to do it in a way that's more systematic and is clear about who's doing what as part of the team, uh, and also to hold them accountable for that, but also to address their incentives appropriately, as well as, you know, as Juergen pointed out that, you know, by and large, uh, you know, a large portion of the psychiatric, uh, labor pool, if you want to call it that, um, has opted out of participating in the system, um, and taking, uh, just cash over the barrel head. Um, and so we need to think about how to adjust those. And it's not just psychiatrists, it's other mental health providers as well. How do we adjust the incentives? Um, but also is, is Rena said to use them specifically for what they do best, um, as part of this broader team.
Rhonda Robinson Beale (00:51:03):
Thank you. So here again, I know that we've had previous conversations on this, and I think you have done some very nice study to understand that given the number of mental health providers, we have, we would never have enough to really address the population as what I would call using the typical Freud methodology, where you sit down with a provider for 45 minutes, 50 minutes, and you have a therapeutic session. What have you learned through your experience that allows us to start thinking about the delivery of care differently?
Jurgen Unutzer (00:51:39):
Yeah, I am. So what you referencing is a little exercise that we did a couple of years ago. We took all of the psychiatrists that are practicing in this country, for example. And we said, what are they taught? They're taught to do something we call the 50 minute hour. You, as you said, you sit with a patient for 15 minutes and you do an assessment. You develop a treatment plan, uh, you know, and then you do another one later. And if you, if you just said, that's the product, uh, if you made a conservative assumption that, you know, 3% of the population really needs to see somebody like that, at least once a month, that's a very conservative assumption. Uh, you know, uh, we are not anywhere near being able to offer that even. Uh, so if you're living in rural America, we have about a minute and a half for you every month.
Jurgen Unutzer (00:52:26):
So the numbers just don't add up. So we have to leverage people who have that high level of skills. So a doctoral level psychiatrist or a psychologist should be really have to leverage them through backing up partnering, supporting other kinds of providers. Uh, and there is a number of ways of doing that at the end of the day, as Harold and Rena have said, you can build different kinds of behavioral health teams, but you do have to look to say, is it still getting the job done? It's really important. So there's lots of behavioral health care that, that, that payers are paying for that employers are paying for that consumers are taking that, frankly, isn't getting the job done. So we need to be able to say, if I'm going to treat the depression, is that depression gone? If it's not gone, if the job is not done, it's no different from hypertension. If you treat my hypertension and it's not down, I'm still going to have a stroke. So I think whatever teams we build, uh, as long as we can't say, we can demonstrate that the depression has gone, the anxiety is the person isn't
Kevin Larsen (00:53:26):
Using substances anymore. We still have a problem. So
Harold Pincus (00:53:32):
Just to follow up on what you're going to saying, a number of years ago, Juergen and I, and Wayne, Kate, and I had an NIH grant together, um, and where we had data, uh, from people that included both healthcare claims, as well as PHQ nine scores. And when we look for where the most, uh, sort of the lack of improvement of PHQ nine score is worth, it was largely where people, it, it wasn't where there, uh, there was a lot of unfound depression. It was the greatest cases where those who were actually in treatment, um, and hadn't reduced their, uh, PHQ scores.
Kevin Larsen (00:54:08):
So we have a number of questions from the audience. I'll, I'll pick one out here, how do employers and other private and public purchasers of healthcare support offering integrated services for their employees and our members. So if I'm an employer, am I'm a purchaser of healthcare. How do I make this model happen?
Harold Pincus (00:54:36):
Yeah. I mean, you have to build accountability into the contract that included, you know, essentially, uh, a balanced portfolio of structure, process, and outcomes measures that, uh, with the structure measures, documenting the ability to put together the capacity to provide evidence-based care and put, put together the appropriate teams to do that. Um, as well as the appropriate information capacity to report on their, uh, evidence-based care processes, as well as their outcomes, and then hold them accountable for that, it has to be built into the code, built into the contracts. So I think, um, I think an important employer to enable this as a challenge, to be active, to be honest, right? I think that payers have to enable it. Um, they have to support it financially. They have to make it a cover, you know, available as a benefit and, um, put together the solution set that they can make available to their area.
Harold Pincus (00:55:38):
So customers to ensure that they have available that the suite of solutions that are integrated with physical health. I think we are the word silos from, from Harold. I mean, the fact that, um, you know, is this happens even within Optum, it happens at Aetna. It happens in Anthem, you name the payer, um, that, that they're still siloed from a PNL vantage point, right? And that proves challenging when it comes to the fact that, um, addressing behavioral health cost of money, but, but the value, uh, accrues to the medical side of the house some of the times, and we've got to figure out how to continue to move towards breaking down those silos so that our financial incentives are aligned and we can make these things available as covered benefits in a meaningful way.
Jurgen Unutzer (00:56:25):
Yeah. Just offer a very concrete example of how this might happen. This is something we did a couple years back. I managed Medicaid plan and our state, uh, and an employer purchaser and a state, which is a big purchaser of healthcare. Uh, and what we did is we had the payer tie 25% of the payment for services, uh, to one of two outcomes either had to show that you got people's depression better. And if you didn't do that, uh, you had to show that you didn't sit on treatment for too long. There you were making active changes in treatment. Uh, you know, we required one of those two things. And when we did that, uh, we more than doubled the likelihood that people had the right clinical outcomes, we shortened, uh, the median time until people got into remission from their depression from 50 years to just, uh, from 50 weeks to just about 20 weeks. So if you, uh, look at the actual outcomes or the right process change, and you put a significant enough, uh, chunk of the money of the payment on that, you can make a tremendous difference. We demonstrated this with a population of over 50,000 people, uh, and it was a pretty effective across the board.
Harold Pincus (00:57:35):
Yeah. And I think it's a combination of number one with the, uh, providers having the capacity to report that information. Number two, having the financial incentive and number three, having the flexibility to apply their, uh, their care model. That's not limited by the fee for service system.
Rhonda Robinson Beale (00:57:57):
Harold, I think you bring up a very, very important point for employers, as well as health plans to understand that there are some limitations that are posed by the fee for service system, particularly as you're going as talked about, um, with the collaborative care model where consultation and being able to have peer to peer interaction is real important in terms of furthering the learning that one gets from having the measurement based care, uh, developing the accountability. So, uh, you're going in, in Rena and Harold, what would you do or recommend? I know we don't have much time to a purchaser around the way the contracts are set. You know, we're moving to pay for performance, which is performance pay. Then there's also shared savings, and then there's a with upside and downside, and then there's full capitation. Um, can you talk a little bit about your experience in any of those in how those models have helped or did not help the promotion of integrated care?
Harold Pincus (00:59:08):
We have to make it short. So just a couple of words from each and then me and we'll move on to the next section.
Rhonda Robinson Beale (00:59:14):
Okay. I'm happy to start, um, and give you a sense of what we've done, which is, um, engage in value-based contracts with our partners,
Reena Pande (00:59:22):
Um, but really on a fee for service chassis. So, uh, recognizing that there's still a simplicity in that, um, let's start with that, but then hold us accountable for clinical outcomes and hold us accountable for the value proposition we offer, which is around medical cost offset. And we'll put fees at risk on the backs of those meaningful and meaty outcome measures. And that's worked well for us. Okay. Well, Kevin, sorry to bring such a deep question at the last moment here, what I'm able to bring this up.
Kevin Larsen (01:00:01):
Think all of our speakers, this is terrific. We're going to now transition to part two of the program. You can see the little widget on your screen. Please click on that, go to part two. Now we will take a short five minute break to let everybody give we positioned, and then we will be back, uh, with the panel discussion and more chance for Q and a thank you very much and see you all in a couple of minutes.
Kevin Larsen (00:04):
Welcome to part two of today's webinar, integrating behavioral health to drive the quadruple lane. If anyone is just joining us, my name is Kevin Larson. I'll be your host. Our moderator for today's panel will be dr. Rhonda Robinson Beale. Who's the deputy chief medical officer for mental health services at United health group. And I will start by introducing the panelists. We're still waiting for Rhonda to join us back from the other session. So we will start today, um, with Martin Rosenzweig, from Optum behavioral health, uh, we will then move to Sam Norberg from reliant medical group. We will have Charlotte EA from ARP, Catherine Hobbes. Can you send from Optum behavioral care and finally David Moore from Northwestern university Feinberg school of medicine. Each of our speakers will give us a few minutes, a highlight and overview, and then we will have a half of the session for a panel discussion and Q and a. So please, uh, be listening and asking your questions, put your questions into the chat box, please. All right.
Martin Rosenzweig (01:44):
Ready for this. So what I'd like to do, um, you know, in my role, I'm the chief medical officer with Optum behavioral health, um, wanted to sort of outline, you know, the, some of the issues that we sort of see as a March, April health, um, payout in the space as it comes to integration. Um, and obviously we're hoping there's a discussion, uh, later on that we can kind of flesh out some of these points. So first piece over here, and I think you've probably those of you that were on the prior panels, sort of heard about how common, uh, behavioral conditions are, um, you know, around one in five adults, uh, certainly suffer from a mental health condition and substance use. This is data from the community sort of a survey, but what's really interesting about it that I think people overlook as we always talk about depression or mood disorders as sort of being the condition that we should be going after.
Martin Rosenzweig (02:37):
What's interesting is that anxiety disorders are actually more common and significant. The substance use disorders are also very prevalent and a comedy show up in primary care settings where they've very underdiagnosed and undertreated. Um, depression is not the most common presenting condition in these of settings. And, um, I think that in of itself conditions in our screen creates some of the issues. The other part to recognize is that there are certain sort of at-risk populations that, um, have a much higher rate of prevalence of, uh, behavioral conditions. Um, for example, a 68% of patients with chronic medical conditions, all lucky to have a comorbid mental health condition that is either undertreated or unrecognized and probably impacts on the outcome of their medical condition. Um, the other part that I think gets overlooked is that in just because someone has one diagnosis doesn't necessarily mean that they don't have co-morbidities or onto the risk for them. And there's a very high prevalence of substance use, uh, psychiatric conditions that are often not seen or treated optimally.
Martin Rosenzweig (03:53):
And what
Martin Rosenzweig (03:54):
Is the sort of reason behind this? A lot of behavioral treatment occurs in sort of a very, um, you know, uh, in efficient, uh, system. Um, I've already mentioned about the under recognition, uh, what's most striking is that the substance use about 90% of, of individuals who would have a diagnosis of substance use receive no treatment. So it, you know, there's a very low and there are all kinds of reasons, you know, stigma and so on, but it has a profound impact on the medical presentation. It's been estimated, you know, in some medical settings, like a hospital that, you know, up to 20% of people on a medical bed may actually have be there because of complications of some substance use disorder, which was not recognized even in patients where we do identify them. Um, they're often not connected with appropriate services. Um, I think one of the prize speakers sort of mentioned around what's different about behavioral conditions is they really start for most people in the second and third decade of their lives, teens and twenties, meaning that a person is really going to need to manage their condition for the majority of their life.
Martin Rosenzweig (05:09):
You know, uh, probably 75% of their life is, is going to be dealing with their condition and that can create challenges as well. There are access issues with, uh, two service that I think were highlighted as well. Um, one third of the United States really as designated as, as being mental health provider shortage areas, and even in patients that are identified from and are treated, most of the treatment just occurs in acute settings. They may be admitted to a hospital or emergency room, but a high number of them really get no care beyond that. And some of it has to
Martin Rosenzweig (05:45):
Access. They do have access
Martin Rosenzweig (05:47):
To medical services and that's sort of one of the arguments around sort of integration. Um, and certainly we see this around the delivery of behavioral services. That that's a real challenge. We know that these patients with mental health diagnoses overall drive higher total cost of care, and that includes the sort of amount that's being spent on their medical conditions as well. Um, if we dive a little sort of deeper into this as well, particularly from a primary sort of setting point of view, you know, there's a very high prevalence. The issue is really around, um, access because of a shortage of providers. And this is both a therapists, but also psychiatrists folks in the United States. It's estimated that somewhere between 13 and 14 psychiatrists, per hundred thousand population, um, if you compare that to the numbers across the partners in Europe, um, the numbers there around 20 to 22 psychiatrists, a hundred thousand, um, compounding is, is the fact that only about half of psychiatrists actually participates in sort of insurance panels, which, which makes the access even more difficult. Um, what this really boils down to is it primary care is, is really the frontline for delivery of behavioral care services. Um, uh, majority of, um, you know, diagnoses that results in a mental health diagnosis are made by primary care physician, not by a mental health specialist and almost three quarters of patients who do have a mood disorder, major depression are really treated in primary care settings, not
Rhonda Robinson Beale (07:30):
To wrap this up a little bit so we can keep on time.
Martin Rosenzweig (07:34):
Yeah. So just, I, I, we do understand that behavioral health support in primary care settings is, is cost-effective and leads to good results. And that's really the challenge. Thank you.
Rhonda Robinson Beale (07:45):
Thank you Martin. Um, now we're going to go to Sam Norberg Sam, we'll talk about opportunities and integrating care.
Sam Nordberg (07:55):
Great. Thank you very much. Um, so I'm going to speak about, uh, the, uh, experience at reliant medical group, where we over the last four years have, have designed and built. Um, what is now one of the largest integrated behavioral health departments in the state of Massachusetts, um, uh, staffed by roughly 75 licensed clinicians, um, and, uh, and grounded in an architectural redesign of primary care where we share space. So a real, real embracing of the full behavioral health integration model team-based collaborative care, um, and importantly, a big part of the driving force behind this is that reliant, um, has over 50% of its patients in capitated risk contracts. So cost savings for a reliant is a really important part of our mission, um, and behavioral health, uh, integration really drives one of the principle pillars of our strategy for, uh, for addressing that quadruple aim that includes total cost of care.
Sam Nordberg (09:05):
Um, so just really quickly to, uh, to walk you through what we've got in play. Um, the linchpin of our model is a behavioral health partner who sits in primary care in primary care team space, alongside the PCPs, advanced practitioners, MAs nurses, basically a part of the primary care team and the bulk of their time, uh, is unbooked. Um, and so they're not conducting scheduled appointments so much as they are available on the fly, uh, for, uh, real-time triage, real-time consultation, warm handoffs, crisis management, et cetera, et cetera. Um, and, uh, and they're the sort of critical component of the model because they're the gateway then to triage patients into the remainder of the model, which looks more like traditional co-located care, where we've got, um, therapists who are also embedded in primary care space. We're also available for consultation, but because they're booking, you know, a great many visits aren't available in real time, the same way that the partners are.
Sam Nordberg (10:08):
And then we've got a variety of other, um, services. We do, uh, uh, psychiatry consulting. Um, we run a lot of groups. Um, we do a DBT center, we have a substance use disorders, treatment team. Um, and then we manage referrals into the community. Um, what we've tried to do, or what we are trying to do is to really build a full spectrum model of care that can handle patients at the, sort of the bottom of the, the acuity and complexity paradigm, all the way up to, you know, sort of highly complex, highly acute patients, uh, by getting them into care with, with partners in the community, uh, when necessary. Um, so forgive me, I'm trying to move fast and I'm happy to answer further questions about the model, but again, a pretty comprehensive model, very closely integrated with primary care. Um, and over the last 18 months, we've hired a we're 50 clinicians.
Sam Nordberg (11:08):
Uh, you're finished staffing this up. We've been roughly a full staff for about a year. We basically got fully staffed up just in time for the pandemic. Um, uh, all right. So just really quickly, um, talking about challenges, um, as Martin alluded, there are not enough providers available for the behavioral health need. What ends up happening is when you screen and triaged within primary care, you become acutely aware of the gap between the amount of need and the number of providers available. So one of the first things that we learned is that we, we sort of had this model where we thought we would get patients connected with the care and the community that they needed while also providing a lot goal-oriented brief psychotherapy interventions, um, uh, internally and providing psychiatry consultation internally turns out that even with the amount of patient load we're able to manage internally that the community still isn't able to manage our, our full needs.
Sam Nordberg (12:13):
Um, and I can say currently we have over 1500 patients on a wait list for community resources. Um, fee for service makes this really challenging. I think integration and fee for service just don't work well together. Um, and fee for service quite frankly, has made it more complicated, complicated for us because of all the important conversations you have to have for informed consent with patients around billing, copays, et cetera, et cetera, it makes what could be a really seamless handoff, a much more complicated and siloed affair. And we can talk about that in greater detail. And then lastly, you know, um, staying payer blind in here in particular, I mean, I'm building a model for capitation versus, uh, a blended or fee for service model, um, really is different. And our DBT center is a perfect example of what you can do in a fully capitated model. We offer dialectical behavior therapy, the gold standard for borderline personality disorder, and we offer it for free to the right risk patients who get enrolled in our program. But if we open it up to fee for service patients, it would create a, a compliance and regulatory nightmare that makes flexibility much more difficult in a mixed payment, uh, setting. So let me stop there and, and, you know, looking forward to, uh, to the greater discussion and answering questions.
Rhonda Robinson Beale (13:32):
Thanks. Thank you so much, Sam. Um, you certainly have opened, I think, quite a few subjects for further discussion. So now we're going to go to Charlotte gay. Uh, she's going to be speaking on resiliency, aging and strong assets for aging, with vibrancy and vitality. This is a very, very interesting and new, uh, I would say approach that is very, very exciting. Charlotte,
Charlotte Yeh (14:00):
thank you so much introduction. And it's such an honor, a privilege to be on this panel. Uh, personally, I'm extremely thrilled that all the collective efforts that we are bringing the fragmented person back to the whole person. So that could just shifting gears a little bit more from the other panelists to say, we have to be adding one more lens. So one more lever for better health and wellbeing, particularly as we age and I call it personal determinants of health.
Charlotte Yeh (14:32):
So think about this in healthcare. Um, we go to the risk factors. We go after risk reduction, mitigation treatment, clinical conditions, and yet all of us have seen people with the same clinical condition and one person walks out and the other one is all pathways to pathway. So for the past five years, um, with RP services in a collaboration like United healthcare and our Medicare supplemental plan members, we have started to flip the coin and say, why are we going after risk when you can we go after, what are the positive assets that we bring to the table as a person? Can we go after the secret sauce, the Thrivers, as opposed to the failure to thrive? Um, and, um, and can we stop looking at the deficit model for billing, help and start looking at how we can build people's tents? So for example, I know we're talking all about mental health disorders, and we all know that since COVID, um, mental health stress anxiety all brought up.
Charlotte Yeh (15:39):
Um, but interestingly, if you look at every one of these surveys, um, and you look across the age, jams is worse than agendas. And with every generation down, the amount of stress and anxiety has gone down. And in fact, the CDC just came out with a report looking at 2019 pre COVID, looking at the, uh, anxiety across ages and it for the 18 and 29 year olds, it's about a 19 and a half percent rate of anxiety. But by the time you're 65 and older, it drops to 2%. And then there was a recent study just published by Laura Carstensen, from Stanford, who looks at aging and longevity. And she has been looking at surveying people during the COVID and found that age is associated with greater emotional wellbeing, even in this prolonged era of stress. So instead of marginalizing age, can we somehow embrace the positivity that comes with age? So you're probably saying, what do I mean by this, we've explored a number of different factors that I call in the personal determines on what are the skill sets that we can bring individual that are meaningful to health or mental wellbeing, and trying to play the cost of care. Um, legally that has to do with an overall fee.
Charlotte Yeh (17:01):
However, and we have three PS purpose people and possibilities that we have started as being meaningful factors to explore. So let's start with the purpose in our population. Um, 35% of our population have a low sense of purpose, and it turns out we flip it around those with a higher sense of purpose, have fewer strokes, better sleep, um, lower stress hormones, more organic surfaces. If you were hospitalization and fewer doctors visits, and those who had a low sense of purpose, actual cost us 12% more. Let's talk about people and social connection. Now we focus on loneliness, not the size of your network, but how you feel about your social interaction. And that's using the UCLA scale that 90% of our population, right? And by the way, this man for use in health systems and health plans, we found not five years ago, that loneliness was the strongest predictor of dissatisfaction in health care, more than health literacy.
Charlotte Yeh (18:09):
And I'm sure you all, haven't seen the news about loneliness that you got 26% higher risk of mortality, 29% more cardiovascular disease, 32% more strokes. And even in the 1990s, when that they did an experiment where they exposed adults to the cold virus, the coronavirus, but the cold virus, that those who had a stronger network when they adjusted for everything else, those who had a stronger social network actually got fewer symptoms. So the power of people is extremely strong. And I'd like to take a moment and felt this specifically on a very actionable space, because everyone's talking about what can we do about you, especially in this era of COVID. And I don't want to talk about hearing loss as a very strong driver of loneliness and social isolation. Maybe, you know, that we worked with Optum bread couple of years ago and found that 10 years, a lot of corrected hearing loss, by the way, that's 40% of 60 and older two-thirds of people, but it's hugely prevalent that 10 years long court to hearing loss, you see it's associated with a 52% higher risk of depression, uh, start dementia, 41% higher risk of depression at 29% high was the false, how many of you were here dealing with a depressed older adult, actually checked for hearing and hearing and hearing comprehension.
Charlotte Yeh (19:34):
And if that doesn't drank, and what about the costs? We found 10 years of one correctly increases healthcare costs by 46% of October $22,000 per person. Number two thirds of people sending over at hearing loss 47% higher risk of hospitalization, 44% high risk of readmission. And think of this era in COVID. When were masks, people cannot read lips when you're socially distancing. It's harder to hear those of you who are doing virtual health, great rise and telehealth. It's very, very exciting, but how many of you actually have cash on your virtual health platform? He SCC gives free caption for hearing impaired for the telephone, but right now, most virtual health platforms to have captioning is a premium service. And it's not just for older adults. ARP did a survey. This has already identified that 31% of millennials say they have trouble hearing in a noisy environment.
Charlotte Yeh (20:32):
37% of gen Ys are having difficulty hearing in a noisy environment. So if you're trying to do a virtual health and you're in a home with a lot of kids running around yelling and screaming, that's a noisy environment. So are you thinking about one of the aspects that you can correct for depression or loneliness is hearing loss and the third P um, which is also highly actionable instead of perception of aging, about 40% of our members had a negative view of aging. And we know if you will, a positive view of aging, you list seven and a half years longer. If you have higher 44% more likely to fully recover from disability, a 55% reduction in hospitalization. And all of these factors that I've just described, those are the negative perception of aging cost us 43% more per member per month. There was one of the study out there that says it costs us $63 billion a year, and this is extraordinarily relevant here.
Charlotte Yeh (21:35):
We did a study with university of Michigan and nearly 90 10, 88% of older adults, $15 have experienced ages every day. How many of you have seen older adults need a joke? BME. We are totally whitewashed out that media and everything it's about anti-aging. And yet, interestingly, not in the same survey two-thirds of 50 and older say life is actually better than expected coping skills that you've learned over the years, but the sad part for those of you in the mental health business, one third of these older adults are 50 and older. That was surfing, already have internal laws and loneliness with aging. And so we looked at these repurpose, people are possibilities.
Rhonda Robinson Beale (22:29):
Can you wrap up? We need to move on to the next.
Charlotte Yeh (22:34):
So we looked at, um, additional factors, um, and, uh, just published a study, looking at five positive factors. Um, Oh, sorry. I don't know about the slide. Um, and it turns out it doesn't matter whether it's resilience, purpose, optimism, social isolation, or, or locus of control. The more positive factors that you have are buffers, the lower, the rate of depression, the low rate of anxiety, the better your, your personal health and, um, the more functionality that is self reported and, Oh, by the way, for every positive factor, it doesn't matter which one you have from zero to five that can save $1,356 expenditures. So I can just thrill it with going back to the whole person, because when we live our lives, we, we live our lives as a whole person with our families, with our communities. And with that, I just want to say, thank you. And let's start thinking of that.
Rhonda Robinson Beale (23:39):
Thank you so much, Charlotte. Uh, so now we'll go on to King dr. Kate Knudsen. Who's going to talk about
Kate Knutson (23:46):
Behavioral health in practice success in value based care. Okay, great. Um, thanks very much for having me, um, could we advanced the slide? I can do it all right. I got it. I'm empowered. Um, so this is, has been a great conversation. Um, you know, we, that the points that I will, um, bring to the conversation is, is how do we pay for, um, for integrated behavioral health treatment within primary care. Um, and we got a preview of it earlier with the reliant model that it really helps. Um, if the primary care providers, um, are in some sort of capitated arrangement, um, especially when they're at risk for total cost of care, um, in that environment. Um, there's, uh, there's there there's often, um, recognition of how behavioral health conditions, um, impact, uh, uh, both the behavioral health outcomes, but certainly the physical health outcomes as well.
Kate Knutson (24:47):
And if we can do interventions to help, um, you know, disseminate integrated care, but then we should be able to realize improvements in total health and cost, um, and that sort of the Holy grail, right. Of these, of these capitated arrangements. Um, so several health systems have been successful in this space and it's, well, not several, but some, um, you know, Intermountain as an example, um, Montefiore, um, Kaiser has done a lot of work in this space, um, and there, there are others, um, and looking at looking at these systems and trying to learn, you know, how have they taken more of a population health approach, very similar to what the Alliance is doing. Um, what are sort of the core components of these models? And this is a graphic that I took from the Intermountain model, um, that, that shows that on the, on the X axis there, you can see the range of mental health and substance use for mile all the way over to severe and mild to moderate is, um, is really effectively treated in, in primary care.
Kate Knutson (25:46):
As you've described, as it's been described, um, reliant actually does treat more severe and complex conditions within primary care. I would say my experience is that that's, that's relatively rare. Um, often, you know, we are primary care providers are referring out into the community, um, for more severe and complex conditions. Um, you know, and, and, and for these systems to work, we've got to really be coordinated across the, across the continuum from mild to severe, um, between the behavioral health and the primary care providers. So again, ideally we, you know, all, uh, all of these providers across the spectrum roll up to the same sort of, um, health outcomes and cost outcomes, the same incentive structure. Um, oftentimes that, that doesn't happen, right. And especially in ACS, one of the challenges has been that, you know, a lot of ACS, you know, can, can do integrated care the mild to moderate population, but again, when it gets to more severe and complex, they're referring outside of the ACO into the community, and they're experiencing a lot of what, what reliance is, is, is experiencing. Whereas, you know, the providers aren't really set up to, um, acceptance patients, um, and, and there's substantial access as to also many of these providers aren't measuring quality. Um, and so, and so the quality may be variable, uh, for the treatment that that's being, that's being received.
Kate Knutson (27:12):
Um, so there's,
Kate Knutson (27:13):
There's two potential ways to do that. Um, you know, uh, uh, ACS could, um, you know, expand and, and, and build out their psychiatrists and therapists on staff to help address these, these more severe and complex conditions, um, especially through, uh, tele-health and other expenders. The other is to create specific value-based contracts with the mental health providers. So that even though, again, they're not part of this centralized, you know, ACO contract, their incentives through their contracts are set up to align. So they're incentivized to improve access for patients with some severe and complex conditions. And also they've got some quality measures in our contract. So again, everyone in the system is aligned across. So happy to talk more about that in the discussion, um, what are some of the outcomes and, and I've, I, the panel is, is certainly a panel of experts on this and has written a lot about this.
Kate Knutson (28:07):
There are plenty of outcomes that we could consider to use to incentivize integrated behavioral health within primary care. I chose these two because we do have some national experience with them. Um, so, uh, as you know, a lot of the integrated care within primary care is focused on depression and anxiety as, as Martin spoke to. And so these measures in particular, speak to treatment that that is amenable to integrated care. So encouraging screening for the prep, universal screening for depression and follow up, and then also depression or mission and response. And again, we've got this collaborative care model that we can deploy within primary care to help primary care providers maximize their outcomes on these measures. And of course, what's in the process of that is that we're improving access and outcomes for people with depression. So happy to talk more as well in the discussion on outcome measures to incentivize integration.
Rhonda Robinson Beale (29:04):
Yep. Go ahead.
Kate Knutson (29:07):
Slide. And this is, this is really been covered. It's very hard to deliver integrated care in a fee for service environment. A lot of the work that we do, I need a fee for service requires basically a face-to-face visit or through the collaborative care codes. There's some team-based care that supported, but in general, it mainly reinforces the face-to-face visits. But as you know, in mental health, the Mo some of the most impactful work we do occurs in between those face-to-face visits. So the collaboration we have with other colleagues, when they call a patient to check about checking the side effects for their medications, and it's really hard to do that in a sustainable way, um, in a fee for service environment. So this slide here just walks through increasing, as you go top to bottom, increasing levels of account provider accountability for health outcomes and costs.
Kate Knutson (29:53):
And as you, as you move down this list as well, that's where providers are really incentivized to, to take on these, um, initiatives and these innovations to really delve in and improve access and quality of behavioral health care, just like, um, uh, has been the experience of re I reliant for their risk population. Thank you all. Thank you. Thank you so much. I appreciate it. So now we're going to turn to David Morris is going to talk about digital health, innovative interventions in outcomes, which is certainly the way the behavioral health, as well as healthcare in general is going David.
David Mohr (30:33):
Uh, thank you, Rhonda. And it's a, it's a pleasure to be here. So I've been working in doing, doing research in the area of, of remote treatments for, in mental health, primarily depression and anxiety for my entire career. And for the past 15 years using digital technologies like web-based tools and, and, uh, uh, um, uh, and, and, and mobile phones. And so I'm going to talk about our experience with one platform and Telecare and take you take you through this, uh, kind of quickly, uh, this work started at Northwestern in research about six or seven years ago, a couple of a couple of years ago, we moved it into a startup, so where I have equity interests. So that's the discloser I should, I should make. Um, and when I look at the, you know, when we looked at the, the, the field of digital mental health, you know, we see a gap there's, there are hundreds of randomized controlled trials showing that these kinds of interventions are effective, particularly for depression and anxiety.
David Mohr (31:33):
And yet we saw that when this stopped, rolled out into real world settings, like for example, Kaiser Permanente have tried, has, has tried this many times, you know, the, the, the, you know, it's often disappointing that, uh, patients don't use the tools, uh, the providers are supposed to manage it, don't use it, they don't get referrals in. And, and so there's a big research to gap that practice gap. And so we looked at this from a perspective of a design problem, you know, designing for patients, designing for providers and designing for healthcare organizations, and I'll go through each of those fairly quickly. Uh, so for patients, you know, what we see is that, that the approach that's generally taken is kind of to deliver psychotherapy over the internet. So through new medium, so often it's fairly curricular, there's this reading or videos that people have to watch, uh, and, and exercises.
David Mohr (32:23):
And a lot of people, you know, don't, you know, don't want to engage with those. Um, so, you know, we, we took, uh, uh, when we looked at what people are, we realize we need to design this to fit into the fabric of people's lives, how they use the devices that they're on. And we with phones that people tend to use them, you know, with, with, in, in short purse, you know, for example, I, you know, we all use our phones for, for transportation, but we don't have a phone, a transportation app. I've got, you know, some ride share apps, the Chicago transit authority app, parking apps, airline apps, mapping apps, to find where I want to go. We have little apps that do one thing that, that help us with a task. And so that was really the Genesis of the idea here for, um, you know, for, uh, uh, um, let's see for four in Telecare.
David Mohr (33:13):
And so it's, it's not one app, but it's, it's, it's a suite of multiple apps. Each app just has a single, uh, you know, focuses on a single behavioral strategy, like behavioral activation, cognitive restructuring, increasing, uh, you know, increasing, uh, physical activity and so on. And each of these apps is pretty is, is, is pretty quick and easy to use. So most of them take less than 30 seconds, so it can be fit into the fabric of people's lives. And we don't have a curriculum per se. We're just trying to find something that works for the person that they are willing to use to nudge their behavior in a way that's going to help them. Uh, you know, most of the work that we've done has included coaching, but we try to keep it brief. And, and cost-effective, so most of that is done through messaging, uh, with a, you know, awfully, typically a brief phone call initially to, to, to, um, set them up in the program.
David Mohr (34:07):
Uh, we collect data, uh, to help manage the patients. So PHQ nine data, uh, risk assessment. They can see, you know, whether they're using the apps. Um, and then all of the studies that we've done, uh, you know, eight week, um, treatments. So this is a, uh, an example. This is one of the most recent studies that recently came out in JAMA psychiatry. And so this was done in the university of Arkansas is primary care setting. Uh, and patients were selected who met criteria for depression or anxiety. Um, and so they received eight weeks of treatment. So you can see here, it doesn't quite come out on the slide, but the, the, um, the, you know, they were randomized to receive treatment as usual in primary care or in Telecare. And the green line there, you see a nice drop in, in their depression scores and just the modest drop in, in, in treatment as usual at week eight, uh, the people that were in treatment as usual, they were given and Telecare, and then you can again see a nice drop in depression.
David Mohr (35:14):
So it was, it was effective. Um, and, but, but the, the, the big challenge, you know, as I alluded to before is engagement. So patients often don't engage often when we look at engagement graphs, they're sort of like a hockey stick. So people start, uh, you know, start off using it. And then they're, they, you know, after the first week or two, they start drop off and you see kind of a curve like that. So in this study, which is, you know, what we've seen in all of the others, we've seen much stronger engagement. So over the course of six weeks, people used on average the apps 146 times. So that, that averages out to about two and a half times a day. So we're seeing that it fits into the fabric of their lives and 90% of people completed the eight weeks of treatment.
David Mohr (36:04):
So this is all kind of the research that we've done, but now how do we get this out into real world settings? So we are now in the process of engaging with rush university medical center, they trying to embed it in their, in collaborative care. Uh, and we've finished a series of, of, of, uh, of the series of work design work to try to understand how, what needs to be done to fit it into a collaborative care. So rush has about two serves. Their primary care serves about 250,000 lives. Uh, they, they do a good job of screening. So they get about 90% of their patients get annual screening. And those patients who screen positive, get moved, get, get a referral to collaborative care. When we work with collaborative care, we see a number of, of, of, uh, of, of challenges. So they're not surprisingly overwhelmed by the volume of patients.
David Mohr (36:56):
They also have a lot of difficulty contacting their patients. So they, they contact, they communicate with their patients, largely remotely using the telephone and, you know, nobody answers their phone anymore. Uh, there's low follow-up, uh, on the, the acquisition of PHQ nine data. So it makes measurement care difficult. Um, and the care managers, their, their objectives are poorly defined, uh, and there's no consistent workflow, which was, uh, you know, more sort of issues at the leadership level. So what we saw was we really need to build on top of this intervention, a patient management system. So at this point, the data PHQ nine data is we've integrated it into Epic, and it flows into epics and, and into the, the, the collaborative care registry. Uh, they also wanted some information about a medication. So whether people are taking the prescribed medications, if they're having side effects, um, you know, they can see whether they're using the apps.
David Mohr (37:53):
Uh, they can communicate via messaging as well as telephone. And then a series of alerts have been built in, uh, to, for, for, to manage suicide risk, uh, the medication issues that might come up with medication, uh, they, you know, patients are asked who are referred for psychotherapy. There can be a follow-up question to make sure that they follow up they've, they've connected with a therapist, uh, and then, you know, monitoring, you know, alerts around their progress. So being able to monitor a patient, identify patients who, uh, you know, shown signs of deterioration, or who have not improved over four weeks or importantly in collaborative care patients who have reached their treatment target, uh, because it's important to move them out of active and into monitoring. So that more room can be Nate for, for, for new patients going to get to the Q and a.
