Rather than defining addiction as destructive, compulsive behavior, this ideology focuses on physical dependence. If you need a drug to avoid being physically ill, you are considered addicted. So Prozac would be considered addictive, but not cocaine, because quitting Prozac abruptly can cause flulike symptoms while stopping cocaine doesn’t, even though it elicits extreme craving.
In the 1980s, crack cocaine made clear just how addictive cocaine could be, even without physical withdrawal symptoms. Today, both the National Institute on Drug Abuse and the Diagnostic and Statistical Manual of Mental Disorders reject the idea that addiction is synonymous with dependence. Unfortunately, many clinicians, including doctors, haven’t caught up.
What is addiction, then? The root problem is craving, which drives a compulsion to use drugs despite the harm they cause. That’s what makes crack addictive, while Prozac can be therapeutic.
Because methadone and buprenorphine are opioids themselves, it’s easy to assume that using them is “substituting one addiction for another.” However, the pattern of taking the same dose every day at the same time means that there is no high or intoxication. Patients on maintenance doses are able to nurture a baby, drive, work and be a loving spouse.
In these patients, addiction is replaced by physical dependence. And that’s not a problem for those who have health care coverage: It’s no different from needing antidepressants or insulin. When a drug’s benefits outweigh its risks, continued use is healthy, not addictive.
Sadly, though, there’s another reason for widespread skepticism about addiction medication. It comes from the fact that many patients will continue to misuse opioids. Medication reduces relapse more than abstinence does — but relapse is still common, as in Mr. Thompson’s case. In abstinence treatment, however, relapsers drop out and are invisible; with medication, they often remain in treatment.
And remaining in treatment is important because it cuts overdose risk, even during relapse. Many highly traumatized people also need the continued health care support before they are able to quit street drugs.
When we fail to understand that these medications can be used both to reduce harm and stabilize people in recovery, we risk letting the perfect be the enemy of the good. For some, medication is a way to reduce risk while drug use continues. For others, it’s a path to rapid recovery. Often, people will need to take the first route to survive long enough to reach the second.
For harm reduction to work, maintenance drugs need to be almost as accessible as street drugs. Whenever people take buprenorphine rather than heroin, their risk of dying is lowered, especially since so much heroin these days is tainted with deadly strong fentanyl. For stabilization, people need empathetic counseling that doesn’t view dependence as continuing addiction.
Change will require innovative measures. The government should stop funding and insurers should stop covering any program that does not use all the F.D.A.-approved anticraving medications and does not provide informed consent about their effectiveness. While abstinence can work for some, we need many options. We also need to rethink our regulations for methadone and buprenorphine prescribing.
Then we need to publicly recognize that recovery on medication is every bit as valid as any other treatment. What matters is whether, as Freud put it, you can love and work, not the chemical content of your brain or urine.
Funding for community health centers could finally pass in the coming week as Congress faces a new government funding deadline.
House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) told The Hill on Friday that lawmakers “hope” to add money for the health centers to the short-term spending bill to be considered before a Feb. 8 deadline for funding the government.
Funding for the health centers, which serve millions of primarily poor people, has been delayed for months, causing uncertainty and in some cases hiring freezes or other steps.
Lawmakers are considering providing two years of funding.
In addition, a number of other health-care items could ride on the next government funding bill, or wait until a longer-term deal in a few weeks. A range of Medicare programs known as “extenders” need to be renewed, for example.
There is also the more controversial issue of actions aimed at stabilizing the ObamaCare marketplaces.
Momentum appears to be increasing for funding known as reinsurance that is aimed at reducing premiums.
Walden is backing a bill to provide the funding in the House, and Sen. Susan Collins (R-Maine) has been pushing for a similar measure in the Senate.
There is still some uncertainty and many conservatives deride the funding as a “bailout” of ObamaCare insurers.
Any action on ObamaCare stabilization appears more likely to wait as lawmakers try to craft a longer-term government funding deal by March.
Congressional committees are stepping up their efforts to examine the opioid epidemic.
On Tuesday, the House Ways and Means Committee will hold a hearing on preventing opioid abuse through Medicare. On Thursday, the Senate health committee will hold a hearing on the effects of opioid abuse on children and families.
Later in February, the House Energy and Commerce Committee will begin holding hearings to examine specific legislation related to the crisis.
The recent breathtaking flurry of mega-mergers coupled with increasingly challenging market forces and an ever shifting political landscape has cast a cloud of confusion regarding where the U.S. healthcare delivery system is heading.
So, where do you go to find the map?
Every year, the JP Morgan Healthcare Conference provides an incredibly efficient snapshot of the strategies for large healthcare delivery systems, the hub for healthcare in the U.S. Most of these organizations are also the largest employers in their respective states. The conference took place this week in San Francisco with over 20 healthcare systems presenting, including Advocate Health Care, Aurora Health Care, Baylor Scott & White Health, Catholic Health Initiatives, Cleveland Clinic, Geisinger Health System, Hospital for Special Surgery, Intermountain Healthcare, Mercy Health in Ohio, Northwell Health, Northwestern Medicine, Partners HealthCare System, WakeMed Health & Hospitals and many of the other big name brands in the market. Each provided their strategic roadmap in a series of 25-minute presentations from their “C” suite. If you’re looking for the GPS on strategy and a gauge on the health of healthcare, this is it.
How do their strategies differ? What direction are they heading in? There is a great line from Alice in Wonderland that goes, “If you don’t know where you’re going, any road will take you there.” You would think that line applies perfectly to the U.S healthcare system, but the good news is it actually doesn’t.
While the exact destination for everyone is TBD, the direction they are heading in is actually pretty clear and consistent. It turns out that they are all using a very similar compass, which is sending them down a similar path.
So, what are the roadside stops health systems consider absolutely necessary to be part of their journey to creating a more viable and sustainable value-based business model?
Based on the travel plans for over 20 of the largest and most prestigious healthcare delivery systems in the country, here’s your GPS and list of 12 things you “must do” on your journey.
1. You Must Scale
Clearly the headline at #JPM18 was the flurry of major announcements regarding major mergers. With that said, two of the mergers were front and center: teams were there to present from Downers Grove, Ill.-based Advocate and Milwaukee-based Aurora, which will be a $10 billion organization with 70,000 employees, as well as San Francisco-based Dignity Health and Englewood, Colo.-based Catholic Health Initiatives, which will