David Mohr (38:44):
So I'm just wrapping up. So, so that, you know, I mean, the main, the main thing that I, you know, the takeaways here from this is that, you know, for the patients, what we've, the approach we've done is to try to design, to fit into the fabric of people's lives. And what we've found effective are these micro interventions things that can be used quickly and simply, uh, and then, and then we've seen that it's really important to integrate fully into the, into the care system we've seen working with with care managers. We really have to, we have to be able to solve a problem for them to use it. So we think we can do that. Uh, and, and, and with, um, you know, making communication easier and data capture. Um, and we've done that with a patient management system, and this was, I wanted to have data to show you, but, um, we were supposed to start in September and we've been delayed by this applicant integration. We're actually rolling, you know, launching it on, on next Monday. So that's where we are.
Rhonda Robinson Beale (39:41):
Thank you, David. I really appreciate your presentation as well as the presentation from everyone. So just to go back, we've had a look at this whole issue of behavioral integration from a network and population perspective from Martin, uh, from Sam, we looked at it from a integrated system, uh, that was, um, based in a value-based contract. And so really talked about how to do that with them, that type of framework, Charlotte brought up very interesting study, really looking at personal determinants of health and how an approach from the standpoint of view of resiliency can and does correlate very well, the cost of medical care, as well as self care and the shaded by patients or Kate has talked about the value of integrating behavioral health into primary care, and some of the issues that one faces in doing that. And David, you certainly have given us a really good view of really some tricks in some ways of thinking about how to engage patients into digital health and what needs to be taken in consideration in terms of our attention span and how we right now function in the world.
Rhonda Robinson Beale (40:54):
So with that, let me ask some questions, um, until we get some questions from the audience. So given this, uh, and I'm going to really direct this to Charlotte, as well as David and others, to chime in, what should the patient's experience really be like going forward, given that we have COVID COVID is now affecting the emotional response to COVID is affecting a far larger population that we, then what we do usually have, how can we use what you've presented to help us to understand the patient's experience that need, that we need to strive for?
Charlotte Yeh (41:37):
I can go ahead
Kevin Larsen (41:40):
And try
Charlotte Yeh (41:44):
To say, you know, one of the things we've learned is we are challenged with life, and we can't always remove the challenges like we can't take COVID away creating that socialization and social connections that you can make virtually to remind people, that therapist purpose. And we volunteer, we help other people. I don't want people to think I have to wait for the healthcare system, the doctor to see me, or I have to wait, you know, for transportation. So there are things you can do yourself positivity as a person. Yeah. I think the, the, you know, what we're trying to do is develop these is, is have kind of a, a low intensity treatment that can be delivered very quickly at the time that that a patient is, is, you know, is identified. So a lot of times it's difficult to get somebody who's going to be available for psychotherapy.
David?? (43:01):
Uh, this is it. And, and, and so to make that work, I think there is, you know, as I said, I think from the patient's perspective, we want it to fit into the fabric of their lives and provide them something of value and, and lot different people interact with their devices in different ways. They want different things. And so you, you know, we need to have platforms that can be flexible in, in meeting people where they are, uh, you know, if people don't want to use their phones in the way to help their doctors, they want to use them to help themselves. Um, and, and so I think that's, I think that's really it's understanding the end user understanding the patient's needs. Uh, and, and you, you know, we're, we're using this as kind of a frontline treatment within rush. Um, so, uh, you know, we don't expect that everybody is going to respond to it. Um, but you know, what we, what we're expecting is that that enough people will respond. And then over six to eight weeks, those who don't respond can be triaged up to, uh, to a higher level of care, uh, you know, ultimately resulting in cost savings. So this is Kevin. I, you have a question from the audience. I was just going to bring another question from a summary of a few questions here. Maybe this is for some combination of Sam, Kate, and David are
Kevin Larsen (44:32):
Happy to have any of you, how do we combine the best of these collaborative care models with technology, uh, into, uh, uh, a really good set of interventions? So that is this both human intervention and technique.
Sam Nordberg (44:48):
Okay. So if I can jump in, cause we're, we're tackling this right now, um, in, in March this year, um, our entire department, uh, went digital, um, and, and now we've got, um, some of our sort of linchpin integration folks back with primary care in the office. Um, but one of the things that became apparent was what will come as no surprise to others, um, that there are, there are a lot of opportunities for scalable digital, uh, innovation in behavioral health that can take some of the load off of the providers. I mean, therapy is a remarkably limited resource. Um, you know, any given provider can only really do good work with, you know, 30 or so cases, um, at a time. And so, you know, what we're looking at is, uh, developing sort of digital front door technologies that, um, that welcome a patient into a model, explain the, the pathway through the model to them, and then also give them access to some of those technologies that can be really helpful for self-motivated, um, you know, mild to moderate, um, severity patients who have access to good social deport supports don't have significant, um, uh, challenges with regard to social determinants and try and address a lot of the need for patients in that way while having a way of escalating and identifying patients who need to be brought up a step in the level of care and connected directly with somebody in person.
Sam Nordberg (46:18):
So that's sort of a broad overview of what we're trying to look at. And then there, there are so many technologies, um, coming online now that, uh, that we've been working with UHG, for example, to sift through them and figure out what we should be, uh, pulling online and incorporating into sort of our digital mall for our patients to have access to. But I think it's, it's gotta be scalable and it's gotta have some way of escalating patients into that in-person care model, um, on the fly, the same way that we would in, in primary care when we, we triaged. So I'll stop there.
David Mohr (46:53):
Yeah. I, I largely agree with every, I mean, I completely agree with everything that you just said. I, you know, I think there's a, you know, to kind of put it into buckets. I mean, there's gotta be, there's gotta be data that, that flows. I mean, technologies can be used to acquire data that can support measure the measurement based care, um, that you, you just described and then re you know, I think what we're talking about are kind of using technologies as, as, as, as frontline treatments, to be able to essentially treat those people who can be treated, you know, who respond to those, those low intensity treatments. And, you know, some people may do okay with just being provided to, uh, you know, digital tools and work on their own. And we do see that some people would prefer that, and they don't really want to communicate with a coach, but we do see that coaching or a care management, just, just the knowledge that a human being is behind it increases, increases the likelihood that people are going to use it.
David Mohr (47:55):
So there's a sense of accountability. Um, and so it doesn't necessarily need to be that intensive, but just knowing that there's a human being on the other side, makes it more likely that they're going to fill out their PHQ nine, makes it more likely that they're going to look at the materials that are presented to them. Um, and so, so that, that, that human component is, is, is, is really important for a lot of people to, to, uh, you know, to have their, on the issue of severity. I think this is kind of a, you know, one that often comes up. And so, and I, so I'm going to say like the, the trial that we did in, in, in Arkansas, uh, 20% of the population was below the poverty level. Another 40% was between one, you know, the poverty level. And two times the poverty level, it was, there was a large, uh, group of those people who were, were, were minority.
David Mohr (48:45):
So it was a good representation of little rock. Um, and, and, and, and, and they were able to engage and do well. We also have never seen in our studies, um, a correlation with outcome and PHQ nine severity. So, you know, just measured by symptom severity. Um, you know, these kinds of tools can be effective across a range. Now that's not to say there aren't other severity markers that are important, like somebody who has a history of being refractory to other treatments, or, um, you know, who has more severe mental illness or, or, uh, you know, you, you know, really terrible partial conditions that needed addressing, but just based on symptom severity. Uh, there's, there's not a lot of evidence that, that, that is, uh, uh, a good reason to keep people out or refer people in.
Kate Knutson (49:35):
The only thing I'll add is I think there's, there's the, the beauty of this is that it does help us extend our limited workforce. So you can, you can target these interventions, you know, to a mild, a much more, uh, early intervention, mild to moderate population, um, and extend, again, your workforce as specialists, do the other pieces for the severe and complex. You could potentially increase the touch points in between those face-to-face visits again. So you do have the in-person visits, but maybe you can extend them. And maybe there's a better sort of titration of the actual engagement in between those visits. If we can use technology again, we can use our specialist workforce potentially builds capacity within our specialty workforce. Thank you. So let me ask a question here in Charlotte. Again, I'm really enthralled with what you've done. What about the addition of just as we are now looking at social determinants
Rhonda Robinson Beale (50:28):
Of health, in terms of how it impacts a patient's ability to seek help and to utilize the help and to access help? What about personal determinants of health? You know, as you talked about, uh, having a sense of purpose, socialization and other things as part of what we as human beings use to remain resilient, I'm going to ask you what about those types of pieces starting to be incorporated into our screening? Uh, just as we would also look at therapeutic Alliance to see how much a person is viewing the interaction that they're having in a positive way, I'm asking those like, um, David, Sam, and others. What about looking at adding another dimension of personal determinants of health?
Charlotte Yeh (51:20):
So this is Charlotte. I just want to say we've actually a built-in survey. So instead of doing health risk assessments or assessments, so we're getting much header three 60 view, and then secondly, we're combining the digital in-person or person to person connection. So we can testing interventions with digital health tools to increase purpose of solving optimists, and we're finding that they do. Thirdly. We also believe in the power of Judah here. So how neighbors can reach out to share how they can try and think about how many of us are taking our older adults and actually share as opposed to worry about the stress of the uncertainty. And we found that older adults at these challenges to be extra helpful to others. So that's a way to combine digital for skillset development, and then even up here, an older person to person human content.
Sam Nordberg (52:39):
I mean, my observation would be that from a population health perspective, so much of our healthcare system is dedicated to that crisis care, right? We, we only catch people after their first schizophrenia break. We only catch them after they've hit the emergency department a whole bunch of times, and finally cost enough to get on our radar or the insurance company's radar. And, and you know, what we, what we have is a whole bunch of delayed maintenance for people who are already pretty, uh, you know, pretty challenged and really struggling. And we need to shift our focus to preventative medicine to early intervention and resilience training, for example, is a terrific way of inoculating against, um, you know, adverse stress reactions. But again, it's, it's, it's a challenge of, of, you know, limited resources and where do we put them and how do we redesign the system? So it incentivizes that kind of more preventative work rather than right now emphasizing the crisis stabilization work.
Kevin Larsen (53:38):
So with that, thank you, Sam. That was terrific. We, we are at the end of our hour, this was a wonderful discussion and want to thank you all here on this screen. You can see the additional sessions that we have coming up. I want to have a really encourage you all to take some time and, and answer our survey that is on your screen. It's really important to us in, uh, we hope that you'll come and join us for these next three sessions. The next webinar is on the 11th, and it will include the presentations from seven different investigators who will showcase the research and work that they've done using our Optim lab data and our optimum partnerships. Thank you again, and look forward to seeing you all and continue to collaborate in the future.
New models for behavioral health
What can be done to improve behavioral health outcomes? Hear from our panel of experts on the value of integrated care, digital health treatments, and resiliency in driving the quadruple aim.
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Virtual ideas exchange
Seven researchers from OptumLabs partner organizations show their novel use of OptumLabs data. Each tells the story of how the data is generating insights to help improve the health care system. Topics range from transgender health to low-value care to opioid tapering.
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Kevin Larsen (00:00:05):
Welcome to our third session of the Optum labs connections, 2020 part of our research and translation forum. My name is dr. Kevin Larson. I'm the senior vice president for clinical innovation and translation here at Optum labs. And I'll be your host and your moderator today.
Kevin Larsen (00:00:29):
Before we begin, I'd like to introduce you to very briefly talk to him labs. We're an evidence-based innovation collaborative within Optum and United health group, applying diverse perspectives and scientific rigor to a very rich data sets, uh, to generate actionable and publishable insights. As you can see here, we have leading partners in diverse sectors of healthcare. We have academic partners such as Johns Hopkins, and you see Mayo clinic. We have consumer advocacy organizations like ARP and physician practices as represented by the American medical group practice association. We also work with quality measurement partners like the MCQA and the pharmacy quality Alliance. Additionally, uh, we have a long standing relationships with the U S government and Optum together. We combine our healthcare expertise and data science techniques to work on one of the industry's leading data assets from this we extract insights that can help achieve our collective mission. Our data asset is unique. It's very longitudinal it's de-identified link claims, electronic health records and socioeconomic data carefully curated and enhanced with our different views and tools. This makes it easier for our partners to work with. And today we're going to be talking, hearing from a number of our partners who have been using this data asset for some really interesting and cool projects.
Kevin Larsen (00:02:05):
The virtual ideas exchange is the third of our five two hour sessions. We would love it if you could join us for the remaining two of our sessions, uh, those come on Tuesday, the 17th, we're excited to have a program around telemedicine, living better through health in the home. This will be beyond just telemedicine. We'll talk about digital health as well, especially in this time post COVID. Our final session is on Tuesday, December 8th, again from one to 3:00 PM Eastern time there we're highlighting chronic kidney disease, uh, ESR D and the polychronic population. There is a lot of new work and research in this space, uh, as well as new opportunities for care management and, and value-based programs with, uh, yesterday patients, newly being eligible to opt into Medicare advantage, hope that you will join us for those last two sessions as well.
Kevin Larsen (00:03:06):
Before we begin, I'd like to cover a few quick housekeeping items and how the virtual ideas exchange will work. You can expand your slide area by clicking to the maximize icon on the top right slide, or by dragging the bottom right corner of the slide area at the bottom of your audience console are multiple application widgets. You can use these to customize your music viewing experience. If you have any questions during the webcast, you can click on the Q and a widget to your presentation. We'll try to answer these at the end of the live presentation. And also if you're having any technical difficulty, please click on the help widget. It has a question, Mark icon and covers common technical issues.
New Speaker (00:03:06):
Kevin Larsen (00:03:52):
Today. We are excited to hear from seven researchers from our partner organizations, they will showcase novel and high value use cases of OptumLabs data. Some of these projects are early in their development. Some of these projects are further along, but all are committed and started doing their research. They'll tell a story of how the data is helping them generate new and actionable evidence and insight to improve the healthcare system. The projects you'll hear about, um, as I mentioned before, will be in varying stages of development. Some will be concept, and the researcher is just starting to work while others are finalized and publishable data. Here's the list of presenters. I'll introduce each presenter as we go.
Kevin Larsen (00:04:40):
The seven projects you'll hear about our opioid dose tapering from Josh Fenton, that UC Davis complex diagnostic journey. Uh, we did have scheduled Sarah Meyer from the Mayo clinic, but we now have chape goof for, uh, presenting for the Mayo clinic, neighborhood migration and clusters and health status from Marianna. Our Kaia of MIT patient cost distribution from David Jang at the Mayo clinic, transgender health care from Kellan Baker at Johns Hopkins school of public health and telemedicine and ophthalmology from Glenn U at UC Davis. Finally, we will be hearing about low value care from David Kim at Tufts.
Kevin Larsen (00:05:25):
We're excited today because our showcase will be a contest. It's a contest in storytelling about the data and the methods that made it work. Each speaker will have seven minutes to explain their project and how they use Optum labs, data followed by five minutes of Q and a, which I will moderate after that you, the audience will have an opportunity to rate each presentation. The scoring rubric is only one question based on the four elements, creativity, potential for impact storytelling and effective use of the Optum labs data. Again, those are creativity potential for impact, storytelling and effective use of our data. The poll will appear as a slide when it pops up on your screen, you'll have 30 seconds to lock in your vote. You'll vote after each of the presentations individually, after all seven researchers have presented we'll tally the results and the top three will win the prize. Their prize is a charitable contribution that Optum will make on behalf of one of the charities of their choice. You can see the charities highlighted here below the first prize will win a thousand dollars. The second prize 500 and the third prize two 50.
Kevin Larsen (00:06:51):
I would like to start now with, uh, Josh Fenton, professor, the department of family and community medicine at UC Davis. And he's going to present the clinical consequences of dose tapering and long-term opioid users. I will turn it over to Josh.
Josh Fenton (00:07:12):
Good morning. Uh, are you able to hear me? Yes, we can hear you. Great. Okay, great. Our project is, uh, has clinical significance for the millions of Americans who are prescribed long-term opioids for chronic pain due to concerns about efficacy and risks. There has been increased interest in reducing or tapering long-term opioids while tapering has the potential benefit of reducing overdose risk. There are also potential risks of tapering, such as heightened risk of overdose. Particularly if physically dependent patients are tapered rapidly, um, inter withdrawal and then substitute illicit opioids. There are also potential adverse mental health effects of tapering. And indeed the FDA has recently warned providers that rapid tapering may precipitate serious depression at risk of suicide. Um, lastly tapering can disrupt the patient prescriber relationship with potential, um, ramifications for, um, the delivery of chronic illness care. And our team has been working with the Optum labs data warehouse to, uh, describe secular trends and opioid tapering over time, and to assess the associations between tapering and the risk of emergency and hospital episodes for overdose and withdrawal and mental health crises.
Josh Fenton (00:08:35):
We're also looking at whether tapering is associated with differences in chronic disease, medication adherence among patients with hypertension and diabetes. We designed a retrospective cohort study. Um, our cohort includes adults prescribed stable doses of opioids, uh, greater or equal to 15 morphine milligram equivalents or MME in each month of a 12 month baseline period. And these patients all have at least two months of follow-up. After the period of stable dosing, we then use an empirically derived algorithm to identify tapering events during follow-ups in this algorithm, tapering is identified as a greater than or equal to 15% relative dose reduction as compared to baseline during any one of six overlapping 60 day periods during followup, I'm going to show you some analyses that look at trends over by year and by baseline dose and tapering. And I'm also going to show some analyses, um, of several outcomes in particularly looking at the association between tapering and emergency and hospital visits, stream followup for overdose or withdrawal, depression, anxiety, or suicide, and among patients who are prescribed two or more prescriptions for antihypertensive or antidiabetic drugs. During the baseline year, we looked at adherence, uh, with these drugs during followup. Um, and this is, uh, quantified using the measure percentage percentage of days covered during followup with a hundred percent indicating perfect adherence.
Josh Fenton (00:10:16):
This slide shows, um, age and sex, standardized rates, uh, dose tapering among patients using long-term opioid therapy by baseline dose from 2008 to 2017. Opioid tapering has become more common over time in all of the dose categories, but especially so among patients prescribed higher doses, which are shown with the yellow and the blue lines here. Um, we also found that tapering increases, especially in 2016 and 2017, potentially in partial response to the dissemination of a CDC opioid prescribing guideline in 2016, in 2017, 40 about 42% of patients in the highest test category and about 30% of patients in the next highest dose category, underwent tapering.
Josh Fenton (00:11:10):
This slide shows, um, um, incidents rates of emergency and hospital events during up to one year follow up among, um, non tapered and tapered patients in the first row. One can see that the adjusted incidents rate of overdose or withdrawal of ed was 4.6 per thousand person years among non tapered patients as compared to 6.8. Um, uh, and then per thousand person, years of non tapered patients, this difference represents an incidence rate ratio of 1.48. And the second row one could see the adjusted adjusted incidence rates for depression, anxiety, or suicide, um, events. And these were 2.8 per thousand person, years and non non taper patients as compared to 5.4%, 5.4 per thousand person years, and then taper patients. This difference represents an incidence rate ratio of 1.97, nearly a two-fold relative increase associated with tapering. This slide shows adjusted overdose rates by baseline dose and tapering status. While the adjusted overdose rates were higher among tapering patients in all baseline dose brutes, it was especially diversion among patients at the highest baseline doses, although not shown here. We also found that patients prescribed, um, higher baseline doses were also at especially high risk of mental health events during taper, after tapering.
Josh Fenton (00:12:49):
This slide shows antihypertensive and anti diabetes drug adherence by tapering status during follow-up the first row gives data for over 41,000 patients prescribed drugs for hypertension while adherence during followup change little from baseline to follow up for non taper patients, catering patients had an 8.1% decline in adherence during followup, there was a similar pattern among over 23,000 patients prescribed antidiabetic drugs in this group, the adjusted inherence with 7% lower among tapered as compared to non tapered patients during followup.
Josh Fenton (00:13:32):
Okay,
Josh Fenton (00:13:33):
So we found that opioid tapering was increasingly common and associated with increased risk of overdose and mental health crisis, as well as reduced adherence with chronic disease medications. This is an observational study and identified risks, maybe related to unmeasured factors. We are currently pursuing work, looking at, um, the influence of potential, the potential influence of, uh, dose reduction velocities on tapering safety. We're also looking at whether the changes in drug adherence that we, um, observed were associated with changes in blood pressure or diabetic control using extracted EMR data and laboratory data from the old w we are also studying whether these outcomes may be mediated by care continuity with prescribers. Our long-term hope is that this research will contribute to the improvement of the, in, um, in the safety of opioid prescribing and tapering and on patients with chronic pain in the United States.
Kevin Larsen (00:14:41):
Josh, that was terrific. Thank you. And again, if you have questions for Josh, please type them into the Q and a, I've got a couple of prepared. I will also acknowledge we're having a technical issue in that the speaker that does in this instance, Josh was not showing up on your main screen. We are working behind the scenes to see if we can make that, uh, make a solution there. Um, so Josh, how did you determine in claims data what the tapering algorithm should be? That seems like interesting clinical question to me.
Josh Fenton (00:15:20):
Yeah. To some extent it was, uh, as I said, uh, empirically derived, which, which really means that we, uh, we had to work with a lot, do a lot of descriptive analysis, um, to see, um, um, what the patterns and trajectories of opioid doses are after a period of stable baseline dosing. We also, uh, made some decisions about, um, uh, based on some recommendations from the CDC and the VA and other organizations about, um, how doctors ought to taper patients and how fast they ought to take care of patients. And we design the algorithms so that it would be sensitive enough to, to capture a, a, a slow taper over several months, um, as well as a more rapid dose reduction.
Kevin Larsen (00:16:11):
Cool. Um, we have a question from the audience were, were patients that were tapered provided Naloxone. Do you have an idea of what rate those patients had Naloxone? Did you look at that?
Josh Fenton (00:16:23):
We did not. We have not studied that. And that's a great question, um, that we have not that's perhaps we should put that on our list.
Kevin Larsen (00:16:32):
Uh, another question from the audience are using the EHR data optimize queue to look at age sex, weight, et cetera, as data points in your tapering algorithm.
Josh Fenton (00:16:45):
Um, no, we're not. Um, I we're using right now, we're using the Panthera data, uh, to access blood pressures. And, um, and then hemoglobin A1C is, uh, although the A1C is, are also available from the laboratory claim data, but, um, we have not accessed to my knowledge. We're not using the, the Optum IQ data, but that's, that's, that's something that makes me feel like I need to do some learnings.
Kevin Larsen (00:17:14):
Yeah. I think it's actually the same as the Panther data. It gets rebranded and depending on its use. So, um, but you're not looking at weight for example, in the data.
Josh Fenton (00:17:27):
Uh, no, we have not been using BMI data, um, at this point, um, perhaps that's something we should think about though.
Kevin Larsen (00:17:40):
Um, another question, how do you see these findings translating into smarter approaches for tapering?
Josh Fenton (00:17:48):
Yeah, well, one thought is that, you know, one thing we want to model specifically is actually Ailey, uh, uh, we thought w w we currently are thinking about, uh, approaching this from a quality metrics standpoint and trying to think about, um, um, not looking at individual events, but maybe a composite outcome as some type of adverse outcome, and then trying to model in a predictive way, um, a safe opioid, um, catering process. And if we could identify at kind of a parsimonious set of predictors, um, uh, of, of safe opioid tapering, this might, might lend itself to the development of a simple quality metric. I mean, my hypothesis is that, um, the rate of paper and especially how fast a patient is tapered might be particularly strongly predictive of safety. And, um, if that were, if we could, we could identify such a, such a metric, um, that might, might be something that could be disseminated along with other quality metrics that are currently out there that are, that are really encouraging doctors to taper.
Josh Fenton (00:19:01):
Uh, but that there's a, you know, there's a high dose tapering quality metric. Um, so I think that quality measurements, um, might be one way that we could actually affect, um, clinical practice in a positive way. Very cool. One final question from the audience, did you look at the causes of chronic pain to see if there was any difference of based on the reason for the chronic pain such as failed surgery, migraines, et cetera? Yeah, no, we did not. Um, I, that was really a decision that it's very difficult to do that. Um, with claims data, not impossible, I've seen some approaches, um, but, um, just due to, because people often have multiple, multiple different reasons for pain and, and, um, it's very hard to, to really, um, to have a lot of confidence that you're identifying why people are in chronic pain, but, um, that's something we, we thought about, but decided not to pursue. We are out of time for the questions. Uh, we will now give you 30 seconds to vote. So, um, I'm not seeing the voting widget are other senior voting legit. There we go. So again, please rate this on a scale of one to four and you'll have 30 seconds to do that.
Kevin Larsen (00:20:53):
[inaudible]
Kevin Larsen (00:20:53):
All right. Thank you. And we will move on to our next speaker. Um, uh, we have in, um, one of the research partners of Sarah Meier, Che Ngufor pardon me, if I pronounce your name incorrectly, who has agreed to speak, uh, for Sierra today, the topic that they have is diagnostic Odyssey and complex needs identification algorithm, and they're from the Mayo clinic. So Che we'll turn it over to you.
Che Ngufor (00:21:25):
Well, you hear me? Yes, we can hear you. Great. Uh, so, uh, as mentioned, um, so I hope so. Okay. So, uh, so we in primary claims by complex patient, these are some, because this is really difficult to really kind of describe these patients. We simply call them patients will wonder or joke around in the healthcare system. So basically we assemble, uh, you know, uh, desperate experts in data science services.
Che Ngufor (00:22:28):
So one of our studies is that our expert in data science and in treating complex patients. So really, as I mentioned, it is really challenging to actually describe the characteristics of these questions. So, uh, the initial phase of this project is really a proof of concept. We did assess in a way to identify these special populations. So, uh, the potential, so you can imagine such a really significantly Shazam this system has previously, we've done [inaudible] so they're reusing cost, internalization calls and other criteria for management perspective, of course, uh, normally to say, it's not going to really improve their quality of life or reduced hours.
New Speaker (00:22:28):
Che Ngufor (00:23:59):
What you're talking about. [inaudible] so basically we started about 2019. So basically we enroll all patients 18 to five years old, uh, 12 months of continuous enrollment in a commercial plan or prescription drug coverage. And then she should have at least one medical for 2019. With that said, we will acquire the initial story now for the expanded story, which will easily have these proof of concept. We plan to enroll all 18 years plus patients to include Medicare advantage population modeling, and currently expanded from a population of more than 7.5 million lives.
New Speaker (00:23:59):
Che Ngufor (00:25:08):
[inaudible] while we use raw tables on the professional level, and also now in conjunction with our collaboration with Optum labs, we are variables like while we call it a medical extra variable, this is basically on it that says if a patient received outside impression. So this such a variable to those patients who are churning or jumping around, no, uh, she is the metrics we really want to, um, in our collaborators, we see, uh, using the, we identified this population now in the hearing about cost model, the central idea is assigned to these patients, at least by the aspect of wandering in the moderate and moderate approach, it can actually be done moderately. We, the issue of identifiability. So we actually engage those patients and then once level in some ways, but right now this typical approach is very popular in recency frequency. So basically the recency frequency of the purchase, not usually men deficient, hopefully shown into Sarah operation, which will enable us to provide those patients with higher cost lifestyle [inaudible] lifestyle. Usually not that efficient, uh, actually in, uh, for example, we use with our writing patient, all our patients who, uh, complex patients that would not have now a long standing program.
Kevin Larsen (00:29:06):
Thank you. Che th that was really exciting. Um, uh, one of my questions is let's say that you hit a home run and this really works. What will we be able to do? What will we know, uh, when your project has succeeded?
Che Ngufor (00:29:23):
Uh, so really do sample Fisher kind of tell me some of these patients, so this project will enable us to get up in that sense. We kind of see by saying, okay, so we'll be fine. We'll see.
Kevin Larsen (00:30:26):
Terrific. Um, we have a question from the audience. It asks if you can define wander
Che Ngufor (00:30:34):
As far as you're wondering the patient. Yeah. So yeah, I think everybody will appreciate the fact that we have patients that you see that come back, they just keep bouncing around. Some of them may be watching basic would just find these patients. We don't know. Then we go into that segment.
Kevin Larsen (00:31:38):
Yeah. I think many of us as clinicians have taken care of these people that are searching and searching for the diagnosis. Um, another question from the audience, is there a way you can assess whether these patients have had diagnostic error, errors or diagnostic delays?
Che Ngufor (00:31:58):
Uh, currently, uh, we, we, uh, we, uh, are tracing that aspect, but I think in one of our meetings, well, instead of something like, it would say that a patient has, these are not equal in the diagnosis, but also with that diagnosis was one thing that, uh, one thing that we started meeting, so he's like, terrific. Um, and it gets to my question. Do you have a sense that you'll be able to tell when someone has their final or definitive diagnosis and their wandering has stopped? Yeah, I think this study because why now we have all that, uh, we have all the factors, but you'll quit because the frequency recency patients come in last.
Kevin Larsen (00:34:03):
Terrific. Thank you so much. We will now go to the survey and again, please rate diagnostic Odyssey and complex care needs, identification algorithm on a scale to one to four 30 minutes, and then we'll move to our next speaker. Thank you so much, Che. All right. I would like to now introduce, uh, Marianna Arcaya from MIT. She will be talking about health selective migration shocks or neighborhood effects, understanding reciprocal relationships between health and place. Thank you. And welcome, Mariana.
Mariana Arcaya (00:35:03):
Hi, thanks. Um, so I'm going to try and get my slides loaded. Not sure if that's yeah. Okay, fantastic. Thank you. All right. So thanks for having me today. I'm going to talk about an application of the Optum labs data to study the relationship between neighborhoods and health. And what I'm going to do is take about two minutes to describe the study context, and then about five minutes on the analysis. So the, um, the study I'm going to show you
Mariana Arcaya (00:35:38):
Is actually a product of a participatory action research study called the healthy neighborhood study. It's a multi-site longitudinal, um, participatory action research study that centers, resident driven insights into the complex relationship between health and, um, neighborhood change. And here's just a photo of our study team. Um, we work in nine communities in Eastern Massachusetts that have traditionally been characterized by low neighborhood's socioeconomic status, but are now experiencing early to mid stages of transformational economic growth. And our study team has been primarily interested in whether and how different forms of neighborhood change, including gentrification, which is, um, you know, one of the effects of the economic growth, these neighborhoods have been experiencing affect health. And so for the past five years or so, we've been working collaboratively on this question about neighborhood change and health. We've collected about 3000, um, community-based surveys and conducted about 150 in-depth qualitative interviews and our study sites to understand, um, the relationships between neighborhoods and health.
Mariana Arcaya (00:36:52):
We, um, I'm going to say a little bit more about participatory action research. This is an equitable research practice that is really based in collaboration in our case, it's academic institutions, nonprofit organizations, public agencies, and a network of 45 resident researchers. Um, and this collaboration allows us to integrate diverse perspectives on health and its determinants in low-income communities. And so par participatory action research means that we do everything together. We collect data together. We, um, designed data collection instruments together that highlight constructs that residents are interested in. We collaboratively analyze our data together, our quantitative data together. We collaboratively analyze our qualitative data together. And while we have been primarily interested in how neighborhoods affect health, um, as we were doing our work, our organizational partners in resident researchers also noted that, um, with transformational economic growth, we might also be seeing the in migration of socially advantage movers to our neighborhoods, um, in what we're terming health gentrification.
Mariana Arcaya (00:38:01):
And this really matters because if healthier people are moving into our neighborhoods, it could be that, um, reports on neighborhood health that appear to show improvements in health, um, could be due to, uh, basically the idea that health better, um, health is causing people to move to better neighborhoods rather than how real health gains for long-time neighborhood residents. And our consortium was really concerned that overlooking this potential for health gentrification could bolster false narratives that gentrification related health, uh, gentrification related changes could improve, could improve health when in reality, such changes might actually harm health. Um, and so before I show you the results of our analysis, I just want to acknowledge our community partners. I don't have time to go through all of them, but your, their logos are up here. And my doctoral students, Sebastian AlaskOmega who actually did this whole analysis. Um, and so I don't, I want to just make sure that this is a very collaborative process.
Mariana Arcaya (00:38:58):
Okay. So, um, our study included, we used, um, all balanced calendar panel of 3,502 enrollees from the Optum labs warehouse who had, um, lived at some point in a zip code in one of our nine, um, communities and had, was continuously assured, um, insured either through commercial or Medicaid, Medicare advantage insurance between 2009 and 2018. Um, we have a balanced panel again, of 3,502 enrollees. We, the first thing we did, because we're interested in the differences between people who stay in place and newly arrived to the neighborhood and leave the neighborhood is we grouped all the enrollees into six groups that described their tenure in our neighborhoods. Um, so people who had lived in the neighborhood early in the study observation period, who left those who left in the later half of the observation period, those who arrived in the early part of our observation, people who newly arrived in the late part of our observation period, and people who stayed put the whole time.
Mariana Arcaya (00:39:59):
So people who stayed in our neighborhood, people who were in our neighborhoods during an observation period are in green. And those who were outside of our neighborhoods are in purple here. Um, what showing our analytic approach to understanding the relationship between staying and leaving and arriving in the neighborhoods and health involved, a series of two level random effects models, where our outcome was used, the CMS chronic condition warehouse algorithm to get a count of total chronic conditions, just chronic physical conditions and just chronic mental health conditions between 2010 and 2018. Um, we have time fixed effects and individual covariates age, gender, and whether the insurance was commercial or Medicare advantage, um, standard errors were clustered at the enrollee level. And so we're having a kind of conservative estimate of statistical significance. And what we're interested in is whether people who are arriving to the neighborhood are healthier than people staying in place.
Mariana Arcaya (00:40:55):
So this graph is just showing us descriptively with no statistical adjustment, how many chronic conditions enrollees had over time. And what we're seeing is that for physical health conditions are stairs, the blue line appear to be the least healthy. And when we plot the, um, adjust, when we plot the coefficients from our adjusted model, what we're seeing is that relative to people who stay in our neighborhood, it's not the people who are coming in that are healthier. It's actually the people who are leaving the neighborhood, who are healthier, people who are leaving very early in the observation period and people who are leaving later in the observation period. And what we're noticing is that, um, the health differences are actually emerging prior to the move. And so we're seeing some evidence of, of health selective migration. So in short, we don't, we're not seeing obvious evidence for this idea of health, gentrification, healthier people moving in, but we are seeing a different and also very interesting and important phenomenon, which is that healthier people are leaving our neighborhoods. And these differences are emerging kind of early in our observation period and predictive of moves out of our neighborhoods. Um, so it's, it appears that our neighborhood sites are differentially retaining residents who are burdened with more chronic physical conditions. And we can now take this insight and update our community-based primary data collection protocols to get information, more depth, uh, resident centered in depth, qualitative information about why this might be happening and more importantly, understanding what supports support, and resources and urban planning and policy change our local residents might need.
Kevin Larsen (00:42:30):
Yeah, no, that was terrific. Thank you. Um, what have your research partners in the community thought of the findings? What are their insights?
Mariana Arcaya (00:42:40):
Um, you know, I think that we, this is, these are pretty new results. Um, we, again, this is a little bit, again, not, it's not that result we were expecting to find, we were expecting to find these healthier people, um, moving in. And I think right now we're just sort of digesting and processing. What does it mean, um, to have this sort of differential retention of people who have more, um, health needs. And so I don't want to speak on behalf of the whole consortium before we've all had a chance to kind of process the implications.
Kevin Larsen (00:43:11):
Cool. Uh, another question, uh, there's a strong correlation between income and health and income and disability. Have you been able to do any work either with this data or another data to understand the connection here with income and the leaving and arriving?
Mariana Arcaya (00:43:29):
So in this data, you know, the best sort of proxy for socioeconomic position of any sort is whether the insurance is commercial or, um, or not. And so, you know, we do see this, we do see this phenomenon when we restrict to just the commercially insured population. Um, we also do sensitivity analysis where we look at lab values and it looks like this sort of holds up when we're, um, not when we're measuring health status differently. Um, I don't think that our, um, I don't think that this data is going to allow us to get at that phenomenon at all, but there is a big literature in the urban planning, urban sociology, literature about, um, people becoming stuck in place. And that, that might be a relevant literature, um, to try to understand what sorts of, um, factors may either promote or hinder, um, residential mobility.
Kevin Larsen (00:44:24):
We have a question from the audience, how could this research help support health systems and plans as they for social determinant of health support?
Mariana Arcaya (00:44:34):
Yeah, I think this, this is such an important and great question. Thank you for the question. I mean, we w one thing we have reflected on is that we have findings that are very specific, um, to our sites, but I also think that this could be an interesting application, more broadly for health systems to kind of understand the places that they serve in a different way. Um, and I think that we probably need to do more work to understand the mechanisms from a resident centered perspective of about why this has happened. Things that will help inform what people actually need. But I do think a good first step might be trying to kind of create a different sort of description of places. That's not just, um, sort of repeated cross section of like what's the prevalence of diabetes, because what we're seeing in this analysis is that there are places that are sort of sinks for healthier residents, and there are places that appear to be areas that are attracting or retaining, um, people with different types of health problems in different health statuses.
Kevin Larsen (00:45:38):
So in my earlier research life, I studied in great immigrant health, and there's a whole healthy immigrant, um, uh, trope that may or may not be born out by the data. But some of the theories are that people that are healthy are, were able to move. Have you studied anything around the effects of who are the movers and why does they might be able to?
Mariana Arcaya (00:46:00):
So that's a great question. So we have not with this data, we have not been able to do that, but, um, we are, um, not the, not the whole community-based consortium, but my research group, um, inspired in part by these findings have, um, started looking at the panel study of income dynamics data set, which is a population-based sample of us households and starting to look at, um, who is whether, whether this is really a reflection of people moving at lower rates, or whether it's people moving at equal rates, but moving to different sorts of places. Um, and it's separate, completely separate data set based on what the PSID collects around health. Um, and that paper is not out yet, but what we are, um, finding is that it does appear that there is a bit of a, um, relationship between health status and the likelihood of moving, and then the neighborhood environments that people are moving into. So yes, not different data set, but, but yes, we are starting to see this effect that you're describing
Kevin Larsen (00:47:03):
Terrific. And our time for Q and a is up. Thank you so much. Um, I, we will now have, um, the, uh, the vote on, uh, this fantastic work health selection, migration shocks, or neighborhood effects. Um, again, you have 30 seconds to vote and we will move on to the next speaker. Okay.
New Speaker (00:47:46):
[inaudible]
Kevin Larsen (00:47:47):
All right. I'm very excited to welcome David Jiang from the Mayo clinic who is going to tell us about the work they're doing on analysis of the distribution of healthcare costs. I will turn it over to you, David.
David Jiang (00:48:01):
Uh, thank you, Kevin. Good afternoon, everyone. As you may know, the patients, uh, in the United States currently spend more than $1.7 trillion per year on healthcare. And that is expected to grow by 5.5% annually over the next decade. And so, as you can see by the graph here, the distribution of healthcare cost spending exhibits a significant right skew whereby the majority of the people spend nothing or close to nothing on healthcare. And most of the cost can be attributed to a small minority of people. The top 1% of spenders, uh, account for about a fifth of total spending and a top 5% account for just about half, uh, the bottom 50%, uh, only account for about 3% of spending and as such just of their current research exhibited in this area, uh, on cost saving and care systems has been targeted toward, toward these top 5% or the high need high cost patients and intuitively this makes sense, right?
David Jiang (00:49:01):
Like it tries to cut the cost of the highest spenders, but realistically, uh, trying to reduce costs in the site percent spending group, uh, is particularly challenging. Uh, research has indicated that these patients who are in the highest strata of healthcare spending are those who are often seriously ill or experienced a traumatic injury. So while some costs could be saved from these high need high cost patients, uh, most of these slots are inevitable. And so we hypothesize that, that it's, it's really difficult to be, to reduce, uh, due to practical or ethical concerns. For instance, it's almost impossible to prevent a patient from getting into a catastrophic, uh, car accidents, uh, or to prevent a patient from getting cancer or to prevent patients from seeking treatment so chemotherapy or radiation therapy that they may need.
David Jiang (00:49:53):
Uh, therefore, uh, in this study, we think it is better to, uh, get costs, uh, to cut costs, uh, from the next tier, the 80th to 95th percentile of the spenders, who account for 31% of total spending, or about, uh, $650 billion. Uh, there's virtually no studies trying to identify the, and categorize who these spenders are. Uh, and this project attempts to, uh, answer this particular question. And we hope that by identifying and categorizing the types of diagnosis and procedures of this port of spend, again, that's the 80th and 95th percentile of spenders, uh, we can make, uh, cost cutting more actionable. And so Optum's lab data is really the most suited for this project due to its ease and how it compares to the distribution of costs in the general American public in 2018, there were about 10 million unique patients, uh, in the medical claims, uh, table and of these 10 million patients they account for about 63 billion in total medical expenditure.
David Jiang (00:51:02):
Um, and as you can see distribution, uh, in the Optum labs, uh, distribution and the U S distribution is generally very similar. The only caveat is that, uh, Optum labs doesn't include people, uh, if we don't have health insurance, uh, which does skew the data a little bit, but, uh, that's a negligible in this case. So, uh, in this study, uh, we use 2018 data and after identifying all a unique splendors, we total their spending 2018 and group them into our cohorts of bottom 80% target cohort of the ATS and 95th percentile of splendors. And then the top 5% of spenders, and then took their ICD diagnosis and classified them via the clinical book classification, software CCS categories. And as you can see the diagnosis with the highest costs in the target cohort are listed here. Uh, the general takeaway here is that these tend to be, uh, either procedure based, such as hernias, uh, appendicitis, tonsillitis, uh, or other chronic conditions such as diabetes and mental health disorders.
David Jiang (00:52:06):
Also very notable is, um, uh, life birth, normal birth, and, um, complications of pregnancy, uh, these, uh, sort of combines, um, account for the highest cost in the target cohort. So next we wanted to see, uh, aside from diagnosis, how procedures were reflected within our cohorts and to get procedures, I separated them into Medicare advantage and commercial data, and then further took the commercial data, uh, and delineated them into, uh, inpatients, uh, and emergency departments, uh, and outpatients. Uh, and so the results here, uh, are shown by, uh, the outpatient classification by dose 2.0, uh, is a way of categorizing outpatients, uh, uh, procedural codes. So overall, uh, the top 5% spent more of the other and treatment categories while our target cohort spent the most on pristine leisure and anesthesia sort of confirming, uh, what we were expecting previously. And so after noticing these, we wanted to go and take a closer look into what makes up these specific categories and what are the drivers within these categories?
David Jiang (00:53:21):
So within treatments, um, the, uh, sort of the top, uh, the top 5% of spenders spent more on dialysis, chemo and radiation therapy, which confirms our initial suspicion, uh, of the type, uh, of patients at the top 1% contains. And also in, uh, others category, the majority comes from ambulance services, which again, shows that it's the emergency nature of, of the, of the spenders. Uh, and that's really difficult to sort of say, you know, you, you, you, you can't get an ambulance ride or you can't take chemotherapy, um, within the first, uh, category, uh, the target cohort again, uh, if you remember the top, the target cohort spent the most here. Uh, and then the target cohort generally spent more on procedures of the eye, the GI and digestive system and the musculoskeletal system. Um, and this also confirms, uh, that, uh, these procedures fit, uh, and our previous ICD diagnosis classifications.
David Jiang (00:54:24):
So in terms of next steps, uh, this is just the beginning of a project here, but the next steps you really wanted to like, take a look at the latent class analysis, uh, which allows for, um, the computer to look at underlying latent classes and group them in a way that's, uh, these categories, these categories and existing, uh, ways of classification might not be able to do. So. We want to take a look at multi-year tracking where we want to look at how long does it individual spend within each cohort. So is there a particular event that triggers them to be in the top cohort and what makes the dates, do they stay there for a number of years or do they go off, uh, you know, just a one year event and also further deep, deeper dives into identifying where the costs between the 80th and 95th percentile comes from. So, and with that happy to take questions,
Kevin Larsen (00:55:16):
Terrific work, David, that's really interesting. Um, what surprised you most in your findings?
David Jiang (00:55:24):
Uh, what surprised me the most, I guess, is, uh, the, the in terms of procedures, right? Let's go, let's go back. Um, within procedures, just in general procedures across the board, uh, is, is pretty much higher in our target cohort. And so these may, we don't know what these procedures are yet, and that's the next step, but we suspect a lot of them are elective procedures. Um, also intriguing, uh, are these, uh, imaging categories that, uh, we really wanted to take a look at. Um, so there, uh, among imaging, right? So some, some of these imaging may or may not be necessary. Some of these procedures may or may not be necessary. So that's where, where we want to take a look. And, and this is really an ethical issue because like we, at the same time, we don't want to overdiagnosis and overtreat, but also we want to provide sufficient treatments. So
Kevin Larsen (00:56:17):
Here's a question from the audience are the major cost drivers for your target population and driving
David Jiang (00:56:25):
Costs or providers seeing this population is able to pay and therefore pricing higher. The ideas about that, how much of this is we is market effects?
David Jiang (00:56:38):
So that's a good question. We don't know specifically whether or not the patients are, uh, whether their ability to pay is factoring to this. I know that in opt-ins we can see in terms of costs, which, which one of, uh, how much of the cost is patient. So out-of-pocket, and how much of it is paid by the plan. Uh, we haven't taken a deeper look into that particularly yet, but I do think that when it comes to sort of the elective procedures, uh, some of them may maybe to the fact that the patient requests or the doctor thinks that they have the ability to pay another question from the audience. Um, do you have any plans to utilize the data, to look for underlying root cause analysis for things such as maternal mortality in the us? Uh, we haven't, uh, gotten to that stage yet, but, um, I'll definitely make a note of that. Um, and, uh, sort of these underlying, um, trends, uh, we will definitely have to take a, take a look, uh, in a deeper, on the next level. Yeah. Another audience question. Um, have you done any work to define what is necessary care in the 80 to 95% group? Um, are you using things like clinical guidelines into deciding what's necessary versus not necessary?
David Jiang (00:58:03):
Uh, so far again, we just want it to sort of start classifying these and, and there's been no research on who these patients, uh, even are, uh, out there in literature. So I think the first step is what we've done so far, which is to say these are, these are the type of patients. And then the next step would be to say, which one of these, uh, clinically can we cuts without losing, um, the quality of care. So, um, that's a really great suggestion. And, um, that's what we're going to do next. I have a related question to in earlier, when have you looked at anything about, um, how much of this is volume of utilization versus cost of procedure?
David Jiang (00:58:47):
Um,
David Jiang (00:58:48):
Take a look at sort of, go ahead. Yeah, so we did, we did take a look at the, the sort of frequency, uh, of, of cases, uh, and, uh, by claims. Um, it turns out that, uh, the, the frequency sort of almost matches perfectly with, uh, what we see in the cost. So that's why I didn't present the frequency analysis here. Um, I did take a quick look and see sort of cost per case. Um, and in terms of cost per case, um, the, the top 5% far I'll I'll I'll Spence,
Kevin Larsen (00:59:22):
Um, uh, the, the, uh, our target cohort, which makes sense as you know, there are complications and et cetera, et cetera, that comes along with it. So thank you, David. That was really terrific. We will now move to the audience voting. Um, and so again, please rate the analysis of the distribution of healthcare costs on a scale of one to four, based on the following criteria and creativity potential for impact storytelling and effective use of OptumLabs data. You'll have 30 seconds, and then we'll move on to the next speaker.
Kevin Larsen (01:00:18):
[inaudible]
Kevin Larsen (01:00:20):
All right. We will now have Kellan Baker, who is a Centennial scholar and the Robert Wood Johnson health policy research scholar at Johns Hopkins Bloomberg school of public health Kellen will be speaking on transitioning coverage, the effect of expanding insurance coverage for gender affirming care on hair, health care, utilization, and costs, and the transgender population. Uh, I will turn it over to Kellen.
Kellen Baker (01:00:47):
Thanks so much, Kevin, I'm thrilled to have the opportunity to talk with you all today. I really wanted to introduce you to a question that I hear a lot in my field of work, which is me something. And this typically isn't meant in sort of a snarky Paris Hilton kind of way. It's meant literally tell me all of the things that we don't know about transgender populations, who we are, what type of health care people need, and what sorts of experiences they're having. Fortunately, the OptumLabs claims data is an incorrect types of this information, particularly morbidity and mortality, health services, utilization, and costs.
Kellen Baker (01:01:27):
So I took a look at the optimized claims, uh, claims data to find the transgender folks that I could identify with what I like to call the silver standard. So this is based on an algorithm that was, uh, that was originally developed by the centers for Medicare and Medicaid services and the veterans administration. And it uses ICD nine and ICD 10 diagnostic codes that are highly specific for transgender people to identify folks who may be, or should be considered to be transgender in claims data. Since these codes are highly specific, we really do not anticipate, or it's actually been shown another work that we don't really pick up people who are cisgender that is not transgender with these codes for better or for worse. We also don't necessarily pick up everyone who is transgender. The United States has a long history of insurance exclusions that actually keep transgender people from being able to get coverage for gender affirming care.
Kellen Baker (01:02:19):
They're also getting access to coverage for any care at all. So transgender people in the clinicians that they work with have typically been, uh, careful in the past to keep these diagnoses out of their claims history. But over the last 10 years, there's been a lot of policy reforms, a lot of work that's been going on that I've been a part of at the federal end at the state levels in order to remove these exclusions and ensure that people can get access to the care that they need. And as a result, when you look at the history of which folks can be identified as transgender in the Optum labs, labs claims data, it's very, very, very low until about 2010, 2011, when it starts to shoot up in an exponential curve. So that's very exciting. It shows that there are a lot of transgender people in the Optum labs claims data and for better, or for worse though, when we look at the types of experiences that they're having with regard to health status, we see for example, that they have many more chronic conditions than comparable cisgender enrollees.
Kellen Baker (01:03:14):
So these are folks that are matched three to one with transgender, uh, with cisgender people, uh, in the Optum labs database. And you can see pretty much across the board, transgender people, that's the yellow color on the right, have many more chronic conditions than cis-gender people. Particularly if you look at the bottom conditions such as anxiety and depression, it's really important to note that these conditions, all of the chronic conditions, the disparities, greater health services use and higher costs, all of which we can see for the transgender population in the claims data they don't come about because transgender people are inherently sick. The minority stress framework shows that the relationship between being transgender over there on the left and the chronic conditions, health services use and costs that we can see in the Optum labs data are actually mediated by a variety of minority stressors, which include prejudice, discrimination, abuse, material deprivation, and a lack of gender affirmation.
Kellen Baker (01:04:14):
These experiences are also moderated by, for example, other targeted identities. So people who are black or from other communities of color have different experiences than white transgender people also moderated by coping and resilience, as well as by barriers to care such as uninsurance or some of these exclusions, these coverage exclusions that we've been talking about. It turns out we can also see some of these minority stressors in the Optum lives, claims data. So this is again, looking at that cohort and identifying minority stressors that include social exclusion, homelessness, family employment, and education issues, and abuse. These are documented in ICD nine with the V and E codes and an ICD 10 by Z codes. You can see all across the board, again, a substantially greater prevalence of these codes, which are the type of providers that are most likely to assign these codes. So my research really tries to look at what Optum labs claims data can tell us about transgender health.
Kellen Baker (01:05:19):
Because as I mentioned, there are so many gaps. There are so many things we don't know, including some of the basics, like what are the differences in healthcare needs costs and use between transgender and cisgender people also trying to evaluate that mediating role of social needs or minority stressors in driving these differences and documenting costs and utilization of gender affirming care, both in a snapshot, a sort of cross-sectional way, and also looking at people over time to see how their trajectory is through care change. And finally, on the basis of all of this work, building a predictive cost model that assesses the potential benefits of risk adjustment for the transgender population. This is work that is very personal and very important for me to do, uh, because I'm interested in it from a research perspective, but also I know that things really need to change when it comes to the legal and medical situations environments that transgender people are encountering in the United States.
Kellen Baker (01:06:21):
For example, a major goal is to actually expand non-discrimination protections for transgender people, not only in education and employment, but also in healthcare settings, that map here shows the patchwork that currently exists in those light blue, uh, those light green States. There are no non-discrimination protections for transgender people in healthcare. The type of information that we can get from the Optum labs claims data that actually shows us the relationship between minority stressors, such as discrimination and poor health outcomes and higher costs is something that's really critical evidence for policy makers to use. When understanding why making changes such as new non-discrimination protections are necessary. A related goal is broadening availability of coverage for gender affirming care. This map shows the patchwork again of coverage, uh, in the Medicaid program. Those States that are in orange have outright explicit bans on coverage for gender affirming care for transgender people.
Kellen Baker (01:07:22):
And all those States that are in light green, don't mention it at all, which typically means that coverage and care are denied state Medicaid directors. The courts and policymakers generally are increasingly looking for evidence about how much gender from in-care transgender people actually use what that care actually is and how much it costs. And that type of information is something that's really only available from the types of, uh, claims data that are available through Optum labs. So this is an effort to build the evidence base that we can actually hand to policymakers, um, in encouraging them to do the right thing and improve the ways that transgender people can access healthcare and coverage in this country. And I do this work with a variety of partners before I, uh, entered my graduate program. I worked at a think tank in Washington, DC, where I'd focused on, uh, non-discrimination protections, primarily for transgender people. And I also want to note that there are any number of incredible partners out there. This picture that is painted of Trenchtown under health is often very negative. And so I think it's really important to take a look for example, at these faces of these partners who are all elected representatives, who identify as transgender. So these are the types of folks that I work with closely and look forward to having the opportunity to share the evidence that comes from the Optum labs data about exactly what transgender people need in the context.
Kevin Larsen (01:08:51):
Kellen, thank you. This is really terrific work. Um, it's such a pleasure to see this progress. I was part of early work in it from Minnesota called the transgender health coalition. That that was remarking it, how little data there was back in the early two thousands, a question for you. I'd lot of, um, providers that I colleagues that I know, um, no longer see this as a bi-modal condition, CIS or trans, but there are a lot of people with a lot of different choices in the middle. How are you thinking about this as a continuum of gender choices, as opposed to this being, um, purely CIS or trans?
Kellen Baker (01:09:30):
So this is really looking at one end of what you correctly note is a pretty broad spectrum of gender and gender identity. So this is really the folks at the one far side who have pursued care that is related to gender affirmation. So medical care related to gender affirmation is typically the reason that these codes appear in the record. And that is definitely not the entire transgender population in particular people who are non-binary or who, for other reasons aren't pursuing healthcare services related to gender affirmation. We won't see them using this algorithm. So one of the things that I hope will happen with, uh, with this work in the future and with, uh, claims databases, such as Optum, is looking at ways that we can expand who we're able to identify. And that is something that, uh, I'm exploring, looking into, uh, pulling in other types of, um, indicators for who might be transgender. It also goes back to the importance of documenting gender identity and transgender status, for example, so that we actually have that sort of gold standard from self identification of who is, who considers themselves to be transgender. So we can understand that the spectrum of identities,
Kevin Larsen (01:10:40):
Terrific, uh, question from the audience, um, do the chronic conditions vary between transgendered males and transgendered females.
Kellen Baker (01:10:49):
They really don't, uh, very strongly vary between the two. And it's interesting. I should also note that we don't really know who should be considered to be a transgender man and who should be considered to be a transgender woman. The sex data that are in Optum are sometimes associated, uh, sort of, I would say appropriately with the type of healthcare, for example, hormone therapy that people are getting where we can really tell, um, you know, how a person identifies and what through what types of gender affirming care they're accessing. But it's really kind of all over the map and goes back again to the importance of documenting transgender status in multiple ways, for example, the Mars, as well as in population surveys, so that we can try to get a better sense of what the population distributions look like. If you look at population serving data, for example, you can see that about one third of people identify as transgender men. One third is transgender women, and one third is non binary. And so we haven't seen a lot of differences, uh, so far in the work that I've been doing in this database, but that is something that needs to be explored.
Kevin Larsen (01:11:55):
Thank you. Another question from the audience, um, do you have a sense of what characteristics there are of the providers that use these codes for transgender? Presumably it's not the majority of providers,
Kellen Baker (01:12:08):
So we don't know. That's one of the things that I would love to explore using the provider ID information in Optum labs, because one of the things that frequently comes out in a gender, gender affirming care or transgender health is that this is a highly specialized condition that needs to be managed by certain types of providers. But what we actually know is the majority of the type of gender affirming care that people need, for example, is hormone therapy, which is the same sort of garden variety medications that cis-gender people need and use all the time. So looking into the ability for transgender people to receive, not just the general care that anyone needs, but also gender from in-care such as hormone therapy in primary care context is a really important future direction of identifying to what degree that's already happening, so that we can look at ways of expanding the availability of that coverage and that care.
Kevin Larsen (01:13:02):
Have you looked at the interactions between other kinds of, um, uh, health equity issues, like race, like country of origin, like language spoken, uh, with transgenderism?
Kellen Baker (01:13:16):
So the, just as a quick note, the term transgenderism would be replaced by, for example, uh, gender identity, gender dysphoria is something that is typically more often used. A lot of the terminology that's reflected in the claims data is older. Um, but as far as interactions with, uh, other aspects of identity. So there, isn't a huge difference by geography. There are fewer trans folks in the South according to these data, but I think that that's really about selection bias in the sense of which providers are coding, um, with these, these trends, gender specific codes in which aren't, there aren't any substantive differences by race, uh, apart from the fact that the transgender population is slightly wider than the Optum labs population overall. And that really does track with what we know of. Again, the, the sort of minority stress experiences are not they're multiplicative.
Kellen Baker (01:14:12):
And so people who aren't black and transgender for example, are much less likely to be able to access the type of private coverage that would actually bring them into this database in the first place. So there's a lot that we can't see in this database about the details and nuances of transgender people's experiences. But if this is an incredible baseline for some of the macro questions that we really still don't know the answers to how much and what types of healthcare do transgender people need and use broadly speaking, what are the cost dynamics there? So that, that can inform then for example, um, coverage decisions that are being made by Medicaid, which is the type of insurance coverage that alone, for example, black transgender people might have access to.
Kevin Larsen (01:14:57):
Thank you very much. Um, we will now move to the, um, uh, voting again, please rate transitioning coverage, the effect of expanding insurance coverage for gender affirming care on healthcare utilization costs and the transgender population 30 seconds. And then we will move on to our next speaker.
Kevin Larsen (01:15:37):
[inaudible]
Kevin Larsen (01:15:38):
All right. Pleased to introduce Glenn, you associate professor in the department of ophthalmology and vision science at UC Davis Glenn we'll be talking to us about clinical and cost effectiveness and tele ophthalmology. Thank you, Glenn.
Glenn Yiu (01:15:54):
Hi. How are you? Um, so today I want to talk a little bit about a project that we're planning to work with Optum labs to study tele ophthalmology. I'm going to spend more time at the beginning talking about some of the work you've already done, um, launching a Tel ophthalmology programs and the challenges and barriers of that program and why we want to look at class data for that. Um, as you know, diabetes is a growing problem in the United States and diabetic retinopathy is now the leading cause of vision loss among working adults. Um, in developed nations, uh, early diabetic retinopathy is associated with these hemorrhages and exit dates in the retina, but the vision is usually very good.
Glenn Yiu (01:16:33):
And so the later stage is where you can have, uh, what's called proliferative diabetic retinopathy, or you can retinal detachment that can cause blindness. And it's in those cases where people are losing their vision. And as a result of the American diabetes association recommend that most patients diabetic patients should undergo yearly eye screening with knives for providers. Now, the concept of tele-ophthalmology is that when we deploy Adriatic cameras, these are cameras that don't require dilation in primary care settings. And the concept is that the patient would see their primary care doc, get a picture of their eyes taken at the same visit images, the wired to an eyecare provider who reports on the results, sends it back to the doctors so that they can either come back patients and just come back for routine yearly eye screening with the camera, or they have to be referred to in-person visits.
Glenn Yiu (01:17:28):
Now, the coding for tele-ophthalmology is, is a little complex. Generally the current codes use of these 90 to seven to nine eight, which are a tele-health codes that they don't pay very well. The first is first, uh, screening of asymptomatic patients. And the second is for monitoring the people with mild disease. A majority of the people actually use this 92, five zero code, sorry, that's incorrect way highlighted, but it's actually meant ophthalmologists for measuring patients were already being seen by an eye care provider, but it pays significantly more. Um, we actually, um, also, uh, CPT codes, which are used for quality instead of payments and programs generally for telehealth is 2026. Now in 2018, we launched the telephones program at Midtown clinic, which is a clinic that was, uh, an aggregate of multiple small practices in the area into one centralized location. And overall patients love the convenience.
Glenn Yiu (01:18:33):
They were very satisfied with the service. Uh, we screen about 300 patients and you can see at her lunch program, we bumped screening rate from a not very good 48%, about 15% at that one location. And the health system overall showed a small increase cause it's just a single site. Uh, but this was the information we took to our leadership to try to expand the program. Now that a major limitation and barrier is in payments now are out of the charges we made about half of them were actually denied mostly by Medicare because they sided with this was screening of patients. Um, and a half that did pay were primarily private peers.
Glenn Yiu (01:19:16):
And overall the screening
Glenn Yiu (01:19:18):
Was very successful. Only about 5% of patients were considered upgradeable and therefore needed to be referred in person. Um, most patients had none to only mild B that could be followed with tele medicine. Uh, we did find interestingly, a number of other, uh, uh, suspicious features like risk of glaucoma or macular degeneration. They were able to pick up and overall we referred about 30% of the patients for, uh, to the eye center. And this is a nice flow chart, kind of showing how the community of patients we screen ended up in how many in-person visits we were able to eliminate with this type of program. Um, now the major limitation of most great idea, it reduces and eliminates in-person visits in particularly relevant in the era. Um, but the question is the cost. If you take into account the operator of the camera, the camera, cause the, it comes out to about $40 per person, whereas we're really only collecting about $20 for, in terms of team and return on investments.
Glenn Yiu (01:20:27):
And we did some modeling and just to summarize, uh, we do notice that if you do increase, your deputy went up 10% combined with others actors, you could get instead of payments up to about $30 in additional profusion. And then you're also tapping more sick patients into the high Cornick, as opposed to screening patients and just downstream collections. Those are actually significant. So we do find that there is a good amount of gain to the health system. And then for healthcare in general, there's also the cost savings or eliminating ENM visits each patient. Now the goal of our study with OptumLabs then is to try to gather additional information on how is tele-ophthalmology wise affecting humans, and more importantly, to look at how much clinical, uh, uh, improvement there is cream, uh, uh, end-stage vision loss, uh, adverse outcomes. And does it also lower the cost of my chair, just people who get screened by capturing them into the health system, um, whether maybe we can eliminate the costs more expensive issues down the line if they become, uh, some early analysis of our, of the Optimum's labs data shows that indeed telephones utilization has significantly increased over the course of about 10 in the last 10 years.
Glenn Yiu (01:21:58):
Uh, we also found that that [inaudible], that is used by a lot of non eyecare provider significantly, uh, was used more than the others, but this really kind of sets the stage to doing the analysis of trying to look at both clinical outcomes as well as value outcomes. So in summary, our telephone logic program has improved that many would not be screening in an outpatient clinic by about 15% of eliminated, about 200 in-person exams. Unfortunately that costs not adequately covered by direct payments, but could be essentially supported by cost savings. Um, and hopefully our optimum stat, uh, data warehouse study roles trimming, whether it's contribute to better clinical outcomes from better value. Sorry, that's my timer. And I check that's pretty good. Um, and I'm happy to take any questions.
Kevin Larsen (01:22:57):
Terrific. This is great work. Um, uh, we have a question from the audience, uh, any plans for rolling this out for
Kevin Larsen (01:23:06):
Other things like cataract evaluation and monitoring.
Glenn Yiu (01:23:10):
Yeah. There's actually a lot of work that I'm doing. I'm actually, by a lot of my background is in, uh, ocular imaging and we're actually collaborating with colleagues at Berkeley to use, um, deep learning because there's a lot of information, you know, Google in 2016, found that you can automate this without an ophthalmologist and have software, uh, automatically detect whether there's presence of diabetic retinopathy. But those software only tells you yes or no, whether there's actually, we have unpublished data suggesting that you can detect other topologies using them unsupervised objective software, and that you don't tell it what it sees and it tells you what it's, I'm going to question, how are you going to determine outcomes using the data that we have? Are you able to see who's retained their vision, who's lost their vision? How do you know that from the data asset, the most, the most basic clinical outcomes.
Glenn Yiu (01:24:08):
And we're going to start with is just the time to first eye, uh, uh, to the first eyecare visit, because the thing is that oftentimes we're in LA where essentially our, um, anchor date is that data, uh, diabetes diagnosis. And the question is when do they get to an eye doctor? So hopefully the utilization of tele-ophthalmology would get them to see an eye doctor a lot earlier. And a lot of our other data suggests that most patients actually don't end up seeing their eye doctors at all. So I think at the very least wants to actually the most important outcome. Most assessable by the data is how quickly they get to see an eyecare provider. We do have some plans to look at kind of further outcomes, like actual blindness codes, uh, retinal attachments, and other, uh, um, AI-related, uh, and points. And those will take into account town, a lot of other factors. So I think our first-line we'll be looking at, um, I'm screening.
Kevin Larsen (01:25:08):
Terrific.
Kevin Larsen (01:25:09):
We have another question from the audience. What sort of cross diagnoses such as diabetes is scoped within this work? If so, how are referrals back to a primary care provider? Uh, look, how do you understand those and how do you make sure they're connected to the patient with this full closed loop referral?
Glenn Yiu (01:25:30):
Um, so are you talking about in our program, how do we, or how do we get the, essentially the information back to the primary care provider?
Kevin Larsen (01:25:38):
Um, assume that's what they're looking at. I'm just reading the question from the chat. So yeah,
Glenn Yiu (01:25:45):
and I don't have access to the chat. Um, I mean the con in general are our system. That's one of the major limitations, right? Is whether when we send a report back to the provider, whether the provider will communicate that information to the patient and how many of those patients followed up, um, when you look back way to go back
Glenn Yiu (01:26:04):
In our slides, but essentially our actual, um, uh, those who were referred for an inpatient in person visit a large number of them did not follow up. And, you know, this is with multiple phone calls to as patients. Um, so there's some work not relate to what we're working on. And that's trying to understand this kind of loophole where essentially the patients are screened, but the information doesn't get back to them. I do think that the implementation of artificial intelligence was Fastly getting rid of this because essentially patients will come back. Essentially the patients would know the data because using artificial intelligence, we know immediately what they need to be seen by an ophthalmologist, as opposed to waiting for an immediacy or being to get the referral on the day, a physician's office could potentially closest loop.
Kevin Larsen (01:26:59):
Are you expecting, expecting to see a dramatic spike in the tele ophthalmology with the COVID tele-health um, spike? Has that the same for eyecare?
Glenn Yiu (01:27:11):
Yeah, we, we definitely have already seen since the beginning of the year, there's a lot of interests. Like our healthcare, our health system was already planning to expand on some of our data from our pilot site. They were already planning it. And now the utilization is increasing because of the reluctance of patients who go to see an inpatient ophthalmologist and the cost of just deploying a camera is relatively low compared to all these in-person visits.
Kevin Larsen (01:27:40):
That's terrific. Thank you so much. We are at time. Uh, we will move on to the, um, the questionnaire. Let me just zip through your slides here. I got it. And there we go. Um, please rate clinical and cost effectiveness of tele ophthalmology on a scale of one to four, one being good and four being great. Uh, we'll give 30 seconds and then we'll move to our final speaker, David Kiim. All right. Uh, last, but certainly not least is, uh, dr. David Kim assistant professor for the center for evaluation of value and risk and health at Tufts medical center Institute for clinical research and health policy studies. Uh, dr. Kim will be presenting on crisis into the opportunity preventing the resurgence of low value care and close to COVID-19. I'll turn it over to you.
David Kim (01:28:54):
Okay.
David Kim (01:28:55):
Uh, thank you for inviting me to speak at the Optum labs Virtual ID exchange. Uh, today I'm going to talk
David Kim (01:29:02):
About the idea about using the COVID-19 crisis as an opportunity to improve our health care system efficiency. This project is supported by Hunter ventures, uh, in a center for evaluation of value and risk in health and Tufts medical center, and then Optum labs for data access. So all up the graphic that I'm going to show you is really based on the Optum labs warehouse data analysis. So let me turn the clock back to where it all begins when no one hopes that this continues till today and probably in the foreseeable future, but in the mid March in an attempt to prioritize urgent clinical name, preserved healthcare resources and reduce the risk of transmitting this Corona virus, your hospital stopped providing nonessential procedures. And a few weeks later, actually the CMS officially announced in depth in the delay of nonessential surgeries and procedures followed by similar state level guidelines across the country.
David Kim (01:30:13):
Yeah. I think the slides got caught into it, but let me, I will continue it. Yeah. But as a health economist, I've been thinking about this issues over waste in our healthcare system. My call started then I, okay, here we go. So my calls, I was in, I actually thought this coronavirus pandemic is actually some exceptional opportunity to initiate your normal, to address the problem of us healthcare, which is a prevalence of services that deliver no or minimum clinical benefits. Often we call the low value services. So what does this mean? So I'm going to show you some example. So this graph highlights the use of prostate PSA testing for prostate cancer among men prior to the pandemic from the 2009 to 2019 and two lines green and red, actually contrast to use a PSA testing when deemed appropriate, which is the green line for the men eight under 70 compared to when the PSA testing deemed inappropriate red line, which is for the men age over 75.
David Kim (01:31:38):
So you just see in this graph, despite the slightly more use of inappropriate screening, the trends in both lines are increasingly recently, particularly after 2006. And our findings actually highlights that there are some national guidelines and some policy efforts to prevent this to happen. The parents will still receive the PSA testing regardless of its clinical value and appropriateness. So let's revisit our ideas about the why we call the coronavirus. 19 pandemic can be an opportunity. So let me orient you in this figure, which is divided into three segments. One is a pre COVID-19 second during the COVID-19, which technically we are still in. Uh, and then, uh, last segment is the hypothetical new normal. So as you see in this graph, during the coronavirus pandemic, when hospital stopped providing non essential services, the use of both appropriate and low-value cancer screenings actually plummeted, you see those aligns actually plummeted all together around the week of LA 12, which is like March and then April.
David Kim (01:33:00):
So what we argue in this kind of thought piece that now we can actually set the new baseline for us to measure against healthcare efficiency. We should think about how to sustain this substantial reductions of the low value services while providing, you know, incentives to encourage the use of high value services. So you see in this graph on the right panel, that as we fathered down through the new normal, the gap between the high value services versus low value services, you know, continue to increases, which are our ideas, that this is a ways to improve healthcare efficiency.
David Kim (01:33:45):
However sure. We shared this ideas in all the summer. We are actually able to analyze what actually happened in contrast to what we did, what we thought that it should happen. So this is another graph going back to the PSA screen. So this graph is kind of a June in 2019 and 2020. So the solid line representing the trends of PSA screening in 2019, when there was no pandemic. And then the dotted line representing the trends, all the PSA screening in 2020 in a corresponding months, and similarly green light representing the user appropriate screening, and then a red line represented the inappropriate use of PSA screening based on the guideline. And it just see here that it did actually plummeted in the all year in the pandemic in a March and April. You see that bar back in the may actually quickly a resurgence, but again, the important things is that both PSA testing appropriate and inappropriate, actually we surgeons regardless of its clinical value and appropriateness.
David Kim (01:35:02):
And one thing to note that the reductions in the tail end around the June is more due to lag in the updating and the Optum lab data, not really what's happening in the field. So that's the one caveat in our analysis. So why this happen, which is a gaze to what we hope to see. So there are many potential reasons about this kind of interesting things that a few weeks ago, the wall street journal actually shared articles that hospitals, after those days, experiencing those, all the Corona virus pandemic, they continue to provide new creative and elective procedures. One of the reasons is to compensate for the substantial revenue loss that they experienced during the coronavirus pandemic. So what are the implications then? What are the next step in a short poem, we need to investigate the nonclinical factors to drive off low value services during the pandemic, and really try to understand how the patterns in healthcare utilization has been shifted after the coronavirus pandemic.
David Kim (01:36:05):
Telemedicine is a one thing, but from like high value versus low value services perspective, one thing example where the really resurgence of low value services is actually driven by the profitability of services. That's the one idea in the long run kind of to sustain and to sustain and sustain our health care efficiency improvement. Then we need a kind of multifaceted policy level approaches and we share like few ideas. One is the obviously value-based payment model. The ACO is one examples to provide it, you know, incentive physicians, uh, when they meet a certain quality. But we argued that we actually try to implement seizing the pain months when provider actually prescribed a low value or unnecessary services. So that was at the provider level, but also at the patient level, we need to align the patient cost sharing, uh, with the value of the underlying services.
David Kim (01:37:04):
And then finally at the system level, we need to leverage the wide spread of electrical health records systems to change the eating this all during one example, kind of giving like popped up LAR that when providers try to prescribe the low value services, then they can still process in the next, but give a little bit warning that, Hey, you know what you're trying to do actually against the United States, preventative services, task force guidelines. So these are kind of some ideas that we share, uh, to move this field forward. So thank you. And I'll stop here.
Kevin Larsen (01:37:40):
Thank you so much, David. Uh, we will open up now for Q and a. Um, so David, have you started looking at any other low value conditions besides prostate cancers?
David Kim (01:37:53):
Yeah, so, uh, I show just the one example of prostate cancer, but we, uh, analyze it for different types of cancer screening, uh, prostate cancer screening, cervical cancer screening, colorectal cancer, and then cancer screening overall for dialysis patients. So that was more focusing on the cancer screening. We also pull out, uh, you know, trends in the youth, uh, low value services across 27 other services, uh, in, uh, kind of pre-operative testings, uh, pre-operative testing for Cadillac surgery or cardiovascular disease surgery. And then there are like other types of low value services we actually in Stripe.
Kevin Larsen (01:38:34):
And are you finding similar trends?
David Kim (01:38:37):
No. So once you finding is that the trends is actually varies depending on which particular services you're going to look at. It, people like within the cancer screening, the trends in the PSA, the prostate cancer screening, actually going up among the Medicare advantage populations, which is over age 65, who fours that United health plans. But if you're looking at those 30 for cancer screening over age 65, and then a colorectal cancer screening over age 85, you'd actually declining over time a bit. Uh, the trend is quite not like dramatic as much as a PSA screening. So my answer is that it really depends on which particular services you're going to looking at.
Kevin Larsen (01:39:18):
And then, uh, do you have difficulty identifying within the claims, um, which are the low value services?
David Kim (01:39:26):
Yeah, so there are, so we had not, prior to this claims analysis, we actually review over thousand clinical guidelines to identify a low value services or any guidelines that basically they recommend against doing it. And only, you know, to be honest, like only like 32, like 50 low value services that can be identifiable through the claims data. So, uh, we review all their literatures. And then so far we have collected around like 55 lens-based low value care algorithm, which means that there are like more like low belly services. But if you tried to use the claims data, there are about like 50 to 60, uh, low value care can, uh, they can be identifiable.
Kevin Larsen (01:40:19):
Uh, and then, uh, finally a question from the audience. Um, do you have any research or literature that shows, uh, various forms of benefit design or patient cost sharing that, uh, change the use of low value services?
David Kim (01:40:35):
Yeah, so there is a one articles came out in the health economics in, uh, uh, in a few months ago from, by the John groupers at MIT to really try to implementing this value based insurance designs, to look at changes in the low value services. And that depth paper indeed found that off, uh, you
David Kim (01:40:54):
Know, not great by, you know, modest effects of the reducing utilize Jason's of low value services. So more important than it's just talking about, you know, impact of ACO or impact of a value based insurance design on the utilization, a lot of evidence kind of mixed and then. It really depends on what types of services you are going to looking at it. And when they do have a fact, it's more of like modest effect in terms of reducing utilization, uh, particularly on the low value services, there was a one-year-old trust came out. And then, uh, I know like a lot of other research has tried to really push this forward.
Kevin Larsen (01:41:31):
Thank you so much David. Uh, we will now move on and, uh, uh, rate the David's talk on crisis into opportunity preventing resurgence of low value care and post COVID-19. Again, rate from a scale of one being good to four being great. Um, we'll have 30 seconds and then we will move on to the next part of our talk.
Kevin Larsen (01:42:09):
All right. Well, the, we tally the scores from all of the, the talks. And again, thank you so much to each of our presenters for the great work. I'm going to tell you a little bit about our commitment to social responsibility and the health equity cherries that are winners. Uh, we'll be able to choose from. We started our connections 2020 series off with a focus on health equity, because it's at the center of everything we think about. We have a large team within Optum working on social responsibility. These charities were suggested by the Optum social responsibility team and represent a range of important equity related causes. Some are national, and some are locally, uh, based here where the United is headquartered in Minnesota. This array of charities recognizes the complexity of the equity landscape starting with birth through the lifespan. The health equity and leadership exchange network is a national network designed to bolster leadership and the exchange of ideas and information among health equity champions, relative to the advancement of equity and health laws, policies and programs.
Kevin Larsen (01:43:21):
The second charity is the national birth equity collaborative. This collaborative supports maternal morbidity, especially black mothers and babies surviving and thriving. The third charity is one world surgery. One room surgery provides surgeries and builds health infrastructure across emerging markets helping to create global health equity. Uh, the next is called go red for women from the American heart association go red for women, works on building awareness and support for women's heart disease, tackling gender health equity on a disease that kills the most women, nationally heart disease. And finally the Y YMCA equity center for innovation twin cities. This is a collaborative engine of equity innovation serving the twin cities region and beyond is a national center of excellence that seeks innovative ways to solve intractable problems around equity tolerance and exclusion. And again, our winners, all three winners will be given the opportunity to choose, uh, one of these charities of their, of their preference to Joni money, to on behalf of United health care and their organization.
Kevin Larsen (01:44:46):
Again, I will highlight that we have two more upcoming webinars in the connections 2020 mini series. The next webinar is living better through help from the home telemedicine digital and more. Uh, we have a terrific array of national experts in telemedicine and digital health that we'll be doing a combination of keynote talks, a Q and a as well as a panel discussion of a number of people that have been implementing telemedicine telehealth in the code pre COVID and post COVID world. And finally, on a Tuesday, December 8th, we have our final connections, 2020 webinar entitled chronic kidney disease innovation, and the polychronic population. Again, here, we will be highlighting a research we've done in the Optum labs data warehouse with some of our research partners, including the national committee on quality assurance, the university of California, looking at, uh, chronic kidney disease and end-stage renal disease.
Kevin Larsen (01:45:48):
Uh, both of these will also contain, uh, Optum leaders, uh, United health care leaders, uh, uh, in dialogue with our researchers thinking through what are the implications and the translation of this research into the work that we're doing here at United health group. And I will remind you at the end, please take our brief survey by clicking the check Mark icon at the bottom of your screen. And I am very happy to announce the winners of our connections 2020, uh, in first place is Kellan Baker, uh, with the transgendered health in second place is Marianna Arcaya that work in neighborhoods and in third place, uh, we have Glen Yiu, uh, thank you very much to all of our, our speakers and all of our researchers. And again, thank you very much to our three winners and we'll be in touch with the winners about which charities you'd like to donate to. And we've reached the end of a really great, great session. Thank you for sharing your insights. We also wish to thank our colleagues at the Mayo clinic. You see Johns Hopkins and all of our other partner organizations and the people in our audience for joining us today. Um, again, please, uh, attend our upcoming sessions and, uh, thank you so much. Uh, we will see you next week.
Kevin Larsen (00:01):
Welcome to OptumLabs 2020, sorry for that to late start, we were just confirming that we realize where this is our connections 2020 series out of OptumLabs. Before we begin, I'd like to introduce you very briefly to OptumLabs. We're an evidence-based innovation and collaborative within Optum and United Health Group. And we applied diverse perspectives and scientific rigor to a rich data asset. Through this, we generate actionable insights. Um, as you can see here, we have leading partners in different sectors of healthcare, academic partners, such as Hopkins, University of California health, uh, consumer advocacy organizations, such as AARP, physician practices represented by AMGA quality measurement partners, such as NCQA and the Pharmacy Quality Alliance. We also are partnering with the U S government and Optum. Together we combine our healthcare expertise, deep knowledge of research, healthcare and data science techniques work with one of the industry's leading data assets to extract insights that can help achieve our mission. Our data asset is unique. It's longitudinal and includes de-identified linked claims, EHR and socioeconomic data. It's all carefully curated and enhanced with different views and tools that make it easier for our partners to work.
Kevin Larsen (01:24):
Um, this is our Connections 2020 seminar series. We are in the fourth out of 5, um, sessions. Um, we're we began on October 20th and we'll continue through December 8th. If you miss the first three sessions on health equity, behavioral health, and our OptumLabs, virtual showcase, the recordings will be made available on our website, a few reminders. Uh, I I'd like to cover a couple of housekeeping items, uh, to explain how the virtual meeting platform works. You can expand your slide area by clicking on the maximize icon on the top, right of the slide area, or by dragging the bottom right corner of the slide area at the bottom of your audience console are multiple application widgets. You can use these to customize your viewing experience. If you have any questions during the webcast, you can click on the Q and a widget to your question. We will try to answer these at the end of the live presentation. If you have any tough technical difficulty, please click the help widget. It has a question mark icon and covers common technical issues. The webinar will be split into two parts, uh, after the first hour, click on the join now button to be taken to the console for the second portion of today's event.
Kevin Larsen (02:45):
And, uh, the, the first part of this session is we have three keynote speakers each with a short presentation. Uh, at the end of this, we will have, uh, Patrick Conway and I will moderate a Q and a with the speakers and, uh, invite questions from the audience with that. I'd like to turn it over to our first speaker, Dr. Bruce Leff from Johns Hopkins University School of Medicine. Take it away, Bruce.
Bruce Leff (03:12):
Thanks, Kevin. It's, uh, it's really a great pleasure to be here and over the next 15 minutes or so I'd like us to think about three main issues. So I'm a practicing geriatrician and health services researcher. I make house calls and my research has been focused on, uh, innovative models of service delivery for older adults, focused on home and community-based funnels. And I'd like us to think about these three things over the next 15 minutes or so one, we'll talk a little bit about the population at risk. We'll talk about the spectrum of home-based medical care models and some disruptions that are happening in that field, which I think for the most part are good disruption. And then we'll talk a little bit about what it'll take to bring all of this together into a true continuum of home-based care. So, one thing to think about in terms of the population at risk, I'd ask you to understand that a little over 20% of Medicare beneficiaries, about seven and a half million of them are home bound to some degree.
Bruce Leff (04:18):
So there are probably about 2 million or so folks who what I would call completely home bound. These are data from the national health and aging trends study. So about 2 million people who say over the last 30 days, they have really not gotten out of their home. And these are data from the pre COVID era. So this is not a COVID phenomenon. Then there are another five and a half million folks or so who can get out of their house, but they do so with difficulty or need assistance from other folks. So overall, a rather substantial proportion of Medicare beneficiaries completely, or mostly home limited.
Bruce Leff (04:58):
And these folks really are not like you and I. These folks are different. They have functional impairment. They often have limited social capital. So you see here in the sort of orange and yellow colors, these are people who are completely homebound, never get out, or mostly home-bound may get out once a month or so. And these folks are more likely to be from minority populations, more likely to have lower educational attainment, less likely to be married and living with their partner, uh, more likely to be low income. Uh, they're also much more likely to have low self-reported health they'll break their self-reported health as fair or poor. And this is you have after to include a single question and a study that you do be it SF one, that, that self-reported health is always a great question to put in a correlates with everything. These folks are more likely to have symptoms of depression, much more likely to have possible or probable dementia, much less likely to be able to walk about a half a block and much more likely to have been hostile utilized, uh, in the last year or so.
Bruce Leff (06:09):
So a tension, you know, with serious illness, a frail population, as I was doing a house calls as a resident, uh, you know, nearly 30 years ago and started to get interested in home-based care. Uh, I went to the literature is a good academic will do and found that the literature was something of a mess. So if you're not familiar with sort of a basic skeleton of home-based care, I just wanted to set this out for you. And then we're going to add to it in the next slide. So starting all the way over on the left, you have what are called informal services. So if you are frail and you're at home and you have a spouse or someone who loves you, they may provide some care to you. They'll help you take a bath, they'll fix a meal for you. They'll help you manage your medicines.
Bruce Leff (06:55):
Those informal caregivers, probably 10 or 15 million of them, uh, in the country doing it mostly out of obligation and duty and a sense of love and responsibility. If you don't have someone at home with you, when you need those services, you can purchase those. And we call those formal personal care services, probably about 2 million or so people get those. The services tend to be expensive. Usually some somewhere between 25 and $50 an hour in general, tend to be hard to find and not easy to arrange. Uh, and you don't always get to decide or figure out who's going to come to your home to take care of you. You kind of take catches. What catch can, uh, then moving over to the right, and it's not really necessarily a linear linear thing, but you have skilled home healthcare. So the Medicare skilled home healthcare benefit remember a part, a Medicare benefit started in the original Medicare legislation.
Bruce Leff (07:52):
These are for older adults, Medicare eligible beneficiaries who are home bound by CMS definition and who have a skilled need. That's something that a physical therapist or occupational therapist or a skilled nurse does. And when you are eligible for those services, which come now in 30 day episodes from a Medicare prospectively paid during that time that you're getting a skilled service, you can also get formal personal care to help with activities of daily living, but once your skilled need is over, all of those services go away. So skilled home health care is an intermittent benefit, intermittent care, not longitudinal skilled care in the home, moving over to the right a little bit more home-based primary care. So, uh, something I start to do as a resident a long time ago here in Baltimore. So for these home-bound folks who are too frail to get into the clinic, doctors can make house calls and provide ongoing longitudinal care in the home, a pretty strong evidence-based to support the effectiveness of that.
Bruce Leff (08:55):
Probably about half a million people are getting that service now and, but probably only about 10% of people who are completely home-bound are getting those services right now in the us. And then moving over a little bit more on the acuity spectrum to the right hospital at home, which is a model I'd been very interested in over the last few years. Uh, this provides hospital level care in the home as a substitute for home-based for hospital traditional hospital care. Uh, and you basically bring the hospital home to patients, take them out of the ed and take them directly home, or some variation of that. And I look at, it looks like I didn't have a number in there cause it's changing pretty rapidly, but I would estimate at this point, probably about 20,000 or so people have gotten that care in the U S at this point.
Bruce Leff (09:44):
So you go from left to right. You go from low acuity, low medical acuity to higher medical acuity, more of a chronic care construct towards one that is acute care or combined chronic and acute care and models that have little or no physician or advanced practice provider participation to models that have much more of that. So that's kind of the basic map that I started with, but this map is getting very disruptive lately. And I think that in general, that that's a good thing. So a whole bunch of arrows now impinging on various places in this, uh, in this spectrum. So starting up on the, uh, lower left, you have formal personal care services or I'll call it formal care services plus, and now in certain cities, you can go on your iPhone. And instead of having to order a formal care services and four hour Alec Watts, you can order, you can get on, uh, get on the phone and order a care provider like an Uber and say, I'd like a Mandarin speaking woman to come tomorrow at 12 noon.
Bruce Leff (10:45):
And give me a bath and spend one hour, and you may pay a surge price for that, but you can get that. You have what I'd call functional focus, brief interventions. Uh, one w one of which was developed at Hopkins called the capable model. Uh, so a time limited intervention of nurse OT and handyman focused on improving function in duly eligible beneficiaries. And interestingly enough, and astonishingly enough that improves function and lowers costs with an ROI of 10 to one, see a lot of companies now doing home-based primary care comb management and risk arrangements with Medicare advantage plans. So folks going to the home and then those providers collaborating with patients primary care providers in high-risk populations to keep them out of the hospital and lower costs a whole lot going on in telemedicine and sensors and artificial intelligence still in its early phases. I think you have rehabilitation at home in addition to hospital at home.
Bruce Leff (11:42):
So substituting for skilled nursing facility care back up to the upper left a lot, going on now with EMS and community paramedicine, uh, trying to intervene to keep out of hospital a whole lot going on now and transitional care that's been going on now for about 15 or 20 years. There's now urgent care on the floor at home and on the phone. So you can get a doctor on the phone and pay for a single visit. Moving more to the right home-based palliative care has really been coming of age again in risk contracts, mostly with Medicare advantage. And then there are several entities out there trying to do what I would call a real estate play collaborating with continuing care retirement communities, uh, to try and bring medical and real estate models together. So that's kind of, what's becoming a little bit of the wild West.
Bruce Leff (12:32):
I would say that, um, of late, there's been a fair bit, the wind and the sales of home-based care, uh, value-based care is clearly taking hold as a result of a lot of innovation. That's come out of CMS and a change in the culture over the last five to 10 years, the growth and penetration of Medicare advantage has helped that along. I think there's increasing recognition of the population at risk. The one that we started with a few minutes ago, I think finally payers are actually starting to pay attention to payment. That was not always the case. I think in many cases they really just pass things along, but I think they're starting to pay attention and understand their potential role in the healthcare ecosystem. In terms of taking care of at risk populations. There have been advances in technology, portable technology home-based technology that can help.
Bruce Leff (13:23):
I think COVID has really been a wake-up call. We'll talk about that in a few minutes. And I think we're starting to see validation of all of this in the marketplace. So you have, you start to have companies like care more and Oak street, and I are a health and city block and heal and Firefly and village MD all come into the market, all finding funding as they start to pay attention to folks who are more home limited, uh, and folks with multiple chronic conditions and functional impairment. So we're starting to see a whole lot of that, uh, but what will it take? I think that home-based care models can evolve into a full care continuum. Um, but what will it take to actually get there? So if you, things, it is going to take a bit of leadership and culture change. So I put a bicycle up here and some of you may have seen, and if not, I invite you to go onto YouTube later and put into the search engine on the backward bicycle.
Bruce Leff (14:18):
So a guy has folks built him a bicycle that is backwards. That is when you turn the steering handle to the left, the wheel goes to the right and vice versa. And the guy who, uh, did this video uses it as a metaphor, um, to talk about how, when things are really hardwired, it's hard to change. He thought it would take him about two hours to learn how to ride the bike. And it actually took him about eight months. Uh, he also talks about the different sort of being a metaphor for the difference between understanding that you may need to change and knowing how to change and because things are so hardwired, it actually gets hard to change. And I think health systems, many health systems are stuck in a bit of a backward bicycle situation. And it'll take a lot of leadership to move this forward.
Bruce Leff (15:03):
It'll take a bit of supply chain and logistics development. So we have an excellent supply chain and logistics, uh, built for acute care. I would say in home-based and community care that logistics and supply chain is not remotely mature and really will need to come of age. If we're really going to start to move here to the home and a full continuum arrangement, uh, we'll need better tech, uh, it's needed. And I think it's coming. You starting to see the first and second generation of remote patient monitoring and sensors come along, portable diagnostics. I think we need a whole lot better, uh, AI, uh, and the ability to use it to really take data and crunch it, interpret information that's used more useful clinically. And I think we also need to use these means to, uh, both, uh, tech and AI and patient reported data to really develop new and better approaches, to very dynamic targeting.
Bruce Leff (16:00):
We need dynamic assessment and recalibration of targeting and be able to track changes in status to enable better service delivery. And we need policy enablers with costs of course, payment. We there's a lot to be done in terms of scope of practice issues, and we will need to develop a workforce to handle this. Uh, I think COVID has been a major accelerator. I think among physicians, we see a much more positive attitude towards tele-health as we've actually had to use it and realize our heads and patients' heads would not explode when we use it. I think patients have internalized the risks of facility-based care and they have a growing interest in remote care options and also in care coming to them in their homes. I think a lot of systems realize that their business models imploded when all care is tied to facilities and they can't dis-aggregate those.
Bruce Leff (16:55):
And I think finally, uh, policymakers and payers are gaining comfort and paying for non in-person visits and, you know, using this as an opportunity to address inequities, which is something home-based medicine and home based care in general can do. So I'm firmly convinced that, uh, home-based care will evolve into a full continuum. I think one of the harder things to predict in healthcare are the labs. So I don't know how long that that will happen, that will take, but I'm, I'm reasonably certain that it will happen. And I did it in under 15. So I'm feeling pretty good.
Kevin Larsen (17:29):
Thank you so much, Bruce. That was terrific. And again, if you have questions for talk to your left, please put them in the chat and, but we'll do all the question and answer at the end. I'd next, like to hand it over to Steve Ommen, Dr. Steve Ommenn, um, is going to speak about the Mayo Clinics, uh, center for connected care.
Steve Ommen (17:50):
Perfect timing that my pager goes off. Um, so thank you for, thank you for having me here today. Um, I, uh, am a practicing cardiologist at Mayo Clinic, and we'll talk a little bit about what we've done at Mayo Clinic with kind of extending on from what we just heard. Um, so I know many of you are familiar with nail, and this is something that is, you know, kind of, uh, inbred to all of us, the understanding that everything we do needs to have the patient in mind in terms of that's what the goal of what we're doing is, and, you know, that's, that's something that was established with the Mayo brothers when they established the Mayo Clinic 157 years ago now. Um, but we need to continue to use that same model of care as we come forward, uh, into the modern, Epic of, um, uh, care delivery.
Steve Ommen (18:46):
Um, and, and as we get more and more specialized, we continue to deem to focus on the whole person. And we need to recognize that many other industries have moved to in their services available to their customers in the most convenient way possible. And that's a way to that, that we in healthcare need to serve the whole person as well. And the figure on the right tier is grossly proportion. So this is supposed to be a characterization of the fact that most people don't spend their lives in a clinic, but rather they spend their lives, uh, um, outside the clinic, but they still have all health and healthcare needs when they're there. And so taking that male model of care, and we wanted to make sure that we can engage patients where they are so that they can continue to be active participant in their own health and wellbeing.
Steve Ommen (19:35):
So.
Kevin Larsen (19:37):
It's Kevin, let me know when you want to advance the slides I'm advancing.
Steve Ommen (19:42):
Oh, you are? Yeah. Okay. I've been pressing the buttons and they're responding on my screen. Is that not working or,
Kevin Larsen (19:50):
yeah, I don't think so. So just let me know.
Steve Ommen (19:53):
All right. So we should be on slide 25.
Kevin Larsen (19:56):
Yep.
Steve Ommen (19:57):
Got it. Okay. So, um, so Mayo clinic established the center for connected care about seven or eight years ago, uh, to try to transform practice, to meet the patients where they are. Um, uh, recognizing all the features that we just talked about. And the center for connected care is not just a, uh, a technology shop, but it's, it's the people and the policies and the business behind making sure we can deliver various service lines to our patient. And we kind of remotely, uh, divvy up our product lines, uh, into the four kind of, uh, ovals you see near the center of this slide.
Steve Ommen (20:40):
Uh, we talk about synchronous services, which are video telemedicine, activities, both acute and ambulatory asynchronous things are the types of things that you do in the patient portal, including secure messaging with patients. And as was alluded to in the last talk, we have a, uh, for the 20 most common primary care, urgent care diagnoses, a, uh, a branch logic, uh, product that allows patients to log on, answer a few questions about the condition they're having. And then within an hour, a nurse practitioner will review the responses that are teed up for him or her to respond to an, a patient may get a prescription or a plan of care without ever having to leave their home or office, or even actually have real-time dialogue with the provider. We'll spend most of our time and the remaining slides talking about the remote patient monitoring program, because that's where we've seen a lot of activity. And, and, uh, as Bruce talked about a lot of promise for the future, and we want to make everything available with kind of a mobile first, uh, uh, technology platform because of the way that we're seeing this as society moves, uh, generally speaking, uh, go ahead and advance to the next slide.
Steve Ommen (21:52):
So again, this is,
Steve Ommen (21:53):
This is just a reminder that, that, that the team that we set up, uh, at Mayo to do this, this is not just, uh, people that understand which cameras and sensors you need, but the people who understand the practice of medicine who understand product development, uh, and understand, uh, business value equations for, for standing up the service, as well as the, uh, the regulatory environment, which is very favorable in the COVID, uh, time period, but it was not so favorable prior to that. And we are waiting with bated breath to see how that evolves with time.
Steve Ommen (22:29):
This Is a slide that we actually use. Again, we use this when we're engaging a clinical department who wants to start getting or ramping up their, their telemedicine activities. And it just shows that, um, third technological and implementation complexities, and usually the first thing people want to talk about is doing more on demand, real time, video telemedicine activities. And that's probably the most complicated solution to put between ourselves and our patients, because it still requires scheduling simultaneous presence, technologies, and networks, uh, in between the patient and the providers. And that's everyone goes there first because it's the closest to what we do now. And, and, and that change feels comfortable. And I think the COVID has taught us that we need to think farther down into the left here, are there things that we can do with our patients that are a lot lower touch, a lot less scheduling activity, uh, to help be in contact with them more, but with again, less technical complexity between us.
Steve Ommen (23:31):
And so, again, we're going to focus in the middle on the remote patient monitoring as, as one of the aspects in, in that, in that spectrum. So you can go to the next slide prior to COVID. We had established a remote patient monitoring that was really focused on patients who were at high risk for admission or readmission to the hospital. And you can see the four major components are, or patient groups that we were interested in in trying to serve that way. And in our, in our program, the connected care nursing team is the one who monitors and identifies eligible patients for this within the EHR. Then an order is served up to that patient's primary care provider at Mayo to determine whether they want to order and enroll their patient in the remote patient monitoring program. And if so, then it comes back to our team who works with our logistics and supply chain vendor to get the patient onboarded, uh, get the equipment into their homes and up and running and those types of things.
Steve Ommen (24:28):
And then the, our nurses are the ones who monitor the patients, and then they escalate care when they say see deviations or, uh, benchmarks that are met or not met, uh, then they will escalate that care to the primary care provider as needed. But most of our team does, does most of the monitoring for our patients. Typically it's a, it's a two or three week program that the patients are enrolled in and they can graduate from it. They can graduate early if they meet certain benchmarks. Um, and, and we were rolling this out across the Mayo enterprise, uh, at, at all of our national stuff. Uh, next slide, and just give you some idea in preliminary data we had, this is mostly from rural Minnesota and Wisconsin, that among our patients admitted or enrolled in the remote patient monitoring program, we were able to reduce those readmissions in half, essentially with a heavy dose of that being in people with obstructive pulmonary disease and heart failure.
Steve Ommen (25:26):
Uh, so feeling really good that the directional change was there. We know that the remote patient monitoring academic literature is sprinkled with failures or remote patient monitoring. And I think that's because we are in the new era of, or the infancy of trying to understand how best to identify those patients who are going to be most benefited by using these tools and the best way to escalate and deescalate their care when they're on the program. But we were happy to see that our program moved this way on the next slide. We'll talk about what happened then in early March, uh, when, when COVID came, uh, in crushed us all. So in a matter of about, uh, I would say a week, uh, our team doing this developed two new pathways specifically for patients who were COVID positive. Um, one was kind of an extension of that complex care pathway, but included, uh, additional sensors for, uh, oxygen saturation and temperature, and which were not part of the standard kit.
Steve Ommen (26:25):
We were putting out to patients and the other pre-existing program. These are patients again who have COVID and have other high risk diagnoses, you know, diabetes, obstructive pulmonary disease, heart failure, those types of things, where to potentially eligible patients for patients who are lower acuity, they have any common entities. We developed something that we referred to as an interactive care plan, and this is delivered to the patient on their mobile phone, through their EHR portal with us. And this is really more of a facilitated self-help for the patients. It gives them reminders to, uh, do a symptom check in each day. These patients were, uh, issued pulse oximeters and, and, and thermometers that they could upload their pulse oximetry readings and their, and their temperature, uh, to our nurses who would monitor these, these patients twice a day, uh, to determine, uh, if any escalations or deescalations were needed.
Steve Ommen (27:19):
And we have, we have a lot of stories of patients who, uh, we could start to see their oxygen stats dropping. Uh, we could call the patient a few cases. We had to activate the emergency medical response system. Many of those patients were able to be cared for in their homes. Uh, and I've got some slides coming up on, on, on kind of preliminary data on, on our experience with using this for our COVID patients. But on the next slide, you can kind of see the volume trends, uh, that we had. So at the far left is March 11th. So we were already kind of actively monitoring about 300 to 500 patients a day, uh, in that complex care remote monitoring program. And then in early July, which was when we were kind of peaking the first time around in Minnesota, you can see, we got up to about a thousand patients per day, being monitored by our nursing teams.
Steve Ommen (28:09):
And then we were fortunate enough here in Minnesota to not be hit so hard as they were in other parts of the country. So we kind of killed off at the far, right. You can see an unfortunate trend. This is in September. I can tell you that, that that trend continues to go up as the COVID positive volume in, in our, in our home state continues to go up. So you see more and more patients enrolled in this, on the next slide or the preliminary data I was referring to, um, about, uh, one particular department, uh, at Mayo and how their COVID positive patients, uh, uh, or handled. So these patients brought COVID positive. Um, this is comparing patients who were dismissed to home after their initial COVID positive tests with RPM, versus those who were dismissed a home without RPM. These are not randomized patients.
Steve Ommen (29:03):
The patients with RPM or higher acuity patients that the nursing team felt would most likely benefit from it. And those without RPM were felt to be lower acuity patients, less likely to need any intervention. But as you can see a right-hand side, the patients who did not have RPM had a higher rate of subsequent hospitalization, they had more of those patients ending up in the ICU. And more of those patients who had hospital stays of more than a week. So again, super preliminary data. We have a lot of work to do understanding what all of this means, but the directionality of this would suggest that the RPM program, uh, will successful in helping manage patients at home and intervening on them when they were less sick, when they need interventions versus patients who are left on their own and delayed getting care and therefore were sick, or when they got to the hospital.
Steve Ommen (29:58):
Next slide.
Steve Ommen (30:04):
And just to show that we're just not talking about volumes, we do have some, some patient and provider satisfaction data on this. And so again, you can go over all there's a 94% satisfaction. The program patients were super likely to recommending this to other members. Uh, they were slightly more positive than the care providers were. I think that's probably because, uh, we have spent more time on the user experience for patients than we can or scientists. The dashboards can be a bit unwieldy for some people, but we'll continue to work on that. And then the next Jude's lies are just some of the handwritten comments the patient sent in as part of the survey. So these are patient comments talking about how it kept them on track, uh, uh, reminded them to have a routine when they were in and to pay attention to their activities, recommended this.
Steve Ommen (30:53):
They thought it was a great tool to remind them to, to, to do their vitals when they needed to. Um, the patients just felt like they were more connected to our care team when actually it was probably less work on our care teams side in terms of secure messaging or office visits, those types of things. So a very good set of comments there. And on the next slide, our provider comments, uh, in a similar vein, uh, that talk about, um, uh, how they felt like they gave the patient confidence that Mayo was watching them, uh, testimonials about how great the nursing team was to work with, um, and, and the education and coaching to get them on lifestyle management with COPD as well. So this is really the really happy with that. And just a reminder, the next two slides, which I'll kind of finish this up pretty COVID, you know, connected care existed with all the tools and technologies.
Steve Ommen (31:48):
We didn't invent new technologies. We configured some of them to meet the COVID demand, pre COVID bottlenecks, where both supply side and demand side on the demand side, obviously the regulatory environment, which was the biggest barrier to most hospital systems, particularly in the fee for service world to it, to adopting or trying to drive these into practice on the supply side, our individual clinical departments, uh, didn't, didn't rush to adopt these. And, and again, it's, it's part of that. I mean, some of it was the metrics that an individual department chairman to be held to may not promote connected care or telemedicine activities that provoke promote office visits instead. And you have to be careful with your, with how you monitor or incense your clinical departments and, and what the KPIs are going to follow them, because they can have adverse effect of discouraging innovative care delivery models.
Steve Ommen (32:43):
The next slide is the, um, is again, the nod to environment change where that bottleneck on the patient side was wide open. And so I'm really, it was just a matter of patients being aware of where, whether it's male or elsewhere that their cure team, whether their hospital system offered remote care activities on the provider side. You know, we had a lot of lessons. We, we had a roadmap for implementing video Thom medicine activities across the organization. It was a very, uh, handholding, uh, arrangement we had planned. We literally held the hands of the department to get them up to speed. And obviously when March 11th hit, we had to reconfigure figure our implementation program to be a, uh, a self activation program. So we developed a training modules for the clinical departments that were online, gave them the tools and links to utilize this. And so there was a little bit of a wagon video telemedicine that favored phone for the first few weeks of this, and then that kind of reversed.
Steve Ommen (33:42):
And then, uh, then probably, um, one of the, unfortunately if you're looking at a telemedicine competency standpoint, Mayo Clinic did, uh, because of the fact that our hospitals remained free of COVID for so long, um, reopened that press meaning more patients came back on site, probably for our providers and the support staff for the health care delivery team developed all the kind of persuaded competencies you need to make telemedicine or remote care options and an inherent part of the care delivery system. So it didn't quite get fully integrated, but we're continuing to work on that now. And we're seeing a trend tick back up in, in the, in the use and a lot of clinical departments coming up with new use cases for a live patient monitoring for their unique subsets of patients. So, and look forward to the discussion we have later today.
Kevin Larsen (34:37):
Great. Thank you so much. Um, and, uh, I now will introduce Dr. Sonia Samagh from Optum. Um, we are having some trouble with her video but she's here in audio. I'll turn it over to you to Dr. Samagh.
Sonia Samagh (34:52):
Great. Thank you. Hi, can you hear me?
Kevin Larsen (34:56):
Yes, we can hear you. Okay.
Sonia Samagh (34:58):
Okay, perfect. Um, I'm advancing the slides here. So to introduce myself, Dr. Sonia Samagh, I'm an internist. I practice as a hospitalist I'm vice-president of Optum center for digital health and lead. Our digital acceleration team have spent the last 10 years in digital strategy and implementation. So today in the next 10 minutes, we'll go through, um, some of those learnings around the importance of managing and waiting for change, particularly in COVID getting to scale quickly as we, um, deployed some agile and design thinking strategies. And what I'll do is I'll start with the background on Optum health and an overview of, of what we've accomplished in the speed and scale that we did as a response to COVID and beyond with our tele-health and digital capabilities, um, all touch on how we focused, not just on the technology, but also on, um, really designing a digitally enabled, uh, care service, and then some lessons that we've learned moving forward and, and how this has really led us to build that digital health foundation, um, of our center for digital health
Kevin Larsen (36:10):
And, and Dr. Samagh, I'm forwarding your slides here. So just let me know when you want the next one to go. Okay.
Sonia Samagh (36:15):
Okay, great. So we can go to the next slide. So, um, to give you some background on Optum health in slide on slide 42, um, you can see a map here of, of, um, the, the care delivery organizations, medical groups that are part of Optum health. And there's more to this. These are, these are focused on our, um, primary care specialty care and, um, urgent care practices. In addition to that, we've got, uh, behavioral health, uh, services in ambulatory surgery centers as well. So as COVID hit, we knew that we needed to keep our patients safe. We knew that we wanted to ensure the safety of our care team, and we wanted to use this as an opportunity to really propel us and prepare for the future. Um, to give you some background, we've got about 48,000 physicians across Optum health, both employed and contracted.
Sonia Samagh (37:18):
And in the first two months, we onboarded really quickly over 10,000 providers onto tele-health platforms. Uh, no response to the pandemic we had about less than a thousand prior to that. And in that first month completed over 200,000 visits. Next slide. Um, so if we go to slide 44, I'll talk a bit about how we accomplish this so quickly. So what we did was form a team of teams, and we've heard other presenters talk about those teams, um, across clinical operational, it supporting functions like legal and compliance. And every one of our medical groups got a digital response team. And we continue to iterate this model now and what we call our digital acceleration team, that's operating across Optum health. But, um, we know that from a medical grouper or Optim health line of business perspective, we've got clinicians, patients, our care delivery organizations, um, really having strategic priorities and needs and wanting to move those forward from the virtual care delivery standpoint.
Sonia Samagh (38:20):
So, um, they're defining new new ways to drive value from care delivery and then testing and iterating on those solutions to drive best practices in partnership. Our team then, um, works with those care delivery organizations to match those digital capabilities and really try to de-risk testing, launch execution, um, developing those best practices, and then accelerating those service solutions to scale. So we support the innovation with new ideas and learnings from failures, and then also develop some of those services functions that really accelerated our ability to, um, to scale tele-health quickly. And I'll talk about what those are, um, what those are next. So on slide 45, um, you can see that we in this process established that I set of guiding principles, then that those guiding principles really enabled us to rapidly iterate and scale. And in parallel, we built service solutions that helps us do that.
Sonia Samagh (39:18):
So I'll walk through each of them. So what we needed to do when we watched was ensure that we met that the strategic priorities and, and match the capabilities of what our care delivery organizations were asking for. And I'll walk through how we did that in response to COVID for today. The second thing that we did was focused on designing a service that was enabled by a technology rather than, um, a technology or capability centric view. Um, and our government's focused on really enabling that rapid iteration and escalating risks. So, um, we didn't have a long project plan. We operated in a very agile, agile way with our teams across the entire organization to only escalate the most important roadblocks, and then try to solve them, um, uh, fairly quickly the rapid iteration process itself. So as an organization, we had a number of different telehealth vendors that were actually present across our medical groups, and because we needed to scale so quickly at the pace of, um, hundreds to thousands of providers, onboarded onto tele-health platforms per week, there actually wasn't a single telehealth vendor that could meet those business needs.
Sonia Samagh (40:28):
But what it did enable us to do was to test and iterate and learn with different products in different regions. Um, but this did require our leadership teams to be able to be agile and really embrace that design thinking approach and culture. So that if we, we learned in sales in one region, you can use that learning in another. We also developed what we called enabling services and implementation strategies. And we'll talk about those in a second to the right. And then through this process, we're actually able to narrow on a preferred set of vendors based on what was learned from those early adopters and then scale with those preferred, um, set of, of vendors very quickly. So when I say that we built, um, enabling services, um, an implementation strategy. So for example, if you look at that third column early on, we knew that not one, um, not one vendor telehealth vendors could manage, um, onboarding hundreds.
Sonia Samagh (41:23):
And, and at one point we were onboarding a thousand providers per week. So actually built our own telemedicine training center and telemedicine call center. So we actually built our own training modules and a training site that we pointed our providers to help to train them. And then we're actually their first call for providers and patients as they were onboarding on to telemedicine that we could, um, help manage their technical, um, issues and not need to rely on either the local it team or the vendor it teams to, to, um, sell those issues for our patients and providers, because we knew there'd be a long lot of times we developed some adoption and experienced concierge services. So with that, um, telemedicine comm support center, we developed teams that would do digital advocacy. They would outreach ahead of time to our patients and ensure that they were set up and to get on the telemedicine visit, um, and decrease any, um, time that our providers would take doing that.
Sonia Samagh (42:19):
We, um, built access equity initiatives. I know we've talked earlier about that, but we have a vast amount of data around, um, which regions had broadband, um, the socioeconomic backgrounds, um, and, uh, impacts of healthcare of our patients. So we've integrated that into the work that we've done and we've built a center of excellence. Uh, it's currently a virtual clinical decision making center of excellence. So we knew that we had thousands of physicians that, um, might not have been comfortable with providing telemedicine services, closing gaps in care, and now need to do so, um, in a new world. And so built training modules for providers to do that as well. If we go to the next slide. So currently, um, with all of that, we actually now have over 15,000 providers live on televideo platforms today, supported a number of those through our digital response have completed over 1.2 video visits, post COVID across, um, across the U S in parallel.
Sonia Samagh (43:22):
We expanded beyond total video to include elements like symptom checking with provider organizations, onboarding, um, symptom, checkers online. We also launched remote patient monitoring. We built, um, as a part of that service enabler, a digital nurse monitoring center launched, um, COVID management, digital appropriate management response, um, starting in Pacific Northwest at that first surge, um, and then added on remote patient monitoring in virtual care management as a, um, an add-on for, for complex care, and then have expanded that beyond into, um, pathways like social isolation pathways, which has really garnered a lot of experience in it and adoption improvements from our patient and provider perspective.
Sonia Samagh (44:08):
You go to the next slide. So this is, um, a bit of the map that we followed as we sat through capabilities beyond televideo, but also matched it to what are, um, sort of the life cycle of what our medical groups are going through. So a lot of her medical groups first said, okay, we're in a place where we're closing on clinics and we still need to provide safe care delivery. And so this is where we rapidly, um, a number of urgent care and scheduled videos as it's for those positions across the U S then we knew that our car call centers was being inundated. So we, um, launched a website based symptom, checkers, and messaging and triage tools to be able to manage that next. We saw that there was really a patient desire for COVID knowledge and action, and said, this is where we launched our digital nurse monitoring center, and COVID self management and monitoring applications.
Sonia Samagh (45:00):
We then knew that we needed to expand that, to be able to provide complex primary care and digital care management with the ability to escalate to our remote monitoring team and nurses. So launched and scaled that. And now we're looking at these last elements of how do we, um, provide and monitor, um, uh, our patients in a digitally enabled way in the home, and how can we really move to the next level of closing that last mile, um, of gaps for our patients, as we think about telehealth, uh, encompassing, everything that we would do in a clinic,
Kevin Larsen (45:35):
Dr. Sama, can we get you to wrap it up with, we want them to QA?
Sonia Samagh (45:42):
Yep. We can skip to the last slide. This is a bit of a, uh, a visual of our journey ahead. So we know we've started in a certain place and, um, want to get to a virtual health services organization that encompasses everything we learned, um, over the past few months. So thank you.
Kevin Larsen (46:01):
Thank you so much. Um, and I'll turn it over to dr. Patrick Conway and Patrick, take it away with questions and I'll pop in with some questions from the audience.
Patrick Conway (46:11):
Okay, great. Well, thank you all to the panelist. Uh, terrific presentations. Yeah. I'll start with this, a general question for anybody. You know, you all talked about a number of innovative models of home care. What do you think, uh, what are the accelerants going forward? That'll help us transform faster and, you know, what are the barriers that could, you know, uh, hold us back to an old model, if you will.
Steve Ommen (46:41):
Well, so, uh, this is, this is Steve. I, I wouldn't say that first. That's a great question. I think right now we're really dependent on a limited set of sensors that are in these major companies at an accelerant will be when we convert to using consumer grade sensors, to get some of the more basic function, that's a huge barrier, right? Because if we're going to have our EHR is compatible with every Fitbit and Berman, Apple watch, you know, whatever, whatever flavor that patient has. Um, that's going to be a technology challenge. There are people solving them to me. I think that's one of the things we convert to more consumer friendly consumer grade. And the more passive that monitoring become these rather than active in terms of what the patient has to do. I think that will help, uh, garner more uptake. Terrific.
Bruce Leff (47:33):
Yeah, Patrick, this is, this is Bruce. I think, uh, I, I would just go back to the issue of culture change and really at some level rewiring, how leadership thinks about home-based care. It, it, it really is a different model. And I think that, uh, you know, I can tell you, uh, in a certain healthcare system that I know quite well, and I think a lot like others, you know, in the, in March, we switched to from our outpatient clinics, all in-person clinic to full tele video clinic and sort of as soon as the, uh, as soon as the light. So a little bit of light at the end of the tunnel, we switched all the way back to in-person visits. And the video visits for the most part really went away. And I think that was because the old model was familiar. People knew how to run it.
Bruce Leff (48:28):
People knew how to manage it. And there was still some re and I'm sure there were some revenue implications as well, but still the, the, um, some lack of enthusiasm for truly adopting the new approach and not only adopting new approach, but taking a new approach and not just having it serve the old model, but actually rejiggering it so that it's actually better than just doing a clinic visit on, on a screen. And, you know, that gets to some of that rewiring in the system, uh, that needs, that needs to change when innovation comes along and you saw with the backward bicycle I had on the slide, the, the corporate, uh, logo for Kodak, and some of you who are old enough on, on the webinar, remember what Kodak was. They made know they made film. They actually, oddly enough, were pioneers in developing digital technology, but they like many new inventions that come along.
Bruce Leff (49:25):
They wanted the new invention to serve the old model. So they actually, their vision was for digital digital cameras to take films that then people would print out the pictures on film, instead of realizing that the real innovation was sharing pictures digitally. And I still think that a lot of what we do in medicine and care delivery, we still haven't put these pieces together in a way that we've really reinvented care and really have taken it to the next level. So I think part of that is culture. Part of that's mindset, part of that's leadership, part of it is just what we're doing here and figuring out what we can do with these technologies and with people to make it better over time. So I think that's still a major barrier and payment can enable that in a huge way. Sorry.
Patrick Conway (50:09):
No, that's a great segue. Just, um, for anyone, you know, in addition to care delivery with that segway on payment, you know, what are the innovation opportunities in the insurance side for products maybe that are digital first or home-based care first? You know, how do you think about how the insurance side can spur and help foster innovation?
Steve Ommen (50:36):
Well, I think, I mean, I would just say, I think we're all, um, required to demonstrate value in doing these things. We can't just throw expensive tools at it and not get any value out of it. Um, I think, you know, within, within Mayo clinic, when I'm talking or doing consulting with other groups, I often get asked about reimbursement for a particular service. And I think we have to look at the bigger picture. So again, if you look at the preliminary day, show it, if you can keep people out of the hospital and the hospital's less acute when they do have to go there, that's a bigger picture view of the potential value of this. And not just whether provider X spent so many minutes doing this at the reimbursement rate for that one particular activity. So I think we need to broaden our scope. And I think that a move towards value based care management is probably more likely to drive this than a fee for service model. This is a related question from the audiences. Uh, what's your speculation. If the CMS coverage under the, under the public health emergency goes away, what happens to innovation and the kind of home-based models that you built?
Steve Ommen (51:48):
Yeah. So we're trying to anticipate that a bit. So with some of our own research, arms of Mayo, we're trying to make sure we understand all of the potential value propositions and metrics to measure that so that if a reimbursement, uh, goes away, is there enough other value there that we can continue to do it? So I think, I think that will continue to spur innovation in terms of how you, how you do pay for the services you're delivering and how do you bring the most value rather than, so I don't think that will make it go away. Um, but it, it is again, each health organization has a responsibility to try to prove that there is value in Mickey Schwerner, looking at the whole picture.
Bruce Leff (52:34):
Can you just go back to Patrick, your question on, um, what payers can do? I think one thing that becomes very important is trying for payers to understand how they can create mechanisms so they can target help to help to incentivize interventions that target different strata and different tranches in the population. So, you know, a millennial probably has not probably those have a much lower risk of ever ending up in a hospital than an 85 year old. So what a payer does, if, as they're targeting millennials with these kinds of models will be very different than what the payer will do in an older population at risk of, you know, high expense care like hospitalization, and thinking a lot about how to line up popular, targeted population with intervention,
Bruce Leff (53:26):
With the outcome that they are really willing to pay for or not pay for. It becomes very important. So I think it really becomes a matter of that targeting, matching it to model matching it to the outcome, and then trying to find ways to target folks that don't rely say just on claims, which is, you know, really kind of looking out the rear view mirror is a system that was along at 90 miles per hour. Uh, and I think also for payers start understand in terms of identifying high need, high cost patients with modifiable costs the importance of functional status, especially when she starts to get into the older population with multiple chronic conditions. And that doesn't need to be all Medicare age. You have a lot of middle-aged folks who meet those criteria as well.
Patrick Conway (54:15):
It's, it's a great point. Kevin, feel free to jump into, but, uh, you know, I'll, I'll pivot a little bit and say conversation earlier today, I talked about, uh, meeting the physical, mental, and social needs of all people in their home. You all both spoke to this a little bit, but how do you think about especially the mental and the, and the social in addition to the physical and, you know, what's the training and care teams we need and, and whatever other interventions to sort of that whole person care and the whole,
Bruce Leff (54:45):
yeah, I think for whole person care in the home, it often takes a, it does take an interprofessional and multidisciplinary team can, I mean, you know, this, I can't tell, you know, the audience should realize the incredible value say of the social worker or the community health worker who, with whom different populations will have a much greater comfort than they will ever have with me, even if I'm coming to see them, uh, in their home.
Bruce Leff (55:11):
So, uh, you know, the ability to actually collect data that lets us understand the social state of, uh, and also trying to understand, and I think this becomes important for payers as well, and it's not written about a lot, but sometimes, and I'm not even sure these are really well-defined terms, but, you know, we often talk about patient need. Sometimes there's a gap. And if you fill that gap, you're going to do something nice for someone it's not going to make, say a difference in utilization or something else. And sometimes there's a need that you fulfill that need, you really will change utilization or something else. So, you know, really understanding what a payer, what are you truly buying with whatever you're providing or incentivizing becomes critical. In my view,
Kevin Larsen (56:00):
We have a question here about it. And what, what do you see leading health systems doing, uh, groups that have long incorporated, um, ACO, like models like Kaiser and how are they, uh, how are they working in this market?
Steve Ommen (56:19):
Well, I, Bruce, go ahead.
Bruce Leff (56:22):
Yeah. I was just going to, I, you know, Kaiser is a really, really interesting system. Um, I know certain of their regions are really going big on certain home-based interventions like hospital at home, in the Northwest region and in the West. So I think they're starting to recognize it. I think they're starting to understand that coming up with a home-based care strategy that straddles the medical and the non-medical is something that they need to, to figure out. I think the challenges, uh, there are challenges in terms of scaling. There are challenges in terms of targeting. There are challenges in terms of figuring out what they really want to accomplish with that. But I think leading systems are starting to recognize the importance of this population and are starting to, you know, for the first time since, uh, I I've been looking at this for a long time, but you're starting to see just much, much, much more interest in the last three to five years. And then I think COVID has really accelerated that.
Kevin Larsen (57:22):
So thank you so much. Uh, we are, we'll be moving to the second part of this discussion. So please join us in part two, you can click on the join now button in the top, right corner of your screen. Uh, Patrick and I will be moving over and we will, uh, introduce a new panel of speakers with the short con with short speed talks, and then we'll have a, a much more robust discussion after that second part. So thank you and look forward to you. Can you, uh, continuing and thanks to all of our speakers today,
Living better through health in the home
How has home-based care evolved and where are there opportunities for scale? How has the COVID-19 pandemic stimulated the re-shaping and re-imaging of home-based care strategies for many population segments?
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The telemedicine explosion
COVID-19 has catalyzed the potential for telemedicine. In this panel, we hear from experts on how they have adapted to the pandemic and ideas for sustainably embedding telemedicine into the health system infrastructure.
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Kevin Larsen (00:02):
Hi, it's Dr. Kevin Larsen. Welcome back to Connections 2020, our telemedicine explosion webinar. Um, I will be your host and our moderator today is Dr. Patrick Conway, the CEO of Care Solutions at Optum and Patrick, if you would, you can go ahead and introduce our speakers.
Patrick Conway (00:23):
Terrific. Thanks everybody for being here today, talking about telemedicine and virtual care, we've got four wonderful speakers who will talk in six minutes or so each, but then we'll have plenty of time for Q and a and discussion. Uh, we have Mitch Thornbrugh from, uh, chief information officer and director of the office of information technology for Indian Health Service, uh, Dr. Brendan Carr, professor and chair of emergency medicine at the Icahn Cchool of Medicine at Mount Sinai and Mount Sinai health system, Kristi Henderson. Who's a healthcare change agent clinician with over 25 years experience designing, implementing, and optimizing the health care delivery system, using digital health tools and technology. She's senior vice president of tele-health and innovation for Optum Health and Peggy O'Kane who's the founder and president for the National Committee for Quality Assurance NCQA um, so, uh, great friends and colleagues, uh, on the panel today and look forward to the discussion. Uh, and I believe we will start with Mitch.
Patrick Conway (01:26):
Good afternoon, everybody Mitch Thornbrugh, I'm the chief information officer for Indian Health Service and a citizen of the Muskogee Creek nation, Indian health services and agency under the department of health and human services. And we provide healthcare to about 2.6 million native Americans across the country. And this is particularly interesting in this time. Um, as we've heard today earlier, uh, discussions about COVID and, and, uh, challenges in rural area and how to provide remote care. This is a particular challenge for us as all of our facilities are located in what everybody would consider very rural parts of the country, um, where, uh, access to high-speed tele-health is, is not always available. So I'm going to advance the slide here and just show an impact on our ambulatory visits. Um, as I stated, we, we run, um, multi-specialty clinics, hospitals and outpatient services across the country, but in particular, um, the ambulatory clinics where we provide, uh, chronic disease management and coordinated care, you know, for a whole whole, uh, communities, um, was extremely effective.
Patrick Conway (02:31):
And you can see the chart starting, uh, all the way back in October shows kind of a steady flow. And then you see this precipitous drop in April and March are starting in March, actually. And, uh, kind of, uh, culminating in a low point in April, um, where we have greatly reduced visits. And we all know that that affects coordination of care that affects chronic disease management. Um, you know, these are diabetics and patients with multiple comorbid, um, congestive heart failure, um, et cetera, that that are not getting the care that they need face to face. And so, um, you know, you see the low point of 200,000 in, in April, um, and we recovered somewhat in July, and then you see that trend starting to come back down. Now, this is a story about the impact of ambulatory visits. And I wanted to highlight this because the digital divide has a significant impact on our ability to leverage technology, um, in Indian country and for any of our rural providers.
Patrick Conway (03:30):
And what that means is if you live in rural areas with no broadband internet, at this point, you have less access to healthcare. Um, and so that's a critical challenge for the country. Um, the next slide is, is the IHS response to that, that slide. So don't, don't want anybody to walk away to say, to see that we had a precipitous drop in services, um, but it shows the difference between the, the, the pressure on the physical access to facilities and providers for face-to-face visits and then how we, um, uh, responded to that demand. Um, and so, pardon me, I may have advanced the slide there we go to a few slides,
Kevin Larsen (04:10):
Mitch. Yeah.
Patrick Conway (04:12):
All right. We should be on the IHS, uh, 80% of telehealth encounters use telephone only. And again, uh, carrying forward, we, we had a large effort to, um, push, uh tele-health. So we expanded some of our existing tele-health platform on Cisco meeting, uh, platform, but we also put flexibility, uh, or the guidance for flexibilities out to our providers. So that under the flexibility is allowed by CMS, uh, by, uh, the OIG by the office of civil rights, we were able to use platforms that wouldn't necessarily be used as tele-health, uh, platforms. And so that's one-to-one type secure connections, not non tech talk and not, um, you know, public facing services, but it would allow our providers to have a FaceTime call, uh, with the patient to make sure that they were leveraging all that, uh, technology at the edge. Um, but what we saw because of the digital divide is 80% of those tele-health hours are actually just telephone visits.
Patrick Conway (05:14):
Um, and so, you know, very few of our sites can support either at the facility, but more than likely at the home, a synchronous video call to support, uh, you know, that level of visit. Um, and so that's kind of the high level, um, response that I just had to that drop in and physical visits, the ramp up of the virtual visits. And we really think that virtual visits we're here to stay because, um, it really created some flex flexibilities in our rural communities. Um, and so we'll continue to augment that, to make sure that our patients have access to the care that they need, whether that's in person or virtual. Um, additionally, just a quick point about one of our use cases, you know, just to highlight, um, where some of our facilities at, um, we
Patrick Conway (05:58):
Had the Chinley service unit in Arizona, as well as a few other sites that, um, extended the facility wifi into the parking lot. Um, and they did this because they had donated tablets that were coming in from the community and for patients that were admitted to isolated units, you know, couldn't have, couldn't have visitors, you couldn't have family and friends. And that's typically something we rely on in our tribal communities is that strong family unit, um, for support and our patients were feeling very isolated. Um, so staff, uh, extended the wifi into those parking lots because the patients otherwise could not connect to their loved ones. And this enabled them to use those donated tablets to connect via FaceTime, even though it was from the parking lot into the room, with the loved ones and help combat that isolation and improve the outcomes for our patients. So just wanted to give you that high level overview and that use case, and I will, uh, turn it over to our next speaker.
Patrick Conway (06:56):
Great. So Brandon Carr, we'll turn it over to you.
Brendan Carr (07:05):
So I'm Brendan Carr, I'm the chairman of medicine at Mount Sinai health system, uh, in New York City. And, and I don't know what the slide is. It's a very nice, um, this is me. I'll talk about this one. So as we were, um, as we were heading into, um, coming out of the winter in December, January, we were watching what was happening in China, uh, of our friend. And I had put together a, sort of a summary of the soup to nuts approach telemedicine, you know, in, in a, in a pandemic or w when we would, when we would theoretically address something like COVID-19. And I wanted to talk a little bit about the acute care flavor of telemedicine in this portfolio. Uh, you know, I didn't have great insight into the fact that we would be at the center of it in New York, uh, you know, two weeks after this paper came out, but it was nice that we were, that we were talking and thinking about it, the way of Sinai that we, we break up our portfolios into these four boxes, the top left here on demand direct to consumer care.
Brendan Carr (08:02):
This can need to be text-based or video chat based staffed by emergency physicians off to the right scheduled visits. This is our sort of routine using our electronic medical records, embedded platform, um, has to happen ahead of time. It's usually with an established provider that you have a relationship with provided a provider consults, come in two flavors, either with a subspecialist to be a text from doc to doc or, um, with the patient consulting in real-time and then bottom right corner. These are, this is sort of an EDD to specialist consultations. These are real time. This is, you know, best known to folks, uh, probably at least historically, um, from the stroke realm, we think about what was happening in terms of, uh, of a surge of patients. This, uh, this is, you know, this is the beginnings of us drawing out how we would forward triage folks forward, you know, trying to sort folks as, as early as possible upon arrival, you know, as the big tent next to your hospital, that's got workflows, this is going to pressure, allows us to think strategically about how we serve people before we let them into our, into our hospital.
Brendan Carr (09:02):
Um, but you know, forward triage, 2.0 is a, is a little bit of a different animal. Uh, the direct to consumer platform, branded for us as Mount Sinai. Now, uh, this is the app based conversation or the app based platform that allows us to have a conversation with folks and to begin triaging them, um, from their living room. This is, you know, we've a lot of conversation on the last panel about, um, giving folks post-docs and thermometers and using remote monitoring along with a clinician assessment to determine how, and when they need to get to a real life setting. Second piece down here, uh, you know, um, telemedicine enabled community care medicine platforms throughout the fire department, um, and EMS platforms in the city. And obviously beyond this is consistent with a portfolio that's about to run out, um, or about to, about to begin from the CMMI, the, the, the T3 platform that allows for consultations and treatment in place.
Brendan Carr (09:54):
And then the bottom right here, you know, once we get you into our emergency department, at least, you know, during the peak of this, we put people behind closed doors with, uh, um, unless they were in extremis with a, with a video screen. And, you know, one of us could have just sort out who needed to immediately go to a negative pressure, closed a room who needed to have, you know, what, what their workup would look like. This is a well-recognized thing in emergency medicine is that we talk about provider and triage, um, pivoting provider and triage to be remote so that multiple, um, hospitals could be staffed by a single individual. Also allowed us to have distance way we needed it, right. Also not my slide. There's going to be trouble when we get to Peggy. I think you're mixed in with me.
Brendan Carr (10:36):
So the classic, the classic version of, of consultation for us, you know, is that a phone and a fax machine took me away from the bedside the way from the patient. This is, you know, this is where we are now. This is all, sorry, this is critical care constitution, 2.0, but you know, this is, this is someone who's a little bit uncomfortable with a critically ill patient. This is me and my living room at some terrible hour in the middle of the night. Um, and yeah, you know, we're looking at, I think she's got the cardiac probe in her hand and we're, we're resuscitating a patient. I've got ethical, but next to me, and I'm looking at the labs, I'm telling her, instead of her telling me as things are coming back and we're resuscitating this patient together, she gets expertise instantly in her, at her side.
Brendan Carr (11:11):
And then sort of just like two more use cases here. People are pretty familiar with these command centers that are looking to tele ICU, allowing us to have remote access. You can imagine, right? You probably don't have to imagine this audience. Um, during the day, this is an infectious disease it's particularly helpful because you don't have to enter the room every time to have an interaction to interact with the patient, you know, have access to the, to the monitors and to the patient. And then the last thing was, we built a very big program during this. We have, uh, we have a very strong department of geriatrics at Sinai, uh, and they were extraordinarily helpful with us on the palliative care front. They both, um, they served as the virtual interface between the family and the patient, um, would, they could, you know, have, uh, they can facilitate complex the light blue.
Brendan Carr (11:54):
It's all written up in the journal Catalyst by blue sort of designating telephone. And then the dark blue, obviously what's up within video enabled referral out of the emergency department. This was transformative for us this forward deployed palliative care of the child that you rarely see. Um, and then I guess I, you know, I would just say that the last two pieces here is that we moved a lot of people back to home and brought all their surveillance back to home so we could see them. And then on the right side there, um, these big, these big grants through the FCC, uh, the other Brendan Carr, um, the guy who works at FCC working to make sure that we could monitor people safely at home and transition them back to where they needed to be. Thanks very much.
Patrick Conway (12:33):
Yeah. So on a personal note, I have to say, the world is small, Brendan and I were already RWJ clinical scholars together at Penn long ago, Kristi and I, the next speaker work together now and Peggy, I was on the board of NCQA. Um, so I am not Kevin Bacon, but I feel good on this panel. And I've worked with IHS and always love everything they do. Um, on that note, uh, we'll turn it over to Kristi.
Patrick Conway (12:57):
Yeah. Great. Thank you. Um, you can be our Kevin Bacon, right. So that's awesome. Um, so thanks for having me here. Um, I had, um, if you were here for the first hour, um, then you got to hear Dr. Samagh really speak to what, um, Optum Health did during the pandemic to deploy technology. So I'm going to take a little build off of that and speak a little bit to, um, from a systems approach. And just what I think is an opportunity. Um, I would say that I've worked most of my professional career working on trying to advance the use of technology and new models of care. And, um, and digital health tools have proven to have such an amazing impact across the continuum, but the wind is at our back right now, right. We, we, we saw the challenges before COVID, we had a window opened up to say, Hey, here's some waivers.
Patrick Conway (13:48):
Um, your clinics are going to close, Hey, try this instead of a clinic, um, and, and see what you can do. So I think that, that, uh, opened up an amazing opportunity and our eyes were open to the possibilities. So I'm, we'll get a little creative here and try to find my slides in here. So, um, I'm gonna, um, don't let me make you dizzy when I go back and forth really quickly, but, um, I'm gonna, um, go first to, um, just speak to it from a systems perspective on thinking about it a little more holistically. Um, when you think of digital health, because it is more than just a video visit, right. And we have this amazing opportunity to blend, uh, virtual care and in-person care to get the outcomes that we want, um, both are needed. Um, and every PA it's not black and white, it's personalized care and using tools to reach people how and where, and when you want.
Patrick Conway (14:37):
And, um, as cliche as that is, there's a lot of really deep, um, meaning there and possibilities, but one of the challenges also always been around. Okay. So that's great. If we believe in it, how do we build a model to actually really redesign our system and our care delivery organization? And so I would say that, um, tracking the dollar and understanding the impact is, is not easy. So if you think about it, though, in two big buckets are pillars around really? How do I strengthen my existing operating model, um, to really drive the things that we're always challenged with? How do I improve access to care? You're going to build a clinic, or you're going to have a hospital, and guess what people move and populations migrate? How do I continue to reach people wherever they may be? So I can have really good continuity of care.
Patrick Conway (15:23):
So that's, that's one. Um, the other is around efficiency. Um, how do I use the precious brick and mortar clinic space or hospital space and the best and most effective way. And I think that there's just, um, as the technology advances and as data and interoperability advances, we have, uh, a lot of opportunity to really do more and more, um, in the home, which means we can use the other locations of brick and mortar, um, for more defined, more complex care and things where we actually can't do it virtually, and that that's going to continue to change as the technology advances. Um, when I think about experience, um, you know, I think that I would think of it, um, around not only just convenience, but around coordination, simplicity. Every one of us can tell a story of where you have to make the system work for you.
Patrick Conway (16:14):
You have to have some real resilience and persistence to call and get the information you need or reschedule, or, you know, understand your benefits or whatever. So how can we think about the technology so that at our fingertips, we can have a better experience for, for those that we serve. Um, and it's not just about access and cool new shiny objects. There is actually a lots of research out there, publications out there that show the impact of improving quality. Um, and, and it may be around that we're having earlier signals from somebody say from remote monitoring so that I can intervene earlier and prevent something from happening or minimizing the negative impact. Um, and it, and it made, there's lots of permeations of, of what I mean by possibilities of, of improving quality. If you think about telebehavioral health and being able to treat somebody in an environment where there's, they're more comfortable and can be more themselves, can we get a better assessment of their, um, emotional health so that I can treat them better?
Patrick Conway (17:14):
So there's just a few things to think about the other is, is that it's not just about, um, operational efficiency and operational excellence within your care delivery organization. It's really a whole nother arm around using that as a strategic growth lever as well. So, um, new consumer models, um, look at all the new entrants that are coming into healthcare and how they're leading with a digital first solution. So as a health system, thinking about how do I use those tools to also, um, provide that type of, um, offering to those that I serve, um, as a health product offering, you're seeing lots of different payers come out with things like virtual primary care. Um, there's going to probably be lots of iterations of that new models as consumers are ready for it, as there's an increased financial pressures for us to redesign, and as the clinical systems are able to respond, um, and then performance and affordability.
Patrick Conway (18:12):
I think that, um, as we really think about how to use the precious and scarce resources of our clinicians and everybody is working at the top of license in this org fondly orchestrated model of care, um, it's really going to give us an opportunity to really think about, um, the cost of it as well, and to be transparent with that. Um, and then healthcare is we know what 80% of it is social determinants of health. How do we connect with community partners and create a health ecosystem to really drive the full, um, impact that we need to across everything from transportation and, uh, other social determinants of health. So, um, the, the next piece that I'll talk about, um, as I kind of flip through some slides, um, to get to the one that I want to give a visual for is that I mentioned at the beginning that I wanted this to be thought of as more than just, um, a video visit there.
Patrick Conway (19:04):
The digital health tools are really around a, an entire, um, across the entire continuum. From the moment somebody thinks about getting healthcare at the discovery point, they go online and they start searching things, me pain, whatever it may be, um, women's health, whatever, and they're going to get information. So as a system or a care delivery organization, how can you be top of mind and be present and that decision point so that you can help people answer their questions self-manage, um, navigate to the right side of care, make sure where they're going is going to be the highest quality and they understand, um, what their options are. So, um, I put this up here really kind of highlight that their digital health tools are really across the entire continuum. And, um, and if you think about each segment, you have an opportunity to really build a coordinated system.
Patrick Conway (19:57):
The risk of not doing that in just doing a video visit is, is that you become just one more app that everybody has on there. I won't have you raise your hands for those that are in the audience, but we all have apps on our phone that we've used once or none. So how do we really become engaged through digital tools to really drive health? And so, um, I think it has to be connected across the entire continuum if we're really going to build, um, a system that people will use and come back to. So, um, I would think about it that way. I would think about, um, every segment, a little bit different when they are selecting a site of care, how can I match and, um, find the right per provider. So that might be by choice. It may be because of a certain clinical condition.
Patrick Conway (20:42):
It may be based on location or just availability based on what the consumer wants or what they need. Um, and so matching tools is another piece of that symptom, checkers, um, navigation tools. Um, everyone knows about the video visit, but how do I use asynchronous tools as well? Um, and then as you keep going along this and into things that can be on almost ambient monitoring and sensing in the home and really engaging, um, uh, an a day to day basis with those and, um, their chronic health conditions, for example, we can really start intervening earlier and be there to support them so that we can hopefully keep them out of clinical facilities and out of the hospital. Um, and so ongoing care management and remote monitoring, um, wearable devices, um, all of those types of things, even into how am I going to get medications to somebody? How can they get easy refills? Those are all digital tools. So I think that we all know that, but looking at it holistically, we can create that seamless experience because really our goal here is to have a simple, convenient, coordinated, and connected health ecosystem. So I'll pause there and, and pass it over to Peggy.
Patrick Conway (21:56):
Thanks, Kristi.
Peggy O'Kane (21:58):
Good afternoon, everybody. Can you see me? I don't see myself. You can't see me. Okay. Yeah. So, uh, what our time we're living in, it's so exciting. And I just want to compliment the OptumLabs folks for putting together a fantastic program. Um, uh, you know, in my mind, tele-health opens the door to virtual care delivery in a way that we could only imagine before, and it really is an opportunity to re-imagine care. So, um, I think one of the things that strikes me is that our early expiration and design may be limited by trying to just mimic the old care models. And so, uh, I mean, I already saw from some of the speakers today that they're well beyond that, but I think that, you know, as an accreditor, um, we have to be careful also that we don't try to smack, uh, standards that made sense for bricks and mortar, uh, healthcare, uh, onto tele-health.
Peggy O'Kane (22:59):
Um, I, another point that I feel completely riveted by is that the payment model will limit or nurture innovation in telehealth and, and making it a really useful part of the delivery system. So, um, you know, it's not like, I think tele-health will only be part of value-based payment, obviously not, uh, patients are gonna want it when they want it. And, um, you know, they'll figure out how to get to it. And it will be a challenge for existing accountable systems to make sure that, that, uh, that the experiences that happen over there and the data that are collected over there become a part of managing the whole patient. So in my mind, the word stewardship keeps coming up and it's kind of, I think about it as we all have a job to stored all of us in healthcare, the health of the people of the United States, which sounds really old fashioned, but it's part of what I believe.
Peggy O'Kane (23:59):
Um, and we also have a responsibility to store the dollars. And I think in a value-based payment model, because you're stewarding within your system, you're also, if you're at risk, the incentives are aligned for more affordable and actually higher quality care. So, um, and then, uh, technology can only be as good as the system it's embedded in and the human touch should be kept as true North. Now, while I'm fussing with the slides here, cause they're all mixed up. Um, I'm going to tell you that, um, I just saw the Mayo Clinics tele-health for COVID and interestingly, um, my brother who has lung cancer and who's actually doing okay with this lung cancer, got COVID and exactly the model that we were shown with the, with the home oximeter and with the home oxygen. And that's what he had. And I have to say that the, the human touch part of it was as important as the devices, because he felt so cared for by his provider.
Peggy O'Kane (25:04):
And it was really quite impressive. It was quite simple and yet very impressive. So, um, I think we just have to remember that. So as NCQA approaches this area, and you may know we conveyed to telehealth task force and we had some really great people with a lot of on the ground experience who shared with us. And so we come to this humble by the complexity and, um, excited by the potential. Um, so, uh, we are in an interesting position because we, we work at the health plan level and we also work at the delivery system level, uh, with patient centered medical homes. And so we can, I think begin to align the tele-health requirements for different kinds of models of relationship between health plans and delivery systems. And we can see like a United Healthcare and Optum Care. Uh, we see that kind of a model.
Peggy O'Kane (26:03):
We see Kaiser Permanente. We see, you know, your typical, uh, model on the East coast, where there are lots of smaller practices and large delivery systems. Um, and then there are the tele-health vendors, which we, we already accredit their credentialing. But what we want to do is create a suite of products that will align across. So we're that they're not fighting with each other as you go to the different levels. Um, so we are, you know, we're, we're very proud. We have, uh, a new chief product officer and our people are working with, uh, agile techniques. And they've been out there talking to, I don't know, 55 practices and, you know, number of health plans and so forth. Uh, but one thing that we're very proud of is that in the, in the COVID crisis, in the spring, we quickly adapted 40 years measures to, uh, to allow for telehealth meeting of the requirements.
Peggy O'Kane (27:03):
Uh, and that was done within the matter of weeks. And, um, we also want to be innovative. Um, I think, you know, we don't want to be the cold dead hand of NCQA, uh, limiting the creativity of the delivery system. And so, uh, we take that seriously and again, we're humbled by the, uh, by the challenge. I I'm trying to get to slide, push to audience. Okay. I can't see the top of my slide. Um, but, um, we have two products that are, um, that are going out for public comment this week. Um, and it's on the slide, but I can't see it. I hope you can. Uh, but the public comment period opens tomorrow. We're very, very eager to get feedback. So what we're doing to begin our tele-health model for health plan accreditation and a tele-health distinction for PCMH, and these are aligned with each other, um, you know, so they have many of the things that those of you from health plans that have been accredited as talking to look very familiar.
Peggy O'Kane (28:06):
And, um, you know, I think that there are special challenges again, around care coordination, uh, when you have members going to telehealth providers and maybe that's not all together yet. Um, but the other parts of it are, you know, there, there are new ways of thinking about it. I invite you to look, I don't have time to go into any detail. Uh, again for PCMH is, um, I think, uh, to me, the ideal combination are activated primary care enabled by technology. That's my, my view of the world. I don't know if that will, will, uh, hold for the future. And I think the job of the primary care physician can be, it can be done very effectively and with less, uh, burden by, uh, enabling it with, uh, AI and, and so forth. So I'm hoping that we can finally make primary care something that people actually want to do.
Peggy O'Kane (29:03):
Um, uh, you know, for other than, uh, you know, uh, altruistic reasons that it could be actually a fun and rewarding job. I think that there are numerous questions to be considered. Maybe we can talk about some of this in the, uh, in the dialogues that we're having after, but what is appropriate for tele Al? And I think that's a moving target. Uh, I think nobody's eager to say no that you can't do that until the health, because next week you probably won't be able to do it. And maybe just as well or better than you can do it today, the coordination of care again, I think, uh, you know, call me on fashion. I think if there's not somebody or something that's sweating about the patient, that's moving through the system and making sure that the right things are happening, then they will not happen as an act of nature or the market or whatever. So, um, I, you know, I think, uh, uh, accountability, uh, is, is it's, it's part of every conversation that we're in. And then, um, we are planning by the way for telehealth vendors and evaluation service that may, may be called accreditation, but maybe not anyway, I'm going to stop there. And I really looked forward to the conversation with this terrific group. Thank you.
Kevin Larsen (30:18):
Thank you, Peggy. And again, you can put questions into the Q and a, but I'll turn it over to Dr. Conway to start us off with a discussion.
Patrick Conway (30:27):
Yeah, just, um, one reflection before ask the first question that great set of panelists, you know, to do. I started in Optum in mid February and was asked to think, start thinking about home care and mental behavioral care, which led to now my role as CEO of care solutions or working on home care, post acute hospital to home mental behavioral care delivery, I SNIPS and other things. Um, it was a unique time and sort of transition period, which a number of you talked about. I think we're capturing a lot of those opportunities in, uh, in a positive way, realizing, you know, those opportunities were created by a devastating pandemic. Um, how do you all think about where we reset to meaning like, what is the new baseline? And by the way, I don't know the answer to this question. Um, but I love your thoughts given the thoughtful panel that we have about, you know, what does it look a year from now? What sort of resets, what doesn't change, et cetera, uh, in whatever order you want to take that in Peggy.
Peggy O'Kane (31:31):
Um, yeah, so I think, you know, I look at HEDIS, you know, um, pardon me for being parochial, but, um, you know, do we, so do we want people to have preventive services? I think we still do. Uh, do we want people that have chronic conditions to be managed to the, to the optimum of their health? Are we trying to store their health? Are there a new set of COVID COVID specific measures? And then I think it'd behavioral health. Um, I don't know what your experience is, but I think, uh, you know, so many of the people I know either professionally or personally are going through really hard times, uh, we kind of have to rethink, I think a lot of behavioral health, uh, there is, you know, there's this, there are these interesting new telebehavioral health vendors that have, you know, recently it says part of their mental model. I think that's part of it too. So those are just some thoughts. It's not a finished product, obviously,
Patrick Conway (32:32):
Others.
Kristi Henderson (32:36):
I'll be glad to jump in. Um, so know, I think of tele-health
Kristi Henderson (32:40):
And, um, as, as healthcare, so, you know, just as other modalities are just think about surgery, all the different advancements in how we do surgeries, um, and you know, they've all advanced and we've adopted those because you get the better outcome, you know, with less risk things like that. So I think it's, this is another tool in our toolbox and the reset opportunity for us is to really, um, embed that tool in our clinical, uh, delivery organizations, to be able to use it easily and for customers to be able to use it easy and understand what the cost of it is and how it fits into their health plan and all of that. I just think that, you know, if we keep looking at it as something different, we're always going to be comparing it. I don't think we're going to ever realize the full potential.
Kristi Henderson (33:29):
It's a tool that we need to use to reach people. And we've got to redesign the whole model of care before this, the model wasn't sustainable. It costs too much and our outcomes weren't going where they wanted to go. So this is really, you know, the pandemic, if we're going to find any silver lining in it, it's our opportunity to really redesign that and really embed the technology we've had those waivers put in place that really unlock the potential and our biggest skeptics became fans of it. And it's not the, it's not the solution for everything, but, um, I just, I think our opportunity and our level of settlement on the other side of this is that it truly is just another tool that we can use. And when you call in for an appointment, you have options between virtual or in person that are actually guided by data and clinically sound to get the right outcome. So I, I know I've drank the Kool-Aid a long time ago on this, but, um, I truly believe that it's our responsibility to really take this and take it forward and make it a sustainable part of our, our infrastructure.
Brendan Carr (34:30):
Patrick it's Brendan, my 2 cents on this as a, you know, there's, there's going to be a long tail on this. There's still, it is still really, you know, people are afraid to get back to normal care. So we have a longer time to, to continue to reinforce this as a, as a, as a means of, and I couldn't agree with more of as Kristi. It's just one more way that we interact with you. And one more way that we'd deliver your healthcare at the same time though. I think the regression back to the bed to where we go is going to be, is going to be substantial. And I think that our gains are not going to be what those of us who believe, um, think they're going to be. I think, you know, we go back to who dropped to a quarter or from what we were doing a month or two ago, um, as our, as our sustained uptake, just because people are so set in the way that they have always received care and because we won't evolve quickly enough to make it seamless and slick and good for them.
Patrick Conway (35:17):
Yeah. Maybe next question, sort of building on that. Um, I, I just did a, I moved, uh, not so long ago, did my first primary care visit, which was tele, was my provider, um, and got to, I'm always a secret shopper. So I got to ask him how it was going and there was some pros and cons listed. Um, but how do you think about the physician clinician burnout issue? And what's, you know, what's the research and your sort of practical advice on how we think about, you know, integrating tele and virtual care in a way that, you know, fosters physician and clinician, and that works in their workflow. Be interested in your thoughts on that.
Kristi Henderson (36:05):
I'll be glad to jump in on that one.
Patrick Conway (36:07):
Sorry. Raise your hand. I'll look for raised hands go, Kristi.
Kristi Henderson (36:11):
Okay. So, I mean, I think that if you think about how these tools could help with that, I mean, there's a lot of different pieces, so it can also become a burden if we don't do it. Right, right. It's another app. It's another data point. Can you imagine all the data that's going to come from wearable devices? I mean, how in the world that's going to overwhelm people. So, so I think that, that we've gotta be really careful in how we implement these, these new technologies so that we don't actually perpetuate a problem around burnout. But the positive side of this is, is that, you know, um, if, if integrated correctly it becomes, um, you know, data can be monitored for by monitoring clinical surveillance unit that is taking all this reams of data and making, uh, finding trends and serving up to the clinical team, what is actually, um, what is actionable and so that it can becomes usable.
Kristi Henderson (37:01):
So it's no different than, you know, when we started doing electronic medical records and it was, you didn't have time to go read through all the notes before you actually walked in the room. So now with AI and learning loops that can be implemented, you really can get smarter and smarter with the data. So that it's right there at your fingertips. That's one. So you could have a, you have an extended remote care team that becomes a part of your care team, managing your patients. Uh, the other is around, you know, there's, there's something really nice about being able to do virtual visits, um, from your home and the comfort of your home versus running around a hospital or running around in a clinic. And so I think that for some, that will be a really good choice for them to be able to be, um, a clinician that is doing virtual visits or even splitting their time two days a week, virtual and three, you know, in the clinic, whatever they want to do.
Kristi Henderson (37:50):
I think there's a lot of opportunities from that space too. So those are just two examples on, you know, of course you get the connection to a multidisciplinary team now through, um, uh, virtual care that you didn't have before. So, um, clinicians love to work as a team and loved to have other experts working with them as well. And so it's an easier way to do that if you're not in a facility with a multidisciplinary team. So I'll pause there,
Patrick Conway (38:13):
Go to Peggy.
Peggy O'Kane (38:14):
Yeah, I mean, for me, this is going to separate the small practices from the people that are working in systems in a very, very dramatic way. Um, it's very, very striking to me to talk to people that are in systems that have been doing this for awhile, you know, admittedly at a small scale, but how kind of seamlessly, they were able to kind of move into
Peggy O'Kane (38:36):
The higher level of tele-health and, um, and actually seem to be having some fun with it with small practices. I mean, even with medium-sized practices, there was a lot of scrambling that had to go on. And, um, you know, there's kind of planning ahead for visits, you know, the kinds of things that you don't necessarily think about, but if you, if you can't do them that the quality of the visit is not going to work right. So I just, I am having a hard time understanding the sustainability of the small practice in a, in a tele-health something that comes along. That's very affordable and remember they always have small margins too, so they can't go out and hire some wonderful, uh, uh, you know, service to, to take care of all that, that back office stuff. So I, I wonder what others think about that, but that's something that I think about a lot.
Patrick Conway (39:36):
Do you want to comment on this?
Brendan Carr (39:38):
That's a key piece. It's not that it wasn't where my head was, but you know, it makes perfect sense. And then again, I think of this from the emergency departments perspective, many of them are relatively small practices, small shops that outsource most of what they do. Um, and we've talked a lot at them about how they could grow this and they just, they just don't really see a path forward. My mind was a little bit more wrapped around the challenge that we have in that for us, it's not the pediatrician's visit. And then a couple of things need to happen after the visit that's the normal or a primary care visit partners. We were talking about, that's the normal blood work done and, you know, scheduled the thing that I need to get done based on my screening.
Brendan Carr (40:17):
Um, for instance, all integrated in the acute care world. So I really need a nimble ability to get a, you know, an x-ray and a couple of lab tests, uh, you know, some of the point of care or some of them, um, um, they'll take a little bit of a longer term time, which means I need to then build an interface that allows me to have a follow-up visit in a half an hour or an hour and a half. I need to build a real time dispatch for an EMT or a medical assistant to go out to the home and do a couple of things so that I can make my, my decision-making is iterative, um, as I get more information. And so that for us has been the hardest part is not just figuring out how to go off, send somebody out for a flu shot, but send somebody out to check three different lab values, and then to tell me what they are so that I can then make.
Kevin Larsen (41:04):
Um, we've had a couple of questions from the audience around, what does documentation look like in this new world of constant monitoring, constant data inputs? How do we not overburden our, our documentation system had already by reform it in a new way?
Peggy O'Kane (41:24):
Um, I'm going to jump in, um, tell me to shut up if I'm talking too much. Um, you know, it seems to me, we have to, we have to kind of rethink
Peggy O'Kane (41:34):
The documentation part and we also have to rethink what, what actually has to come to the attention of the clinician, uh, if you're continuously monitoring. And so I kind of think of it as there should be some kind of AI that's kind of managing in the background and only popping things up as attention is needed or some change in, in the treatment or whatever the plan is needed, um, which actually could expand the capacity of, of your average clinician. It seems to me because so much of it could be going in the background. Um, and so I, I, I think again, it's kind of like, let's not get bogged down in our current models of how care is delivered today and thinks that time it has to be delivered under these new circumstances.
Kristi Henderson (42:26):
Yeah. And I'd love to add onto that too. So, um, you know, I think that if we compare it to like the airline industry and I used to know these stats, I unfortunately didn't those questions coming in, or I would've known these, but just about, you know, we've got there, they have data coming in from everywhere to make sure all the planes don't run into each other. Right. Um, so we have data coming in from all over and it's going to keep growing and we do have to have somebody watching, not managing this kind of, you know, health control center and, and serving up information and trended information, just like I talked about earlier, we've got to have this way to take all this range of information and make it actionable, or just becomes data for the sake of data. And, and, you know, even if we have a great visualization tool, if it was not delivered at the right time to get our intervention in the right time, then it didn't get us any further.
Patrick Conway (43:13):
Right. So how do we think about our care teams in a different way so that we have somebody that is a part of your care team, managing a panel of patients that is monitoring this dashboard of data. Um, and, and that could be a lot of, it could be AI driven that are serving up alerts so that somebody can manage, you know, uh, who needs to actually respond. Is it the physician? Is it the nurse, the diabetic educator, the pharmacist, whoever. So, anyway, I just think we have an amazing opportunity actually with all that data and the AI tools that are out there. Um, and, and they'll get smarter and smarter for us to be able to respond and bring humans in where it's necessary and then have things automated where feasible,
Patrick Conway (43:54):
Maybe, maybe in Kevin May have more, but I'll add another on. Um, for seniors, we've got a house calls program and we do 1.7 million visits to seniors in the home. And as you can imagine with COVID, we had to switch to virtual visits and other things, and a lot of instances, um, you know, how do you think about seniors? Uh, what are some of the barriers or opportunities in the senior population as you think of, uh, telehealth and virtual care?
Brendan Carr (44:28):
Sorry I didn't raise my hand.
Patrick Conway (44:30):
Yeah.
Brendan Carr (44:34):
I mean, I don't know what your experience has been, but, you know, I have been very, very surprised about the ability to do it without, without the struggles that I would have anticipated. Maybe that's overly optimistic.
Kristi Henderson (44:45):
Well, okay. So I would say the same. I mean, I think that, you know, I think sometimes we get in our own way and assume somebody who doesn't want something. Right. And now what we did learn is that if you start saying things like download an app and all this other stuff, you, you might lose some. So we, we learned a whole lot during this time and, and adjusted, and I think most of it was intuitive, but, you know, if you build something that's easy, it should be good to use for all age groups and all, you know, like let's make it real simple, like start here, push this one button. And so we did change things around not having requiring downloads, um, even shipping devices, to people that had data plans in one button to be able to say, you know, see my, uh, healthcare provider, um, or, you know, so that's just two of the options, um, that we, we did. But, uh, I think that just gotta be simple, but it should be simple for everybody too. Um, so we, we adjusted.
Mitch Thornbrugh (45:40):
Yeah. Just want me to share a thought, you know, I think because of the extreme need, it really overcame some, some barriers, um, to, uh, really understanding what is information work, you know, as we transition to the information age and we move out of factories and we're not touching things, I think there was a lot of assumptions about all the patient care was, was really hands on. Um, and I think the extreme need really pushed us past some of the hesitation. And we really got to the root of what can be done remotely, what can be done as information work, what can improve outcomes, um, and then what can be reserved for that really valuable face-to-face patient interaction. Um, so I'm, I'm really interested in how much we learn from this episode in time. And again, how we replay that forward. Um, now that we've brought down those barriers to continue to innovate and increase access, um, because honestly in my rural communities, if we can get the broadband where we need it, we can then extend access in the really underserved populations without having to try to recruit physicians and specialists into the middle of nowhere where the patient, you know, demand the patient volume, doesn't support their models. Um, so just some thoughts there. Thank you.
Patrick Conway (46:56):
Thank you.
Kevin Larsen (46:58):
We have a question from the audience, um, about cross state licensing and credentialing. So there've been some there, some openness to that right now. Uh, what do you think we need in the future around this, um, cross state licensing and credentials?
Peggy O'Kane (47:16):
Yeah, I think we need it. This is Peggy. I didn't put my hand up. Um, but, uh, you know, I think it, it actually, well, it kind of begs the question of why do we need state medical boards? And I'm sure somebody is going to send me a hate, some mail about that. But, um, you know, I mean, you know, we know they vary in their effectiveness. Uh, you know, they do play an important role in the States where they play an important role. Um, but, and often in disciplinary matters and so forth, but, um, the practice of medicine, to me, just the idea that it should be different in Delaware than it is in Washington state, doesn't make a whole lot of sense. So those things don't die easily. So I think we'll be struggling through that
Mitch Thornbrugh (48:05):
Indian health service. And, uh, additionally, the veterans administration has statutory authority to, to, uh, it's basically re reciprocity. Um, and we, uh, are able to credential our providers in a state, um, and use them, uh, wherever we have them deployed. So, um, for whoever has that question, that might be an interesting research. I, I apologize. I don't have the legal reference at my fingertips, but it is, uh, promulgated through federal law.
Brendan Carr (48:35):
We're very jealous of you.
Kristi Henderson (48:38):
You know, it's interesting. I mean, this has been a long timing discussion ever since we started doing telehealth to understand, and everyone always used to compare it to, you know, your driver's license. You can drive anywhere you want, and it didn't get rid of highway patrol men in each of the States. Right. Um, it, it still can have medical boards in every state and nursing boards because their job is to ensure the safety of their citizens. And so it's, it's similar. So, um, you know, I think that we're all very hopeful that we will be able to demonstrate, um, a way to be able to safely move this forward and allow that flexibility to be able to deliver care where people are and having more portability for providers to be able to follow their patients.
Patrick Conway (49:21):
Well, having just finished my, like, I think it's my seventh state licensing. It's exciting every time. Um, so yeah, if we get to a single license, uh, I think a lot of physicians would be, uh, clinicians will be very excited. I think it's a great analogy too Kristi. I hadn't heard that before. So I think that's a good, uh, there may be something there for policy makers to think about that retains some of the state aspects without our current policy structure,
Brendan Carr (49:50):
there's model legislation that's been delivered. You know, the EMS have been strong leaders in this, your paramedic license move across the state line, then model legislation has been distributed. Yeah.
Kristi Henderson (50:01):
And nursing has made good progress there too.
Patrick Conway (50:04):
Yes, that's good examples.
Kevin Larsen (50:07):
Another question from the audience is how can we use digital pathways to do more coordinated care for complex patients with primary care and specialists?
Peggy O'Kane (50:20):
I'm going to just be a crank and say, somebody has to be, somebody has to be in charge of that sub system. And it's somebody worrying about Mrs. Jones. Who's seeing seven different doctors and, uh, they're all in their own practice patterns. You know? So I don't, I don't see a way around that. I mean, maybe the AI could take care of that, but it's still somebody has to be holding that accountability for, for health and for her, you know, the financial side of, of her experience.
Kristi Henderson (50:51):
Yeah. Otherwise everybody makes assumptions of somebody else's taken care of a piece of that, but you know, you hear people refer to the, who's going to be the quarterback and how do we do care pathways, but having interoperability as a start to be able to actually see what others are doing, because, you know, think about every system there's, uh, a care manager or from the payer, there's a care manager from the cardiologists, there's a care manager for, you know, the clinic I could go on and on and on. And I think every time I see somebody research on this, it's about four to six people intervening to try to make Mrs. Jones, um, healthier. And, um, and so being, just think about the duplication and cost waste, and not to mention that we're actually probably all telling Ms. Jones to do something different. And so the opportunity there is enormous. It's not easy to be able to do that, but it's got to start within each system having an accountable leader for, um, a quarterback of health for an individual. And, um, I think pieces of it that allow it to be scalable, um, does include technology to be able to take all this data, understand where people are in their journey and, um, and then how to connect them to, um, different, uh, resources in health, whether that's a specialist, primary care, you know, uh, social services or whatever, but none of that is all aggregated together to see a whole person's view of health. So, um, I think that there's a lot of potential there, but a lot of investments are needed to be able to actually coordinate that.
Kevin Larsen (52:19):
So Patrick, last question to you.
Patrick Conway (52:23):
Oh, with like two minutes, uh, rapid fire what's, uh, what's one word or concept that we need most to advance this. I'll start with Kristi.
Kristi Henderson (52:36):
One word?
Patrick Conway (52:37):
Or concept. I'll give you a sentence.
Kristi Henderson (52:40):
I mean, simple, convenient, coordinated, connected.
Patrick Conway (52:44):
Nice. Brendan.
Brendan Carr (52:46):
Keep it stupid, simple.
Patrick Conway (52:52):
Uh, Mitchell.
Mitch Thornbrugh (52:54):
Broadband.
Patrick Conway (52:58):
All right. Peggy.
Peggy O'Kane (53:00):
Reimagine.
Patrick Conway (53:02):
All right. That's a good end. I love it. All right, Kevin, over to you.
Kevin Larsen (53:06):
Yeah. Thank you all very much. This is terrific. What a terrific discussion. Um, thank you all for coming and and being here today. We'd like you to please, um, fill out the brief feedback survey at the end. Um, by clicking on the checkbox at the bottom of your screen, we have one more of these Connections, 2020 webinars.
Kevin Larsen (53:26):
So please join us on Tuesday, December 8th for chronic kidney disease, innovation and polychronic populations will again be highlighting some terrific work we partnered with NCQA but a number of researchers from around the country, looking at how we can, uh, understand and identify chronic kidney disease before it becomes end stage renal disease and how we can intervene. Thank you all for joining and I'll look to see you on December 8th.
Patrick Conway (53:52):
Thank you all. Thank the panelists. And thank everyone else. Thank you very much. Thank you.
Kevin Larsen (00:02):
Hello everyone. And thank you for joining the final webinar of the OptumLabs connection 2020 series. Uh, I'm Dr. Kevin Larsen. I'm the clinical innovation and translation lead at OptumLabs. And I'll be your host. We're excited for you to welcome you to this option lab OptumLabs, connections 2020. This is the final virtual session that we've had. It's been a historically rich conversation here. We arrange every fall, uh, conference, uh, connecting in-person research and translation aimed at stimulating that health system change. Uh, this year, like all other conferences we've been attending, we've done a virtual conference, split out over a number of sessions. This is the fifth and final session. It we'll be showcasing, uh, national thought leaders and important themes is highlighting both the key research results generated from Optum labs and its many partners. Before we begin, I'd like to introduce you briefly to OptumLabs.
Kevin Larsen (01:03):
We are an evidence-based innovation and collaboration within Optum and UHG. We applied various perspectives and scientific rigor to rigorous data assets to generate actual insights. We partner with a lot of external organizations, academic organizations, government organizations, medical and clinical organizations, such as Johns Hopkins, university of California, health AARP, AMGA and [inaudible] pharmacy quality Alliance. Uh, we also partner with the U S government and a lot of internal partnership here within Optum and UnitedHealthcare together. We combine our healthcare expertise and deep knowledge of research, and we work with one of the leading the industry's leading data assets to extract insights that help achieve our mission. Our data asset is unique and very longitudinal. It includes de-identified linked claims, EHR and socioeconomic data carefully curated and enhanced. We use our data with different views and tools to make it easier for partners to work. We've had five sessions, uh, beginning in October 20th, if you miss any of the, uh, the first four sessions on health equity, behavioral health health in at home, uh, the, and the audit and the Optum labs project showcase the recordings are now available on the OptumLabs website in the spotlight section,
Kevin Larsen (02:35):
And there will be replay available. Before we begin, I'd like to cover a few quick housekeeping items. You can explain, expand your slide area by clicking on the maximum icon on the top, right of the slide or by dragging the bottom right corner of the slide area at the bottom of your audience console are multiple application widgets. You can use these to customize your viewing experience. If you have any questions during the webcast, click on the Q and a widget to ask your question, we will try to answer some of these questions at the end of the live presentation. If you have any technical difficulty, please click on the help widget. It has a question Mark icon and covers common technical issues. Importantly, this webinar will be split into two parts after the first hour, click on the join now button in the upper right corner of your screen to be taken to the console for the second portion of today's event. With that, I'd like to introduce our speakers today. Um, we have Sharon Pearce, Kerry White, Jay Agarwal, Brian Phillips and we have Amar Desai from Optum Care California is our moderator. Uh, and in the second part of the session, we have StephAn Dunning, Donna Spencer, Dan Roman, Connie Ree, and Kam Kalantar. And I would like to turn it over to Sharon Pearce from the national kidney foundation to get us started. Sharon,
Sharon Pearce (04:03):
Thank you, Kevin. And good afternoon, everyone. Uh, as Kevin said, my name is Sharon Pearce and I am the senior vice president of government relations for the national kidney foundation. And I am going to start us off with just a brief overview of the policy environment in chronic kidney disease and what we may be able to expect and look forward to in the next year, um, over the next, uh, 15 minutes or so. I hope we go over, as I said, the kidney care landscape, this opportunity for policy reforms in air, a little history on the advanced American kidney health agenda, and, uh, some other just to level set. And hopefully most of you are aware of this, but for those who are not, uh, 37 million Americans have kidney disease. And unfortunately about 90% of them don't know it. Um, it is a quiet disease. It does not manifest, uh, in a lot of symptoms, the full its later stages. Um, so a lot of patients don't find out that they have any disease until they're about 708,000 Americans. Um, most of whom are on dialysis, some of whom have transplants. And about 95,000 Americans are on transplant, kidney transplant, wait list,
Sharon Pearce (05:18):
Um, ESRD or kidney failure. Uh, you know, we tossed around a couple of different ways. Kidney, kidney failure, um, either way is a serious problem in America. About as I've mentioned, 785,000 have failure. Um, you know, 30% have a functioning transplant, but 70% require in central that are required dialysis. The vast majority of which is provided at in-center dialysis centers. So, um, you know, it's still heavily hit very heavily dependent on the incentive model for dialysis care. Um, patients are have a very high hospitalization rate. They are very frail, they have a lot of comorbidities. Um, and so they are also incredibly costly while there has been some uptick in the use of peritoneal dialysis. That's called PD. Um, you know, we're still, like I said, relying pretty heavily on in central dialysis for these patients. And unfortunately that is one of the most costly settings for repair, um, chronic kidney disease, which is the, you know, kidney disease, like most diseases is a disease it's staged.
Sharon Pearce (06:24):
Uh, so for those who may not yet be at the kidney failure level are still very costly patients to care for, um, spending on patients with chronic kidney disease accounts for about one in four Medicare dollars. Um, so this is a very, very costly disease. Um, the per patient per year expenditures are extremely high and that these patients are at much higher risk, especially for, um, diabetes. Hypertension are, are often comorbidities. Those patients face much, much higher costs if they also have CKD. So if you have a patient who has diabetes mellitus and CPD, their costs are going to be 47% higher than a patient with just diabetes, same for heart failure or CKD is what we call it to these multipliers. So it makes other underlying co-morbidities that much more costly to care for and treat, um, from a policy standpoint, this has been a priority, uh, for some time.
Sharon Pearce (07:15):
And I think really in the last 18 months, we've seen unprecedented attention to kidney disease. Um, very much as a result of that, we were spending about one and four Medicare dollars on this population. Um, and you know, more microliter on the dialysis population about 1.1 and seven, 1% of Medicare beneficiaries are on dialysis, about 7% of the costs are from dialysis. So, uh, again, you know, a lot of focus from policymakers on trying to address the issue of kidney patients. Um, there, there's a couple of key issues that I want to talk about. Some of you may be familiar with the advancing American kidney health initiative, a major initiative of the Trump administration, and, and are gonna want to know where that goes with the change in administration. Um, some other big changes on the horizon with Medicare advantage, and then there's other opportunities for reforms that we think are very, very promising.
Sharon Pearce (08:06):
So just to provide a brief overview of the advancing American kidney health initiative, it was, um, it was the only, or one of the only disease specific presidential, you know, uh, executive orders that's ever been in place. And, um, you know, I think that that for us was a real indicator that finally people are starting to pay attention to kidney disease and the toll it takes both on patients and on the healthcare system. Um, it has three priority goals, three priority areas, um, and they're, I think they're all equally important, but the first is really to reduce the risk of kidney failure. Uh, we know that I slowly, as I mentioned, 90% of patients do not know that they have kidney disease. We think there is significant opportunity to identify, diagnose and get those patients into treatment that can slow the progression of their kidney disease and ultimately reduce their risk for kidney failure.
Sharon Pearce (08:58):
So that's a huge priority. Objective. Another is to improve access, improve access, to treatment choices for patients with kidney failure. As I mentioned, this heavy reliance on the in center dialysis model, um, not enough access to home dialysis, not enough access to transplantation, um, is a big area of focus and then increasing the availability it's available for transplant. We know that there's a huge supply and demand issue when it comes to transplantation. So wouldn't be, um, priorities of the advancing American kidney health initiative was to double the number of organs available for transplant by 2030.
Sharon Pearce (09:33):
So, um, Just to give you a little bit of a sense of how NKF is fitting into this, uh, public awareness is really key. I think that we have looked at what some of our peers in the chronic disease space and other public health organizations have done, and it really all starts with public awareness. And if you have 9% of your patient population, not even aware that they have kidney disease, there's a lot of work to be done. Uh, so, uh, a little over a year ago, and KF signed a memorandum of understanding with the department of health and human services and the American society for nephrology to really launch a public awareness campaign. It went into effect in March of 2020, which is unfortunate timing because I think it was in place for about 12 days before the country shut down due to COVID. Uh, we didn't relaunch in September, we took a few months off.
Sharon Pearce (10:18):
And what we found is that there is an appetite for an interest in this information, I think at COVID disproportionately affecting a lot of patients who are hospitalized as a result of COVID-19 some experience acute kidney injury, which can cause their kidneys to fail. So, you know, I think there's a little bit of an intersection there and, you know, we're using that as a pivot point to really drive information about kidney disease to the masses. Um, and you know, we are finding that it is a successful effort and one that needs to carry forward. So, um, this is a really essential component of the, the advancing American kidney health initiative, Um, Other initiatives that are equally important, um, the ESRD treatment choices model. It is a payment demonstration of payment reform demonstration that will go into effect in January. Um, I don't want to go too deep into the details, but the intent is really to drive improvements in care, coordination of care, um, incentivizing transplantation, so that, you know, the in central model is not the default option for a lot of patients that, you know, we are really doing what we can to preemptively transplant these patients, to try them home. There's a number of payment incentives, both positive incentives and penalties for, uh, providers that don't hit certain benchmarks. And we do anticipate that this will hopefully dramatically increase the number of patients and the options available to these patients. It goes into effect, as I mentioned in January affects about 30% of dialysis providers across the country. Um, so this is a pretty sizable reform that came of it out of the American kidney health initiative. And one that we anticipate will continue in the early days of the Biden administration, uh, will likely be tweaked and refined along the way, but, um, a very, very promising model for kidney patients.
Sharon Pearce (12:09):
Um, There's also been a significant focus on how can we reform the organ transplantation system, which unfortunately at the moment is fairly siloed. Uh, the, the organ procurement organizations are the entities that are responsible for, um, you know, talking to donor families is securing an organ transplant, you know, an organ for transplant coordinating the allocation of getting that organ from the donor hospital to the transplant center. Um, and that, uh, entity, these are government contracts that there's 58 of them. Um, the reforming, the rules and regulations under which those entities operate. And they've made a number of changes really, uh, focused at trying to reduce the number of kidneys that are discarded annually. We know that far too many kidneys are thrown away either because they are utilized a time or the incentives aren't properly aligned. So really trying to drive more donation, making sure that, you know, each potential donor is, you know, that we're reaching each potential donor, that we're securing as many organs as it's appropriate and that we're getting those organs transplanted.
Sharon Pearce (13:11):
Um, so some of the proposed reforms to OPOs are expected to go into effect in January, um, improving accountability in donation and transplantation, um, reporting, making sure that we're using verifiable data and benchmarking to drive performance improvements. So I think that this is again a really significant part of the advancing American kidney health initiative, for sure not the only improvement that needs to be done in the transplantation space. There's still a lot of work to be done on the transplant center side. Um, but you know, these are all three of these very important initiatives under the advancing American kidney health, um, umbrella that, you know, NKF was very supportive of that I think will really help start to drive and improve care in this domain. So,
Sharon Pearce (13:56):
Um, moving On to one of the other big changes that, uh, while the change in policy took place several years ago, it doesn't go into effect until this coming January. And that is Medicare coverage for end stage kidney disease. Uh, as many of you may know for many, many years since the inception of the Medicare advantage program, ESRD patients were not included in MMA populations, so they could not enroll in Medicare advantage. Now, if you have a kidney patient who is a Medicare advantage enrollee and their kidneys fail, they could stay on their Medicare advantage plan. They didn't have to disenroll, but it was a way to protect the plans from what was a very, very costly population to care for. And ultimately Congress decided that plans, if they're going to be in their business of cataract covering Medicare beneficiaries need to be responsible for all of their care and passed this legislation several years ago, I think it was in 2019 or 20, I guess it was 2016.
Sharon Pearce (14:51):
Um, but it goes back this year. And I think that we think we see this as a really potential benefit to the kidney care population. I think plants have a lot of tools at their disposal to improve care coordination for this very frail population to try to minimize hospitalizations and rehospitalizations. Um, but there's also a, you know, this is a very consolidated market and there's going to be, um, a lot of pressure on both the plans and the providers to try and make the financing of this work. Um, but you know, we have seen some real progress here. And then this next slide is just to give you an example of that. Um, if you look at the graph on the right, you know, where we have seen real improvements in CKD care is in, you know, integrated systems. If the green line is, you know, the Indian health service, they really have been able to drive down the costs of caring for patients with kidney disease and with diabetes through really integrated models.
Sharon Pearce (15:42):
So we are hopeful that this will really help improve care that the plans will be able to make some serious change. And, um, you know, there's a lot of opportunities to, to move the needle. Um, you know, just to give a little sense of that. I mean, I think primary care is what we consider a really huge opportunity that a lot of primary care providers don't necessarily do a great job of identifying the patients who are at risk for CKD, making them, making sure they're screened if they are screened, um, appropriate interventions. There's a number of different interventions for CPD helping manage hypertension and diabetes, um, referring to a nephrologist. So we wanted, we think that Medicare advantage coverage is a real opportunity to address primary care to incentivize the, the handoff from primary care to nephrology. Um, you know, obviously I think plans have a lot more data and information at their disposal and can help figure out what the appropriate timeline is and patients who are likely to progress to ESRD.
Sharon Pearce (16:44):
So, uh, again, we think that this is a really good opportunity for kidney patients. Um, it is going to be a change for the plans. And I think as I mentioned, the finances of this are going to be tough because, you know, there is some concern that the rates that plans will be paid for ESRD patients will not be adequate to care for this population. And especially given the, um, the dialysis market place. I think there's going to be a lot of pressure on plans and on providers to try and find a better way of doing, doing, you know, caring for these, these patients. So again, a big change, but one that we hope will be very, very beneficial.
Sharon Pearce (17:20):
Um, and you know, I think if you're looking for ways that, you know, it could be beneficial, um, one of the biggest missed opportunities in kidney care is living donation. Um, you know, there's, there's not enough deceased organ donors to care for all kidney patients. I think there's about a hundred people, you know, 95,000 people on the wait list only about 25,000 organ donations a year. Um, you know, we really need to do a better job of getting living donors and helping patients encourage them to help find a living donor. Um, so that's a huge untapped opportunity. And can you failure, um, again, minimizing in-center dialysis, especially, um, during the COVID-19 pandemic, we've identified that these are, you know, in central patients are at extreme risk for exposure. It's a close setting, it's constant, you know, you're in and out of dialysis several times a week. Um, so really driving patients to the home as appropriate is, uh, again, an opportunity and that care coordination, because this is a very, very frail population. So making sure that we're coordinating with other specialty care endocrinology, cardiovascular, um, you know, making sure that the patients managed in the primary care setting. Um, so there, there, again, huge opportunities to better serve this popular,
Sharon Pearce (18:31):
A couple of other pending legislative priorities that I just wanted to put on your radar screen. And one of these is very exciting for us. So for many, many years, this is one of the most, uh, non-common sensical things in the Medicare program. If you're a Medicare beneficiary you're covered for your, you receive Medicare coverage for all of your care. The second that you're well within 30 months of your kidneys failing. So anyone with kidney failure is eligible for Medicare. If you get a transplant, Medicare will pay for your transplant, they only will currently pay for 36 months of immunosuppressive drug coverage. Um, this is a huge coverage gap for a lot of patients. Um, they will have coverage for three years and then if they can't find other covered either through an employer or through Medicaid, they wind up losing their drug coverage. Maybe they ration their drugs, can't take them and their kidney fails.
Sharon Pearce (19:19):
And it's, it's, it makes no sense. Um, but today, possibly as we speak, the house is finally voting on legislation that would extend a permanent benefit for all immunosuppressive drugs for the life of the kidney transplant, irrespective of the patient's eligibility for other Medicare benefits. And, um, this is something that's, um, you know, I was joking with one of my coworkers. He was saying that this has been on his radar screen for far too long. Let's just put it that way, um, trying to expand coverage. And we are within inches of the finish line, um, think that it will be signed into law by the end of next week. So a very exciting change for kidney patients. And hopefully we'll start to address some of the challenges that a lot of patients face and even accessing a transplant. Some patients can't even get onto the wait list because they don't have the financial resources to, um, pay for immunosuppressive drugs. And this would be one less barrier to transplantation. So it's a really, really huge change. And one that we're incredibly proud of
Kevin Larsen (20:14):
Sharon, if we could just wrap it up here,
Sharon Pearce (20:18):
I am so sorry. I will finish up, you know, funding, you know, legislation for living donation also really important priorities. Um, I will just touch base quickly on the Biden administration. We do expect that, um, a lot of these priorities to carry over and that's really on NKF to help drive the conversation that, you know, this isn't just a Trump administration priority. It's not a Biden administration priority. It's an American priority. It's an important component of our care. Um, so, you know, we'll be working through that know over the next couple
Sharon Pearce (20:48):
Of months to really continue to keep focus on each of these areas, whether it's CKD awareness, treatment, dialysis care, or transplantation. Um, and also, as I mentioned to kind of keep the focus on COVID-19 and the intersection of care there, um, disparities, we know there's a huge problem with disparities in kidney patients and improving access to care. So hopefully I didn't speak to those last three ones too much. Um, it, obviously you can tell this as a topic about which I'm really passionate. So if you have questions, I really do encourage you to follow up my contact information is on that slide and happy to talk more or take questions from the field now, or whenever that's appropriate. Kevin,
Kevin Larsen (21:33):
Thank you, Sharon. What we'll do questions that they ended the, this first session. Um, but next I want to introduce Kerry Willis who will talk to us about some of the latest findings in the research space, curious also with the national kidney foundation, Kerry I'll turn it over to you,
Kerry Willis (21:51):
Uh, thank you, Kevin. It's great to be here today. So, uh, I'm the chief scientific officer of the national kidney foundation. Um, but I want to emphasize that we really try to take a holistic approach to the public health challenge of chronic kidney disease. Uh, NKF first defined chronic kidney disease through our guidelines, uh, and proposed a staging system in 2002. And since that time we've used pretty much every lever we could find to drive the focus upstream to early CKD, where the greatest opportunities are to change outcomes for patients. But as you heard much of the policy and legislative focus remains on the tip of the iceberg, which is ESRD. So again, as a reminder, we have 37 million adults with CKD in the United States, and only about 10% of them know they have it, the cost of Medicare alone of caring for people with CKD and ESRD. And by the way, this is not an old slide, but it's actually now over $130 billion a year. And growing
Kerry Willis (23:02):
They're actually reasons to be optimistic that after almost two decades of painfully slow progress, things are about to change and people in the medical community are going to finally recognize that treating kidney disease earlier will make a whole host of other problems, easier to manage. So I'm going to touch on some of the major developments that I think will make this a watershed year in kidney disease, and then tell you about some of the work NKF and others have been doing on practical interventions to improve care and reduce costs. So the first is the 33% campaign that Sharon talked about. This is the first ever national kidney disease awareness campaign. And so far over thousand people have visited the minute for your kidneys website and taken a quiz that allows you to estimate your own level of risk for developing kidney disease and urges those at risk to visit their doctor, to be tested for EGFR and albuminuria.
Kerry Willis (24:02):
So we think that when doctors start hearing from multiple patients that they want to be tested for kidney disease, it'll help move kidney disease up on their problem list to where it should be. Also this year, a new HEDIS measure for kidney disease testing in people with diabetes, which we developed in collaboration with NCQA was accepted. So 2021 will be the first reporting year and Dan Roman will give you the details later in the program, but I'll just say that we expect that the kidney health evaluation measure will drive substantial increases in testing for EGFR. And particularly for albuminuria.
Kerry Willis (24:44):
We've also seen major advances on the therapy side, one of the biggest barriers to engaging healthcare providers and finding and treating kidney disease has been the lack of kidney specific medicine for the last 20 years. Treatment options have been largely limited to ACE inhibitors and angiotensin receptor blockers. And it's now been reported in multiple trials that SGLT two inhibitors have quite dramatic effects in reducing the risk of kidney disease progression, also heart failure and death in patients with, or without type two diabetes. So this is going to be a real game changer, although as with any new branded medication, we'll have to deal with access and affordability issues, but hopefully the magnitudes of the effect will be compelling enough that we can get that done. And just last month, finerenone, which is a mineralocorticoid receptor, antagonist was reported in a large phase three trial to have significantly reduced the risk of CKD progression and cardiovascular events in patients with CKD and type two diabetes. So these new therapeutics, along with innovative care coordination strategies, like multidisciplinary care teams that have been shown to be effective, uh, in improving outcomes, have the potential to prevent kidney failure in millions patients. And you really do not have to shift the slope of CKD declined by very much for that to happen. So we really think you're going to start seeing those effects.
Kerry Willis (26:24):
So in the midst of all of these, this heightened attention to kidney disease, uh, we're launching the national kidney foundation patient network, which will be the first national patient registry for people at all stages of chronic kidney disease. This is an interactive online platform that will link for the first time patient entered data on their experiences and outcomes with clinical data uploaded directly from the patient's electronic health record.
Kerry Willis (26:55):
So the platform will also provide individualized education to the patients that enroll and allow patients to join online communities, uh, tailored to fit their needs and stage of disease. So we think this patient network is going to be a fantastic tool for observational research, um, and will also serve as a resource for clinical trial planning and recruitment of patients. We're officially launching in January, 2021. And we hope ultimately to have up to 10,000 and even 50,000 patients.
Kerry Willis (27:34):
So how do we translate all of this knowledge and awareness and new therapies into clinical practice, and how does that impact care and outcomes? This is our working model of the cost-effectiveness of CKD population health. So when you implement an intervention in an underdiagnosed and undertreated population like CKD patients, some costs are inevitably going to go up, which has shown in those orange boxes at the top, but you expect to also save money by preventing complications and expensive adverse outcomes like cardiovascular events and kidney failure. And so how these two sides of the equation balance each other out, uh, is the question.
Speaker 5 (28:22):
So to test this NKF collaborated with Care First blue cross blue shield, the largest health insurer in the mid Atlantic region. So Care First had found in its EHR data, that there was a real underdiagnosis of kidney disease problem. And also that elevated serum creatinine was the most significant laboratory cost driver in its member population. That is the cost per member per month increased in direct proportion to increases in serum cream. And they're not the only ones who found this. So we worked together to design an intervention that was based on educating primary care physicians and also their members with diabetes and or hypertension, uh, that was then integrated into their patient centered medical home model. The intervention, which involves 7,400 patients was based on this heat map I'm showing, uh, which shows the level of chronic kidney disease progression, uh, the level of risk of CKD progression, morbidity, and mortality, according to their EGFRs stage and albuminuria levels.
Kerry Willis (29:37):
And so the albuminuria stages are across top. And I just want to point out how albuminuria magnifies the risk of bad outcomes at every level of GFR. So basically we classified the disease, um, using this, this heat map and shuts slows the care plan that was based on the risk stratification, according to the previous slide. So obviously I'm not going to review this in detail, but I just want to point out that the actions in each class are all taken from existing evidence-based clinical practice guidelines. And also the recommendations are cumulative as you read down the list. So you don't have to do much in the green and yellow boxes, but the intensive management comes later in the red and Brown. So, uh, none of this is rocket science. It's things like the frequency of monitoring nutrition, counseling consulting with specialists and, uh, referring to nephrologists, uh, when GFR falls below 30, also preparation for kidney replacement therapy beginning in class four.
Kerry Willis (30:49):
So basically if you can just convince practitioners that this is important and give them a straight as straightforward protocol it's gonna get, um, uh, and I'm, I'm showing here the results. So, uh, over two years of followup, you can see in the right hand box, uh, is where the results are. There were significant reductions in hospitalization in classes three, four, and five and significant cost savings in class three and class five. Uh, so we published this study in the American journal of managed care last year, and the references at the bottom of the slide, uh, in, I encourage you to look at it. There's a lot more detail there.
Kerry Willis (31:34):
So, uh, I, this is kind of going from one end of the telescope to the other. This is a very, very simple study that we did. Um, one of the things that, uh, has been a huge source of actually confusion and frustration, uh, for us is that, uh, there just is not, albuminuria testing, uh, in any of the major risk groups at anything like the level that guidelines recommend. So, um, this first study, excuse me, which we did in collaboration with Geisinger evaluated at home testing versus in-office testing, uh, for albuminuria. So there's a new product available from a company called healthy IO that mails dipsticks to patients at home then sends them a link to a smartphone app that accurately reads the dipstick and sends the results electronically back to the physician's office for review. So both the Geisinger physicians and the patients who really liked the system and increased, uh, screening completion, uh, from 18% to 28.9%. So we're hoping now to do a larger study to see how at-home proteinuria and albuminuria testing will actually impact blood pressure management and blood pressure control in people with hypertension.
Kerry Willis (33:09):
Uh, so we're also working with Johns Hopkins on incorporating albuminuria measurement into clinical practice and risk prediction. Uh, basically what we're doing, uh, with several large data sets the, uh, you know, longitudinal cohort studies that we have access to. And also some health system data is looking at the frequencies of the albuminuria testing, uh, in these data sets. Uh, and for one thing, trying to assess what might be best practices and the ones that have higher levels of albuminuria testing, uh, and then also using these data sets to see if we can develop methods of converting. So people just have simple urine dipstick measurements, or, you know, sort of non quantitative, uh, you know, urine creatinine measurements that, uh, we could find a way to sort of impute, uh, to convert those other measurements to the ACR. So that with the albumin to creatinine ratio, you could then directly put these things into risk prediction tools. And so that our real ultimate goal, which won't be part of this study, but we hope to do in a future study is, uh, seeing how, uh, using the, um, risk calculators. And, you know, there are several out there, if you can incorporate those into an electronic health record, uh, to really drive practice change and more aggressive management of the people at increased risk.
Kevin Larsen (34:49):
Kerry you're about at time if you could wrap it up. Okay.
Kerry Willis (34:54):
No problem. Uh, I just wanted to highlight, uh, that we're collaborating with OptumLabs, uh, to use data from the OptumLabs data warehouse, and hoping to understand what factors are associated with earlier versus later, uh, chronic kidney disease diagnosis. Uh, we've also formed a joint task force with the American society of nephrology, uh, which I just wanted to quickly mention, uh, we are examining the inclusion of race in, uh, estimating GFR equations and, uh, trying to assess whether there are ways that, uh, even using rigorous science, but, uh, where might be able to find
Kerry Willis (35:38):
Other methods that don't require a race term, uh, and weave that into a national conversation about reporting FGFR. Um, and I just wanted to quickly say that, uh, there are still these gaps that we're hoping that we'll address, um, no standardized management lack of incentives for co-management limited evidence to inform risk of progression, um, and significant numbers of patients receiving little to no nephrology care, uh, pre end-stage kidney disease. Uh, so thank you for your attention.
Kevin Larsen (36:17):
Thank you so much, Kerry. That was terrific. Um, I will now turn it over to Jay Agarwal Brian Phillips from Optum. Who are going to talk about, uh, our analysis and our planning for ESRD patients coming into the Medicare advantage population. I apologize, both Jay and Amar Desai from our team, uh, will be on audio only. Um, we couldn't get their webcams to integrate into this platform. So we'll have Jay on audio and Brian here on video, turn it over to Jay.
Brian Phillips (36:50):
And this is Brian. Um, can you all hear me? Yep. Yep. Um, hi, we have a couple of slides to, uh, kind of set the Medicare advantage insurance context, and then Jay will speak to an actual Medicare advantage ESRD program. Um, so just a bit of background, the, the cares act, um, which is, uh, we think of it as opening up Medicare advantage to, uh, to ESRD patients. Now, in fact, um, they're actually currently several, uh, many people, with ESRD in Medicare advantage. Um, the opening up will maybe double the number of years, 30 patients in Medicare advantage. And we'll go through a couple of the items, um, uh, that play into how many people will actually take up the AMA option. Um, the, the main point, a main reason why we would expect people to take it up because, uh, the limit on out-of-pocket spend and then a secondary, uh, additional benefit is transportation benefits often offered, um, by Medicare advantage. Um, those would be useful, um, to study patients.
Brian Phillips (38:14):
Um, this is sort of a flow chart, um, walking us through, uh, counts of something over 400,000. Um, ESRD patients currently in Medicare, and this is fee for service, all of Medicare. So about a quarter of those are currently in Medicare advantage, um, for the people in original Medicare, we'll split those between fully dual and not fully dual, uh, people who are fully dual cost sharing is paid for by the state. So there's less, uh, incentive there for joining AMA. So we're really going to be looking at the, the non fully dual and within that subset under 65 population. Um, so those disableds are the ones most likely to actually join Medicare advantage.
Brian Phillips (39:13):
And with this slide, we're illustrating the ramping up, uh, the line that shows slopes up where the most, these are dialysis patients, and we're seeing a monthly increments, um, out of pocket costs for the dialysis patients. And typically somewhere in the summer, um, these patients will cross the blue line of a Medicare advantage out-of-pocket maximum. And that is, um, the space in there about the blue line. That's where we're looking for, um, Medicare advantage plans and concerned about the additional costs and ESD patients, uh, probably looking toward Medicare advantage as a way to avoid, um, that additional cost. And now we will move on to Jay and talking about NAAM.
Jay Agarwal (40:08):
Perfect. Um, so with, with this anticipation of members coming into, uh, via 30 members coming into Medicare advantage, um, as well as our existing membership, I wanted to take a little bit of time to sort of describe to you, um, sort of experience from the front line of taking care of patients within the Medicare advantage, uh, from the CDO at Southern California and myself being a nephrologist, having practiced for 15 years and taking care of dialysis, patients wanna sort of walk through, um, how we're approaching this and how we're strategizing to better improve the quality of care that we deliver to our members, um, at, uh, NAMM, which in Southern California and part of OptumCare, when we looked at this population, we knew that there's definitely a opportunity to improve on the gaps in care. And our focus is let around working with our nephrologists.
Jay Agarwal (41:00):
And one of the reasons for that was nephrologist, see the patients four times a month, uh, and are quite quickly real quickly with them and that we needed to have them be engaged in order for us to make a difference when we engage them through creating a alignment of incentives with them. Uh, and so with which they did, uh, based upon the utilization and member outcomes, uh, as well as understanding that the nephrologists would need those operational and, uh, mentorship and some help with clinical implementation. So we meet regularly with our nephrologist groups, as well as, uh, have regular care plans to help, um, guide them nephrologists and help improve the quality of care that we deliver. Um, based upon that and making those interventions, um, we've shown to be able to significantly reduce on both admissions and readmissions and are quite proud to have, uh, 19% of our patients being at home, um, which I think is, uh, which is really important and the way we're working with nephrologists and having us to be, um, working closer with nephrologist is one way of coming about it.
Jay Agarwal (42:04):
Other of our partners that are, that are within Optum care and looking at the same population may use employed models with NPS, but either ways I'm going to talk through some of the commonalities, um, that that need to be entertained when strategy strategizing to improve the care to this population. Uh, when looking at, um, ESRD care within the dialysis center, a lot of this is a lot of this is focused around not just caring about the dialysis, but about the total member within the dialysis unit. And, uh, one of the ways of looking into hospital admissions, right possible missions drive a significant amount of the cost and a significant amount of morbidity for our patients on dialysis. And one of the ways that we've tried to attack this is to really use the interaction with the nephrologist and dialysis unit to be more than just revealing the battle treatment itself, uh, and having practiced in the unit for 15 years.
Jay Agarwal (42:58):
Um, now I know that it's really important to engage nephrologists in that the nephrologists we work with them to do multidisciplinary care plans in our patients. Um, and ones they're not ran by the dialysis unit, but rather by the nephrologist and find them to be quite effective for them to uncover, um, barriers to care on top of that, we have a nephrologist do transition of care visits after every hospitalization, which I think is quite important because when that patient's coming back into Dallas, it's important to know what happened to them in the hospital and to make adjustments quickly, um, and help prevent them from coming back, which has helped our readmission rates. Um, when we look at home dialysis, you know, uh, we know home dialysis is, is a great option for, for many patients. And if you ask most nephrologists, they would rather be on home dialysis.
Jay Agarwal (43:43):
We noticed it's less costly and, um, it's better for the right patient. Uh, what we do is we work with our nephrologists who identify every patient that's on dialysis and identify why are they not on home rather than are they a candidate for home dialysis? Why are they actually not already at home? And that's, what's helped us to drive, um, our high rate of, of home dialysis for patients when we think it's the right thing to do. Um, and then thirdly, also looking at mistreatments, knowing that mistreatments carry a significant and 40% greater risk of hospitalization within 30 days of patient just missed one dialysis from a diabetes study. Um, so we're looking at ways to develop the nephrologist to make sure that we have, uh, uh, appropriate chain of command in terms of, uh, notifying when patients with dialysis and how to interact with them.
Jay Agarwal (44:25):
And we look at not just the medical, but also the social determinants of health that are associated with that. And I think that that's really for us to act upon that data. Uh, but when we looked at our population all, and this is, um, the barn is a graph from Dr. Kalantar will be speaking to us later on today, is that we know that right around the transition to dialysis or significant amount of, for costs and morbidity efficient with our dialysis patients. We know that 46% of our patients starting now are starting dialysis in the hospital, right. Uh, which is not ideal. We want to try new patients out of the hospital. Uh, and, uh, so what we do is we work with our team to create a, to create a checklist for those that are getting admitted to the hospital, they start appropriately. And then we work for intensive care planning after leaving the hospital monthly, after the patient leaves the hospital, and this has been quite effective.
Jay Agarwal (45:15):
Uh, and then we need to move upstream to the CKD care. And so we know that, um, 40% of patients don't receive CKD care. And so what we do is we leverage our feet as being a Medicare advantage, uh, and an a care provider. We have a lab data within a fire CKD four and five patients, and making sure that they go see, um, our nephrologists that's important. And then when they see the nephrologists, we make sure that they have an advanced care plan. So working with them for CKD stage five, to make sure they have a appropriate transition to dialysis or, uh, prevention, dialysis, appropriate treatment for, for blood pressure. And also if they're, uh, you know, getting them preemptively evaluated for transplant and getting access in place them ahead of time. Um, so that's, uh, quite important to help, uh, have this new transition to dialysis.
Jay Agarwal (45:59):
One in is either future areas of focus for us. We know that, uh, there's going to be more patients as Brian alluded to earlier on that coming in through Medicare advantage, and we need to identify those patients and engage them early on. Um, and then working with them just about, um, accurately diagnosing, including, uh, complications of gamification. And then really, as we start looking past the city four and five, the volume and we a, and B is quite large. And so, uh, working with that often to figure out how do we identify those patients that are at higher risk and make sure they get the right care at the right time, but overall, um, as a nephrologist and as a part of a Medicare advantage, we're very excited. Um, I think there's a right alignment of policy research, and then on the boots level of taking better care of these patients. And, and we're quite excited about the change is going to come through.
Kevin Larsen (46:56):
Thank you very much. Um, out now, I want to turn it over to Dr Amar Desai, uh, who will be, um, moderating a Q and a, uh, doctor Desai is the CEO of Optum care, California, if you have questions, please put them into the Q and a section. I'll be monitoring that and supplementing Dr. Desai's questions with you. So I'll turn it over to Dr. Desai.
Amar Desai (47:25):
Hey, thank you, Kevin. A fantastic set of speakers, and I know our time is limited, and we want to get your questions in from the audience. Uh, it's clearly a dynamic, uh, policy and environment right now, and certainly being in an election year, uh, um, that is also going to, uh, cause things to evolve here at. So let me, maybe I can start with, uh, Sharon, uh, um, obviously it's early in the Biden and the, uh, transition here. And as we kind of move forward with the Biden administration, we've heard earlier this week, that Javier Bissera is going to be the new secretary of HHS. Can, uh, give us, uh, uh, your, your, your early sense around, uh, the change in that administration. What's the impact on the policy landscape? And we're certainly familiar with, uh, Mr. Viscera here in the state of California and some of his, uh, uh, stances in the past. I'm curious if you have some early sense of how this may impact, uh, the kidney care world.
Sharon Pearce (48:29):
Um, you know, we don't have a ton of information yet. We we've been doing some due diligence trying to kind of assess what his history was on kidney care. Uh, when he was a house member, he was supportive of a couple of things, but maybe not everything. And, um, but you know, we know him to be a very intelligent and thoughtful and dynamic leader. And, um, you know, certainly I think that he understands the larger health care marketplace very well. And, um, you know, we certainly hope to impress upon we've. We've made some recommendations for the Biden administration generally in terms of what the best and most important priorities are for the first hundred days, but, you know, taking the longer view of what needs to happen and, you know, really impressing upon them that again, the advancing American kidney health initiative is not a partisan idea that these are really important priorities for the entire community.
Sharon Pearce (49:17):
And that a lot of the work that's been underway needs to continue whether it's implementation of the EPC model or the OPO rules, um, really continuing to invest in any health population, health programs, prevention, research. Um, so we are hopeful that, uh, that they will understand and appreciate the importance of these issues. Um, you know, we, we have our work cut out for us in terms of making sure that, you know, to connect with them and, and then that that's on us to advocate. Um, but we feel like that, you know, we're, we're well positioned and we are optimistic that this will be a good dynamic, uh, much as the last four years have been.
Amar Desai (49:58):
Yeah, no, no, I, uh, I, uh, I, I'm certainly hopeful. And, and, and do you see just, uh, we, we heard a little bit about Medicare advantage and use of shared, uh, uh, an overview of the importance of, of that program. Uh, any, any expected differences in terms of the focus around MA growth, uh, from the Biden administration, from your perspective?
Sharon Pearce (50:27):
I think so. I mean, I think that Medicare advantage plans in general are fairly popular on both sides of the aisle. I think, you know, specifically with regard to the ESRD carve in that, you know, looking at the benchmark and making sure that the plans are appropriately resourced and have the flexibility they need to kind of absorb this new benefit is, is going to continue to be, uh, an advocacy priority. Um, but I, you know, I don't, I don't anticipate a huge change now. I don't, you know, I'm not as, as much of a student of MA specifically or more broadly. Um, but I think that, you know, it's, you've seen exponential growth in the program because it's a popular program. And I think that there's going to continue to be emphasis on trying to make sure it is well managed and that well, well funded, um, social determinants of health, I think is probably one of the biggest untapped opportunities. And you're gonna see a lot of pressure from the administration, uh, with supplemental benefits is probably I think the biggest opportunity more broadly.
Amar Desai (51:26):
Yeah, no, thank you. Maybe I can just shift over to, uh, uh, Dr. Agarwal, you and Brian, and, and, uh, talk a little bit more around the, uh, maybe the, uh, the, the nuts and bolts operational pieces that occur when you, when you have a program like MA and its application to the, uh, ESRD population. But do you, do you, do you have a sense for the level of, uh, of switching that may occur between a fee for service and, uh, and moving into Medicare advantage, and are there particular types of patients or, or aspects of benefit design that, that seemed to be attracting, or maybe beneficial to our, our patients with end-stage kidney disease?
Brian Phillips (52:18):
Um, hi, this is Brian. Yeah. Um, as I had mentioned, um, do, um, non dual eligibles, disables, um, those would be, uh, populations that would be that, we think would be most interested in Medicare advantage, um, and interest due to the out-of-pocket maximum. So how does the patient get into the, the out-of-pocket coverage, um, and Jay, any comments on your end on what you've seen
Jay Agarwal (52:55):
And just, yeah, just from, you know, from, from Medicare, you know, expecting, you know, uh, they're saying at least a 63% growth over over five years. Um, I think, you know, most of us Medicare advantage, uh, you know, folks that are plans are dealing with this, or, or CEOs are dealing with sort of looking at probably some over the next five years of a potential doubling of our, of, of our, of our ESL population. Um, and so I think that'll be interesting. I think it'll also be interesting to see sort of what plays in sort of like the CK KCC space with the dialysis units in terms of, um, them working, partnering with nephrologists and possibly taking on risks. So I think there's some, um, some of the variables are, but I think overall most of response, or are most of this organization, Kenny told me that, uh, a potential for doubling over the next five years, um, a very sturdy population.
Kevin Larsen (53:47):
This is Kevin. We have a question from the audience, there's a lot of interest in this new policy around immunosuppressive drug coverage. Um, both questions about, is it under part B or part D and also, will it cover people who are currently, um, transplant recipients?
Sharon Pearce (54:10):
Yes. So it will be under part B and, um, you know, I, yes, it would apply retroactively to patients who are currently, you know, Medicare will, you know, if they're within the three month, three year window. Um, and I S you know, I'll have to double check on if someone were to lose their coverage and need coverage under this new benefit, I believe that that would still be covered. So it's a benefit of last resort. It's important to note that. So if the beneficiary has an option of coverage elsewhere, whether it's their insurer or Medicaid, or what have you, um, that's where they will get primary coverage, but, uh, it would be available to both existing padded patients and to, you know, if someone's on the wait list, you know, they could then become eligible for this benefit.
Amar Desai (54:55):
Kevin, do we have any more from the audience?
Kevin Larsen (54:59):
We do. We have, uh, questions about, um, uh, aimed at Dr. Agarwal, are you looking at any new types of risk-based payment models at earlier stages of CKD?
Jay Agarwal (55:13):
Um, so, so far we've, we've focused on ESRD, but that's currently in development because obviously we need to move on to swim. Right. Um, and so, uh, we're, we're looking at, uh, developing relationships with our nephrologists on CKD four or five, um, right now, uh, we're currently in the process of working on developing that and what would be the outcomes that we'd be looking at and how would that, how would that model play out? So we're currently modeling. Um, but right now we're thinking it just CKD on five, not, not, not really or CKD yet at this point.
Kevin Larsen (55:51):
Sure.
Amar Desai (55:53):
Maybe a, a little bit more. I, I know the, uh, last month JAMA published an article on the association, uh, between, uh, with better outcomes for those patients with ESRD who are enrolled in C snip models. And I'm, I'm curious, cause I know you and your group are engaged in those types of plans. Could you, can you talk a little bit about how, how translatable those results are, uh, from your perspective and, and, and what was learned there about the, the opportunity around this type of, uh, uh, benefit model?
Jay Agarwal (56:31):
Sorry, could you repeat that again? I didn't get your last part, sorry.
Amar Desai (56:37):
I was referring to the article that was published in JAMA last month, around the association of better outcomes for patients with ESRD or enrolled in C snip plan. And, uh, uh, I know in California, we've got a couple of different examples of C snip, so focused on here, ESRD, I'm just curious your take on around how translatable of those results from the study were and what you see as the level of affordability, particularly around cost savings and quality.
Jay Agarwal (57:08):
And so I think that they, I mean, I think the c-snip plan and the translatable translatable into the Medicare advantage is there, um, I think what, what is the issue is really figuring out how to operationalize that right within your, within your, um, within your organization, right? And a lot of that depends upon, uh, the landscape of, uh, of your nephrologist space, right? And depending on what you hear your dialysis unit mix, as well as your, your nephrologists, uh, you know, for small groups, large groups, I think that's really what determines, how are you going to operationalize that and how much that can be done by the nephrologist versus how much that needs to be done within internal resources. Right. And so I think as we, as we come together and talk in terms of Medicare, um, you know, providers and organizations, we think about, um, you know, how do we, how do we have commonalities, which would be, you know, home dialysis, uh, you know, transition of care and really getting upstream for CKD, but then how do you actually operationalize those into a population I think is where the rubber hits the road and where each organization has to look to see what is there, what is the makeup wasn't know you, their nephrology landscape and what makes the right right sense for us to be able to do it.
Jay Agarwal (58:22):
I think it's the environment is right for it. Right. Um, and so, um, I think it really just depends upon the make up. I do think that those are translatable, that depends upon your market space, because each marketplace is slightly different in terms of, you know,
Kevin Larsen (58:39):
Uh, this is Kevin. Yep. We need to move on. Thank you all. Um, this was fantastic. And please join us for the second half of this. Uh, you'll have to move on to an additional, uh, web link, uh, because we're bringing new speakers in, uh, Dr. Desai, and I will be there to welcome you all. We'll be starting again in about five minutes. So if you look at that, join them button at the top, right of your screen with the orange button, um, uh, please click on that, to join the second half of our webinar. And we'll see you there at one oh five.
Kidney disease now
Kidney disease is in the innovation spotlight. Learn about the policy landscape, where gaps in care and opportunities for improvement exist, and how can we better manage end stage renal disease among Medicare Advantage enrollees.
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Kidney disease research panel
OptumLabs kidney collaborative is conducting research across the disease continuum that has the potential to improve outcomes for patients. Hear about research into slowing disease progression and conservative care for ESRD.
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Kevin Larsen (00:04):
Hi, this is Dr. Kevin Larsen and welcome to part two today's webinar, chronic kidney disease research panel. Uh, if you are just joining us, I will be your host from OptumLabs. Our moderator for today's panel will be Dr. Desai CEO of OptumCare, California. So Amar, I will turn it over to you to introduce our panelists.
Amar Desai (00:29):
Hey, thanks very much, Kevin. Uh, I'm thrilled to be here and we have a fantastic, uh, panel, uh, for the second part of our session here. Uh, this section is really intended to showcase, uh, uh, research projects, uh, across the CKD continuum, which have been facilitated, uh, by OptumLabs. And, uh, and it really does, uh, uh, share some real breadth, uh, from identification of patients with CKD management, for those patients with CKD. And then we have system issues and implementation issues and the financing and delivery of care and optimizing choice of dialysis. So we have, uh, a real, uh, breadth of, of topics. Um, I'd love to introduce our speakers and, uh, Stephan Dunning and Donna Spencer from OptumLabs, uh, Dan Roman from the national committee for quality assurance or NCQA and, uh, Dr. Connie Ree and Dr. Kam Kalantar from the university of California, Irvine. We're fortunate to have all these speakers. Let me hand it off to, uh, to Stephan Dunning and Donna Spencer to talk about the research project on slowing progression to late stage CKD.
Stephan Dunning (01:48):
Thanks a lot Amar appreciate it, uh, and welcome everybody. I'm excited to be here today. Um, I always just wanted to take a moment to, uh, to talk about our CKD research collaborative. Um, Let me jump ahead here. Here we are. Um, so I feel really privileged that over the last couple of years, we've come deep convened a premiere set of experts in kidney disease, uh, and established a really robust portfolio of collaborative research with partners. Uh, as you can see on this slide, I won't go through everything here on the slide in detail, but suffice it to say, you know, there's work across, uh, identification and detection, delay, uh, delaying progression, um, optimizing patient choice and kidney failure. In addition, uh, we're also pursuing new research efforts into health inequities in kidney disease, the impacts of COVID and opportunities to, uh, uh, in home in virtual settings today, we're going to highlight three projects, um, that are, uh, in, in Brown on the screen here. Um, first we'll have Donna Spencer talk a little bit about the work that OptumLabs is doing unrecognized progression to late stage CKD. Um, then as I mentioned, we'll listen to Dan Roman from NCQA talk about the kidney health evaluation measure, and then finally doctors Ree and Kalantar will help us uh, understand a little bit more about optimal transitions of care, particularly focused on conservative care management.
Stephan Dunning (03:27):
Overall I'd say we're build- We have a strategy to build tools and systems that identify and intercept CKD earlier and help people live healthier lives very much aligned with NKF and consistent with the American advancing American kidney health initiatives that you heard NFK speak about earlier. Um, the first two bars on this slide really focus on leveraging existing data and new technologies to help determine, uh, patients at risk for kidney disease. Really, we need to do foundational work, um, around CKD screening and monitoring. Um, those things have to happen to sort of build the capacity to bring in data that can help us predict risk of disease, progression, CKD progression, and cardiovascular risk and others.
Kevin Larsen (04:19):
Stephan can I Interrupt quickly. Can I ask all the speakers to mute if you're not speaking, we're getting an echo.
Stephan Dunning (04:25):
Oh, sure. Thanks. Um, really needs to find a quality, uh, what quality, uh, CKD care is. There's no holistic national strategy right now, and there definitely are some calls to pull together a working group to help define that. Finally, um, we want to engage all CKD patients in the right manner, whether that's supported self care in the earlier stages, higher touch, uh, care management, and the later stages are for how those at higher risk or again, optimizing patient choice for those who transition or transitioning to end stage kidney disease, whether it be preemptive transplant, conservative care, or if dialysis increasingly home options with that, I'll turn it over to Donna Spencer to talk a little bit about OptumLabs study.
Donna Spencer (05:18):
Thanks Stephan. As Stephan mentioned, I'd like to share some information about a study Optum OptumLabs has been, um, conducting in collaboration with our two sponsors, the national kidney foundation and Optum kidney services. The goal of this project is to identify and characterize pare patients at risk of unrecognized or undiagnosed progression to late stage CKD or ESRD. Uh, we include, again, not only P patients with ESRD but also patients with late stage meaning stages four and five. Our study includes individuals 40 years of age and older, um, over a six year time period of 2012 to 2017. And we leveraged not only the commercial and Medicare advantage data that's available within the OptumLabs data warehouse, but also had the opportunity to, um, incorporate Medicare fee for service data into this project. So for the purpose of today, we wanted to focus on two analyses that we've conducted under this, this fairly large project.
Donna Spencer (06:26):
Um, these analyses were conducted on separate samples. First is a descriptive analysis to simply calculate the proportion of individuals with late stage CKD and ESRD who did not meet our definition of being recognized in the year prior to, um, disease progression, um, in terms of identifying CKD and in terms of defining recognition, um, early recognition of disease, we relied on diagnosis codes within the claims data. The other analysis we conducted as a competing risk analysis of individuals without CKD, uh, to examine the characteristics associated with being diagnosed later with CKD, as opposed to earlier, uh, this analysis measured patient characteristics over a one-year baseline period, then patients were followed over time and, and, um, categorize into three main events, which would be, um, later, uh, diagnosis of CKD earlier diagnosis of CKD death, um, or patients were censored due to disenrollment or due to study.
Donna Spencer (07:35):
And, um, in the analysis of individuals with late stage CKD and ESRD we found that about 40% of individuals, um, met our definition of recognition of being unrecognized or undiagnosed in the prior year. So this is not a small number, but it's actually pretty aligned with literature that has documented the proportion of patients on dialysis who had suboptimal starts to dialysis and the competing risk analysis. We ran separate, um, Cox proportional hazard model. So, uh, cause, um, cost specific models for each of the competing risk or competing events. Um, here we focus on the results of the two separate models focused on CKD. In other words, the model, um, being diagnosed earlier and the model of being diagnosed later as that was the primary comparison of interest. So not surprisingly the events of late stage CKD and early stage CKD diagnosis, shared several risk factors.
Donna Spencer (08:40):
So these included older age, lower income, higher co-morbidity burden, um, specific conditions such as hypertension, diabetes, um, and, uh, cardiovascular disease. So this again was not, not necessarily surprised based on what we know about risk of CKD in general, um, between the two CKD models, the findings do differ for some of the covariates and this is, this is what we're particularly interested in. So specifically, um, I'm sorry. I thought the slide moved - specifically subjects in the oldest age group. So 85 years or older, individuals of Hispanic ethnicity, individuals living in areas with more limited English, proficiency and individuals with prior acute events. So for example, stroke or contact with the emergency room had higher risk of being diagnosed later. Um, but we also find several characteristics, characteristics that were protective against diagnosis at a later stage. Not surprisingly, these were interactions with select specialists and then also having had lab testing or screening done. So we're still finalizing these analyses. These are, these are preliminary at this point. Um, and we actually hope to build on these analyses in the next year, but we're, we're hopeful that, that the results can help inform patient outreach, patient education and patient screening efforts to prevent undiagnosed CKD.
Donna Spencer (10:15):
So I'll pass it back to our moderator.
Amar Desai (10:21):
Right. Thank you both. Uh, next we have, uh, uh, Dan Roman from the national committee for quality, Dan, I think you're on mute.
Dan Roman (10:47):
Can you hear me now? Yeah. Hi, I'm Dan Roman. I'm a director, uh, in performance measurement at the national committee for quality assurance. Uh, I'm going to talk about, uh, what we've done in last year. Uh, we released a measure of the kidney health evaluation for people with diabetes measure, and I'll finish up, um, with just a little bit about, uh, kind of what, uh, NCQA is working on as far as quality and measurement goes. Um, uh, my previous speakers, uh, Sharon and Kerry already covered quite a bit of this. So these numbers don't probably, you know, they're not new. Um, there's 10% of the population is, has diabetes. It affects about 10 to 15%. Uh, 10 to 15% are ha have a kidney disease, but 90% are unaware that they even have a kidney disease. Um, and so obviously early detection prevention monitoring is, uh, Something that is, uh, really critical to prevent things like cardiovascular complications among other things, um, and to, uh, reduce a irreversible damage to the kidneys, um, with, so with that said, uh, the national kidney foundation, I had reached out to NCQA and, uh, started discussing what we have going on in the measurement space. So I'll just say that to preempt it a start kind of, uh, what I'm presenting there are recommendations around what type of, uh, assessments or evaluation should go, uh, should be, should be done every year. So the ADA and the NKF both recommend, uh, annual kidney health evaluation for adults with kidney, uh, or for adults with diabetes and, uh, kidney health evaluation, according to the guidelines, it includes an EGFR and an ACE. Uh UACR so, uh, estimated glomerular filtration rate test, and a urine Albion creating ratio tests. Despite the recommendations, uh, as, again, as I think Kerry might've mentioned it, um, uh, less than nine, less than 50% of the, uh, US, uh, population who shouldn't be getting it or getting it.
Dan Roman (13:20):
So we have a real quality gap there and NCQA has an it a measure in the space, um, for, for many years, uh, or medical attention for nephropathy. That is part of our, uh, comprehensive diabetes care measure set over the years, we have, uh, gotten, uh, some comments that, you know, the, the measure and the measure, uh, has kind of become a little too broad. It kind of allows too much. And so, you know, it allows, um, uh, a visit with the nephrologist ACR, uh, medications, diagnosis of CKD or ESRD um, a urine protein sample, but there, there, there's a very broad range of things that, uh, qualify for the measure. And so we've kind of gotten these comments over the years, and we also know that, you know, the measure is a little too broad. The signal of quality has gotten a bit cloudy, um, with the existing measure.
Dan Roman (14:25):
And so with that said, uh, we worked with the national, or, uh, with the national kidney foundation with us over this last year to test and, uh, develop a new measure that kind of resets it and starts at the right place and looks at the right things as far as, uh, screening and monitoring goes. So the new measure that we just released in July, uh, that it will be applicable for, um, measurement year 2020 and 2021, um, is our, uh, kidney health evaluation for patients with diabetes measure. It's applied to, uh, uh, uh, health plans, Medicare, Medicaid, and commercial product lines. Um, the measures looking at, uh, patients with diabetes 18 to 85, um, and we assess whether or not they get an EGFR and a UAC CR, uh, annually. There are some exclusions which we have here on the slide ESRD, dialysis, uh, and NCQA HEDIS kind of broadly applies an exclusion for hospice and palliative palliative care.
Dan Roman (15:36):
Um, and then we also have applied a frailty and advanced illness exclusion. Um, we put this measure out just as a little bit of background. We put this measure out, uh, this past February, March ish, uh, for public comment in general, we got very strong support. This measure, the comments received are that, you know, it makes a lot of sense it's, uh, appropriate. It helps to enhance a screening can help with early detection, gives providers kind of, you know, information that can help them make decisions about their patients earlier and ongoing. And it drives interventions to delay, kidney disease and maintain kidney health and our testing of the measure when we tested it. Um, it does, it kind of aligns with the known research about whether or not people are getting an EGFR - people with diabetes are getting EGFR and uACR our testing kind of confirmed what, uh, we already knew in medic in the Medicare product line that we tested with.
Dan Roman (16:48):
Uh, uh, the performance was around 35% commercial rate was 25%. Wasn't really a big surprise UAC, are they getting a urine albumin creatine, test is the thing, that's the limiting factor. Many people are getting EGFRs, they're not getting the UACR. So the measure is out it's, um, uh, uh, just released this past July and so applicable to HEDIS measurement year 2020 and 2021. And as far as what NCQA is doing next, as far as, um, uh, new measures, we are looking to kind of see what goes next, where we we've had a great collaboration with the national kidney foundation. And, um, we're working with, uh, them very closely to try to think of, well, what comes next? Now we also have some work going on about education as far as just letting providers know what to do. Next. One of the issues with this measure and issue is, and probably the right word, but this falls on in primary care.
Dan Roman (18:00):
And we see that UACs aren't done as they should be, but the measure pushes for them to be done. So now when primary care docs get that information, what are they supposed to do with it? And so, uh, NCQA and actually the NQF have, uh, some initiatives going on to educate, uh, physicians and patients about kind of, what do you do with that information, what comes next? Um, and then again, as far as new measure development, um, we NCQA is trying to evaluate kind of where to go next. We've been thinking about, uh, all of the things that were discussed earlier with the policy change around ESRD. How does that affect our measures? What should we do next? Does that, is that mean an exclusion? Is it a new measure where we're looking where we're kind of still in the evaluation phase? And, uh, additionally, just looking at, you know, new measures in this kidney health space, um, whether it's prevention management, or is it, you know, a measure around SRD, we're kind of still looking at uh, what to do next. Uh, so that's kind of where NCQA is at I think that is kind of the end of my time, my slides. Uh, thank you.
Amar Desai (19:30):
Thanks very much. Uh, uh, Dan, uh, uh, uh, our, our last, uh, panelist here, um, Dr. Uh, Connie Rhee and Dr. Kam Kalantar from the university of California, Irvine, they've been, uh, exploring issues of patient choice and, uh, transitions of care for advanced kidney disease patients. So very much looking forward to their, uh, their comments, uh, doctor Rhee and Kalantar.
Connie Rhee (19:58):
Thank you. We would like to thank the OptumLabs, leadership and organizers and acute care innovation session for the opportunity to present to you today. Um, my name is Connie Rhee, and I'm a nephrologist and an associate professor of medicine and public health at the university of California Irvine. And my colleague and collaborator, Dr. Kam Kalantar Zadeh. And I will be speaking to you today on optimizing care choices for those with late stage disease, planted transplants, home-based dialysis and conservative care options. So, as you heard from our other speakers in the us, nearly 37 million adults have CKD and each year 125,000 Americans transition to dialysis every dominant treatment paradigm for patients with terminal kidney failure. Um, our others' research has shown that we are caring for an aging and alien ailing incident ESRD population in whom a growing portion are over the age of 70 years.
Connie Rhee (20:54):
And over one third have multiple serious comorbidities procreating kidney transplantation. Now in 1961, shortly after the development of the dialysis shunt due to scarce resources, the decision of those wouldn't see dialysis was determined by a life and death committee, according to their assessment of patient's social worth and the inception of the 1972 Medicare yesterday for them ended rationing of dialysis through these death panels and led to near universal access to dialysis. However, over the past five decades, there has, there has been little progress or innovation in developing alternative patient centered treatment options for advanced CKD beyond that of dialysis.
Connie Rhee (21:35):
Now, while dialysis Is intended to extend the survival of advanced CKD patients progressing to ESRD our and others' research had exposed the exceedingly high mortality rates of this early dialysis transition period in a study of over 18,000 incident ESRD patients transitioning to chemo dialysis from our large national dialysis organization. My colleague and collaborator Dr. Kalantar Zadeh identified the highest mortality was observed in the first few months of treatment. And these findings have been corroborated by other large population-based studies out of DOPPS and the USRDS
Connie Rhee (22:11):
Now since 2014, Um, I've had the privilege of being a part of the NIH. You were one transition of care in CKD special study led by Kam Kalantar Zadeh which has sought to identify the leading determinants of mortality on this badge out transition period. Well, we and others have well, what we and others have observed is that in certain groups, dialysis may not exert the intended effect and extending life nor is for health, and that incident dialysis patients exhibit high one-year mortality and lack of survival benefit, particularly in those of high comorbidity burden, frequent hospitalizations and readmissions, low health related quality of life, loss of independence decline in physical function, increased symptom burden and higher healthcare costs. All of which may contribute to high dialysis withdrawal rates. Hence one of the core objectives of the US advancing American kidney health initiative as underscored by Ms. Pierce implemented in July of 2019, has been to expand access to patient centered treatment options for advanced kidney disease, including kidney transplantation, home dialysis, and innovative and safer transition to ESRD. Now as dialysis may not confer improved survival nor patient centered outcomes in certain CKD patients, we and others had growing interests and pressing urgency for conservative dialysis beam management, as the viable treatment option for advanced CKD and conservative management. We emphasize multiple facets, which include number one: interventions to the way the progression of CKD. Number two, share decision-making. Number three, symptom management. Number four, detailed communication. Number five, advanced care planning. And number six, psychological support. However, in the US, conservative management has remained under utilized due to major uncertainties regarding number one, the comparative effectiveness of conservative management versus dialysis on heart outcomes and patient centered end points. And number two, which patients will most benefit from dialysis, bringing management
Connie Rhee (24:26):
Thus to address these knowledge gaps. So we have been honored and privileged to have the opportunity to collaborate with OptumLabs in a UC OptumLabs research credit, comparing conservative management versus dialysis and through an NIH NIDDK R01 grant that we were very recently awarded to conduct one of the largest studies of conservative management versus dialysis transition to date known as the optimal study.
Connie Rhee (24:49):
I'd like to take a moment to acknowledge my NIH, Optimal teammates, um, some of whom were on the call who include my co-PI. Kam who will be speaking to you shortly. Our biostatistics expert, Dr. Dan Nguyen, our health services and economics expert, Dr. Dan O'Connell, Dr. Susan Crowley, the national lead program director for kidney disease and dialysis, Mr. Stephan Dunning, who you know, the senior project director of OptumLabs, Dr. Choteau Kovesdy, who was an expert into the epidemiology, Dr. Cheek Norris, our external safety monitor and an expert in disparities in communities, our lead staff, Ms Amy Yu, Dr. Yolande, Narasaki, miss Alexandra Novoa, and to the NIH and NIDDK for providing us with this exceptional opportunity and funding support for the study. And I'll pass the Baton over to my colleague Kam.
Kam Kalantar (25:40):
All right. Thank you, Connie, for the opportunity and the privilege to continue what's you have astutely presented over the past six minutes. So as shown in this slide in both clinical practice and research, one of the cornerstones of conservative management be emphasized is pragmatic nutritional therapy. In that we recommend moderately low dietary protein intake and prioritization of plant-based proteins. So I count for at least half of the source of dietary protein. This is a means to reduce intraocular pressure and glomerular hyperfiltration and accurately to, uh, and, and, and concurrent actually to decrease uremic toxin generations, metabolic acidosis phosphorus very then, so that ultimately we can team up to prevent or delay dialysis initiation. So, um, um, and more specifically in patients with advanced CKD prescribe a patient center, plant dominant, low protein diet, also known as PLADO means Plant dominant in which, uh, patients consume moderately low and also protein 0.6 to 0.8, more than 50% being from protein and high fiber and low sodium.
Kam Kalantar (27:01):
And one of the most critical aspects of this is actually related to, um, is related to, uh, what we call, uh, I'm sorry. I, uh, I'm, I'm losing control here is related to what we call, uh, many called nutrition therapy. One of the most critical aspects of management, uh, is to engage renal dieticians. And, and to that is very important that the renal dieticians be engaged and collaborate. So going to the next slide, and, and here you see essentially a, an overview of conservative management at the heart of conservative management, which is consistent with advancing American kidney health initiative. Executive order of July, 2019 is patient choice. The keyword choice treatment options for advanced CKD is important to reiterate that patients are not per se dichotomize between supportive care on the opposite side of this chart, which is, uh, uh, which also includes conservative preservative management versus the lower chart part of this chart, which is the life sustaining full-blown traditional dialysis therapy in these patients may transition across these areas as shown here with different options, including symptom management, and again, with a keyword of choice.
Kam Kalantar (28:23):
And finally, this is a last slide. Therefore, I would like to close by emphasizing a few points here. First, the 1973 Medicare expansion allowed almost all Americans with terminal kidney failure across to have access, to life sustaining dialysis. It permitted patients to choose dialysis, not just to survive, but also to maintain hope of continuing value to relationships, hope of rehabilitations, hope of achieving goals and live pursuits. Second in the contemporary practice, we have multiple treatment options for patients with moderate to advanced CKD, and these options can broaden and maximize the choices for these patients, including conservative and preservative management for patients to live long and prosper. Second one is to gradual incremental transition to dialysis with once to twice a week, as we are implementing here, number three would be non-diabetic palliative care and hospice to avoid dialysis patient chooses to do so. Uh, number four is palliative or detrimental dialysis. So finally I would like to emphasize that despite all, its perceived and real flaws and burdens dialysis does prolonged life for many people, people who choose to start or continue this therapy to maintain hope in the face of organ failure. And all the patients may ultimately choose to avoid dialysis or to redraw dialysis decisions to initiate and to continue or to withdraw. Those should be respected and protected. Thank you again for the opportunity to speak to you today, and we'll be happy to take any questions.
Kevin Larsen (30:15):
Thank you to all our speakers. Um, again, we would love to get questions from the audience. So please use the Q and a button at the bottom of your screen test. Dr. Desai we'll lead the panel in discussion.
Amar Desai (30:31):
Okay, well thank you again, uh, to the panelists, uh, I, uh, I'll get us started. once we have, uh, questions from the audience queue up and, and, uh, perhaps my, my, my questions will concentrate, uh, uh, on the practical, uh, implementation of, of these research outcomes into day-to-day clinical practice. So maybe what I start with is, is a question for, uh, for all of you, you know, it, if you're a primary care physician managing a panel of patients and, and, uh, um, uh, really, uh, there's obviously a incredible prevalence among a, an average panel of CKD. What is, what is the biggest opportunity? Like what would you recommend to that primary care doctor, uh, to identify patients with CKD and then, and then really identify those at risk of progression who need more intensive management. So maybe I could start with that Dr. Rhee, and I'd love to get input from others on the panel though.
Connie Rhee (31:36):
Um, and I thank you for that. Excellent question. Um, so no question, I think our, our primary care providers are pivotal. They really, on the front lines, um, uh, seeing the vast majority of the CKD patients. It may not be until patients are in their late stages, you know, the GFR, um, you know, less than 30, sometimes that we may, or even more that we may see that patients. Um, uh, so, you know, I think, um, you know, first of all, as an nephrologist, I consider it primary responsibility, um, to, um, you know, also make sure that I reach out to the primary care providers. Um, you know, in an academic setting, we really try to partner with our family medicine, internal medicine, um, uh, and other colleagues on to try to provide as much information about these important initiatives and metrics on that were presented by any of our expert speakers today.
Connie Rhee (32:25):
Um, you know, then in terms of discussion, um, you know, you know, really, um, you all know, unfortunately we're facing a shortage in the workforce in a follow-up, which we're trying to address. Um, you know, we're really, you know, very open-minded about and seeing patient at any stage. Um, even if it's to provide reassurance, um, uh, you know, about the, uh, you know, where their status of kidney diseases, um, you know, what their choices are depending on what their, their stage in the shot a fixation is, um, uh, to try to inspire hope, um, as Dr. Kalantar highlighted. Thank you. I'll differ to other speakers.
Kevin Larsen (33:03):
This is Kevin. I can contribute a little bit here. We are working on projects, uh, to provide clinical decision support into practice. And one of those is in diabetes, and that is looking at, um, also how we think about things like SGL, two inhibitors, um, uh, when people have CKD. So how do we support providers with getting this information right to the time that they're making the decisions? So they can do some shared decision-making with their patients, uh, with the best science, uh, uh, right in there, right in their workflow, right in their EHR.
Amar Desai (33:41):
Uh, fantastic. Uh, uh, I don't know if Dr. Spencer or Dr. Kalantar if you have anything else to add,
Donna Spencer (33:50):
Um, this is Donna actually, I wanted to - Stephan I know that you and I have had a chance to talk a little bit about the use of OLDW too, to help inform providers. I didn't know if you wanted to chime in here on that.
Stephan Dunning (34:02):
Uh, yeah, sure. Thanks Donna. Now, um, within the collaborative, there's been some great work done, um, across all of the partners where they'll highlight for a moment, some of the work that I think Kerry Willis referred to Johns Hopkins, um, you know, and developing some of the, um, so risk prediction algorithms that, um, are capable for, you know, implementing an EHR systems and so forth. So, um, you know, provided that you get that back drop of, um, clinical lab information. Um, you know, the, the verse prediction algorithms are, are improving, um, with their ability to use those data on those biomarkers.
Kam Kalantar (34:43):
Yeah, I think at the end of today, uh, we, we also have contributed to some of these scoring systems and we continue to expand and refine them. And one of them, for example, was d two years ago in Mayo Clinic from, uh, the [inaudible] um, uh, the [inaudible transition of care contract, uh, or be at all. And, and we believe that these are important, but they have to be supplemented and, and, uh, added with, uh, by patients, uh, discussion on a patient's choice. I mean, it's, it's very important. And a lot of patients on that says that I rather die than starting dialysis. And as if the war is only divided into two areas, so we need to, in our uh precision medicine approach to this, this is important to make sure that patient is part of all these discussions and even understanding the algorithms, the scores, the predictions, and the ultimate choice should be by done by the patient.
Amar Desai (35:46):
Maybe I can follow up on, on that one. Uh, Kam that, you know, the tension that you and Connie are giving to the entire issue of patient choice and the support that patients need around care options is just so important. Um, uh, can you talk a little bit, uh, again from that kind of practical aspect of what's the timing, what's the appropriate time to be having these discussions with CKD patients? And, and if you don't mind, maybe even modeling a bit around how do you, how do you start that conversation with a patient in a way that's empathetic and, and, and, and really, uh, provides the full range of options and the information in a way that's understandable.
Kam Kalantar (36:30):
Well, thank you. Maybe I start and others can, uh, expand. Uh, I usually, since I just left the clinic this morning, I had a number of patients with CKD stage three, A and three B usually asked that question for the first time doctor. I have, uh, my primary doctor says I have CKD. It's not even a stage one or two its stage three, am I dying? And then some of these very emotional conversation, not infrequently, including this morning, I had with one of them again, uh, drove from San Diego to see me. And I usually say that, look, the world has not come to an end and I cannot make any miracle. And you and I team up team up to go over different choices. And I want you to go and, and, and look up patient groups and join them because I want the information to my patient comes from patients. And no matter how misleading, sometimes it could be, it's still, there's more value and the patients are together than from me. So I start from here, CKD stage three A and three B. Let's see what others suggest. Okay.
Connie Rhee (37:35):
I would say that, um, you know, I agree with Dr. Kalantar for this place. And, um, I think in terms of timing, um, you know, it's really a longitudinal discussion and relationship that we have with our CKD patients. So, you know, similar to our primary care providers, I, I consider ourselves in a lot of ways. Um, primary care providers that have critically ill now knows about advanced CKD. And yesterday, I wouldn't say I have that their level of expertise that my primary care provider colleagues have in our scope of focus is very kind of narrow in comparison. Um, but we see, and especially as the transition from CKD to ESRD, that patients vary frequently and know sometimes, you know, every, every month, um, as we were trying to manage difficult transition. So it's multiple discussions, um, in over time. And it also involves their family, you know, their care partners as well. So I think, um, the earliest that you can, um, provide patients with as much information as possible, um, repetition and, you know, different venues and, you know, with all of their, you know, support their partners. Um, I think, uh, I think that, um, from the first time we need them, we begin the discussion.
Kevin Larsen (38:45):
This is Kevin, and we have a few audience questions about, um, the various choices for renal replacement therapy. So how do we think through, um, paranetal dialysis? How do we think through home dialysis? How do we think through preemptive transplant? What's the research in those areas?
Connie Rhee (39:10):
So I'll speak a little bit enough. My colleague, Dr. Kalantar to add more. So, um, you know, I think they probably, you know, um, based on that data, we probably say that the gold standard choice for you is starting to be kidney transplantation. But again, I think shifting our focus to patient choice, um, as Dr. Kalantar highlighted, you know, this is it's really what the, the patients, um, in a preference is, is, is the optimal treatment. But I think when we're very fortunate, um, as highlighted [inaudible]. Like we have so many options in armamentarium to care for advanced CKD patients. And in addition to pre-emptive kidney transplantation, um, uh, um, we have, um, you know, um, you know, various forms, you know, out of the home dialysis, a home HG, um, at our unit, um, I've been really excited.
Connie Rhee (39:55):
We've seen a huge uptake in self care dialysis, um, in which patients are self calculating, um, as a bridge to become, becoming comfortable to home HG, and then hopefully kind of platform of home dialysis. Then, then they're there. I think what motivated, um, or where I think become more, um, you know, become better self managers, prepare them for transplant, um, uh, then with respect to patients who ought to be communal, um, I've also really been, um, I think how to, you know, this is actually kinda, that are in our units. Um, our defaults on initiation, um, upper hemo is actually incremental hemodialysis. So you try to provide personalized care and which we don't just, um, administer twice. We can, haemodialysis in a very similar to peritoneal dialysis. We tailor the treatment acquainted with the patients and units based on reasonable kidney function. Um, and then that really helps us to bridge that transition period and also preserve individual you're not put on, which can lead to, you know, you know, benefits in terms of survival, profit quality by et cetera.
Connie Rhee (40:55):
Um, uh, then lastly, you know, the focus of our collaboration, with um, OptumLabs and, um, a project with NIH, um, the ROI optimal study, um, you know, I think, um, outside of the US you know, there, there has been a growing uptake, um, and recognition of the importance of conservative and preservative management for, or advanced kidney disease. Um, and, um, there's growing data. Um, uh, a lot of population-based studies are pointing to this, you know, outside of the US. Um, I think this, um, it's, it's inspiring for us, but we have a possibility, um, in terms of comparative effectiveness studies in US populations.
Connie Rhee (41:34):
And that's really trying to not, that's really the knowledge gap, that we're trying to now address, um, with OptumLabs in terms of, um, you know, what are the, what's the impact on the outcomes and patients centered end points, and what specifically, who are the optimal patients who are most suitable for these management strategies?
Kam Kalantar (41:54):
eah, I would like to also to emphasize, uh, uh, based on, uh, important comments by Dr. Connie Rhee that, uh, I also have the opportunity to serve in the joint, uh, steering committee of the world kidney . I remember March 11, 2021, celebrate this and celebrate throughout the year, the theme of the world kidney 2021, is living well with kidney disease. You have kidney disease, you have your entire life, and you can continue to do well to live well. One of my patient has been on dialysis for 40 years. We're going to celebrate next week, 40 years of home dialysis home dialysis. 40 years. And, and, uh, it's, it's wrong to again, look at these as firewalls, separate modalities, these are all interchangeable. I tell the patients, for example, you have option to start in the center, maybe one or two, twice a week, dialysis, we even continue your low protein diet on non dialysis days. This is what we do the UCI model. That means we start them on once or twice weekly dialysis. And non-dialysis days we give them low protein, dies on dialysis, high protein diet, and then you go home, you start self care, self cannulating, and that you just choose see what's the best for you. And when you are happy, you are essentially we have achieved the goals. And probably these patients live also the longest as studies have shown, we're not making up. These are not necessarily anecdotal observations, even though we do provide these direct care to patients. And we see this anecdotally, these are also based on data. So if patient is happy and patient can live well with kidney disease, that patient probably is, uh, can continue, uh, for a longer time. And, and we have achieved our goals
Amar Desai (43:43):
Great. I'm gonna shift gears a bit. And, uh, Dan, maybe I could pull, pull you in around, uh, quality measures here a bit, um, you know, not every, not everyone on this call or even more broadly is familiar, uh, with, with quality quality measures, uh, including the one we discussed today and then, and then the path to actually have them be adopted, uh, and into the clinical world and move into patient care is sometimes, uh, uneven at best. So could you, can you talk a little bit about how quickly we might, we might see progress in testing related to the kidney health evaluation measure by the provider community?
Kam Kalantar (44:26):
Uh, yes. Uh, so based on, what's also Mr. Dr. [inaudible], at least for example mentioned some, uh, that we are moving out of race, uh, index in EGFR. Uh, that other thing that may happen is to, uh, is an increase in use of Cystatin CGFR. So that's one of the metrics. I mean, it's looking at the EGFR trends over time. That is done traditionally and now to expand using different filtration markers, not just one creatine base and, and, uh, and, and, and then focusing on reproducible symptom management and symptom, uh, assessments. I mean, I can write down and, and give different scores and different ways of showing that my patient is doing well or patients, or these 37 million people with chronic kidney disease, have their symptoms managed correctly and assessed and managed correctly. So that would be probably one of the metrics we're moving towards, even though it's quite known that patient relates to the outcomes, but now for the CKD, we need to come up with more systematically defined and quantifiable metrics and, and to look at them and to, to rank them as a different areas and also adjust them for a patient, uh, uh, individual patient, uh, uh, uh, uh, uh, features on and, uh, and other things.
Kam Kalantar (45:59):
So this is where we're probably going to, and then waste time about transition to dialysis, to, uh, again, perform this, uh, grad gradually and have metrics for transition to dialysis and different modalities. So this is what I foresee, which is already being implemented in some centers. For example, Kaiser Permanente, colleagues are probably one of the pioneers in this area and we, and others partner with them to move to that direction.
Amar Desai (46:25):
Great. Thank you. And Dan Roman, uh, any, uh, any other perspectives on that from a NCQA perspective?
Kevin Larsen (46:36):
Dan you're on mute.
Amar Desai (46:46):
Why don't we wait for Dan to come back online, uh, Kevin, uh, what else do we have from, uh, from the audience?
Kevin Larsen (46:53):
I think I heard him, Dan Roman, are you there?
Stephan Dunning (46:55):
No but but this is Stephan. I can just chime in quickly to say, you know, um, I, I can't comment on the sort of adoption and rate of implementation, but I will say, I think, you know, the kidney health evaluation measures to Kam's point, I think, you know, there are clinical metrics that are required for, um, sort of identifying managing disease and they think, you know, there's a fairly standard clinical definition of 90 days, uh, difference between two measurements. And I think just getting the health, um, community in the standard practice of annual EGFR, annual UHCR, I think that hopefully brings, um, sort of more engagement, not only both aligns incentives of providers and payers around that quality, uh, metric in particular, but also also helps bring, um, sort of the importance of, uh, sort of longitudinal measurement and monitoring of, of the stage into, um, sort of into focus
Dan Roman (48:00):
And, uh, Stephan just answered the question for me,
Kevin Larsen (48:06):
But then where do we frame that in NCQA's experience, how many years of a star measure does it take before you see significant change?
Dan Roman (48:19):
I mean, it, um, boy, I said, thank you for that. Really a tough question. Uh, I don't know that we, I don't know that I have, I can answer it with any, uh, like solid, you know, number. Um, I think it depends on how important the measure is and how much people focus on, but when, when the measure is in the stars program, it definitely gets focused and definitely gets attention. And, and, and, uh, you, we see performance increase for sure. Which, you know, we're, we're very excited with the kidney health evaluation for diabetes measure that we just released. Uh, uh, I think everybody's very excited to have it be out there with NCQA's use in their programs, but also, um, it's on the table for the stars program as well, which does have a pretty big impact on performance. And it usually goes pretty quickly.
Dan Roman (49:26):
I just, well, I will say, I mean, uh, with touching the measure and I think, uh, most, uh, like we worked with the national kidney foundation and we worked with Joe Vasalotti, amazing, amazing, uh, uh, champion for the measure. Uh, he already knew all this, but, you know, the thing we need, the thing we saw with testing the measure, the UACR is the, the thing that drives performance down, plenty of people get EGFRs, but UACR is the thing that doesn't happen annually. Uh, so, you know, hopefully we're, we're, we're very optimistic and hopeful that, uh, you know, the, this new measure being out there and potentially that it would be part of the stars program, um, it'll get attention and that it'll drive, uh, everyone, including primary care to be paying attention to this and to be doing tests annually for people with diabetes. Again, uh, I, I think as I said earlier, NCQA is looking to try to kind of expand our portfolio of measurement related to kidney health. Uh, right now we just put up this measure, which is specific to the population with people diabetes. Um, there's more to do obviously. Um, so we are working on that, but yeah, I mean, we are working to have this kind of be included in the program. And again, I mean, usually once it's in stars, it gets the attention and things happen.
Stephan Dunning (51:10):
And Dan I'll, I'll add to your comment and that, you know, I think one of the, at least, um, suspicions or hypotheses is that because of the EGFR, uh, you mentioned that it's, it's not really where the performance issue lies it's in the UACR and I think part of the potential issue at least that I have opposites is that EGFR really sits on a number of panels that can be ordered. And, um, one of the outstanding questions is really how much attention, um, you know, are we as a health, are we as a health system or community paying to the results and sort of recognizing what the, um, that information that exists there really is there to help, um, inform, I think maybe the UACR coming into the fold as well. And they know that, um, to your point about Joe being a champion and championing the, the development of a kidney profile, um, lab, uh, lab tests in and of itself, where the kidney profile is, you know, both the EGR and the UACR are together in one. Um, I think probably with the hope that there can be more intention around screening and monitoring of disease there.
Kevin Larsen (52:28):
So I've got one last question from the audience, uh, kind of combining a few here. Um, we've seen that there is a low uptake of alternative therapies for, uh, uh, renal replacement. What do you think the impact of moving to Medicare advantage and this more global payment model will have on these various choices, uh, for people that are, um, having late stage CKD, um, moving into ESRD.
Kam Kalantar (52:59):
uh, well, uh, maybe I start to move to alternative care and I have a number of, uh, flying patients. Who've been coming from overseas to see me. They say Dr Kalantar you are the only one who can give me something other than dialysis. And I first I clarify to them that there is no magic diet. We have centers of excellence in nutritional management of kidney disease to defer or delay dialysis, but when you need dialysis, there is no magic diet or meal plan.
Kam Kalantar (53:30):
So, and it has also to be if, if you want to go to make these set, uh, implemented or supported by certain guidelines, that has to be based on data, it can be just start to Kalentar's opinion or Dr. Kalentar's clinic. So we need more data, we need clinical trials. So we still, I don't mean to, uh, to say that we still have a long way to go to that direction, but for now, while we provide some of these alternative cares, there are actually a number of them. We have published in addition to nutrition therapy and plant-based diet PLADO and other things we need to collect data. We need to conduct, uh, credible studies, including coming from OptumLas. And that's why we're partnering with you. And hopefully at some point, once we have reproducibility and credibility and generalizability, then maybe at that point, we can go to CMS and other colleagues in the government and ask them to help implement them, uh, across the nation.
Stephan Dunning (54:36):
It, I would agree Kam and, you know, I think I'd add to that, that I think, um, you know, there is more innovation to do around payment models, um, teams wise, you know, initiating, you know, a few different payment models, you know, one particularly around dialysis with the surgery treatment choice, but other kidney care, um, you know, options, uh, that are further upstream. Um, you know, I think, you know, there, there are a number of options like Kam said, and I think, you know, there's research that needs to be done that bear out who might, who those options might all be best for, um, with respect to patient choice, but really payment model alignment needs to happen as well.
Kevin Larsen (55:18):
I want to thank you all. This was fantastic. Thank you Amar Desai. Thank you to the speakers of our panel. We've reached the end of a great discussion. Um, I want to thank the audience for joining us today. Please complete the brief survey by clicking on the survey widget at the bottom of the console. And then as a reminder, all of our sessions, including this one, uh, have recordings that are available on the Connections 2020 series of on the spotlights page of the OptumLabs.com website. So again, uh, you can go to the OptumLabs.com website and download these and review them again. Uh, you can also please complete our feedback survey. We thank you so much for your participation and we look forward to having you join us again in the future. Uh, hopefully we'll be able to be in person sometime soon. Uh, and until that time, uh, look for us to have some more of these webinars. Thank you again.
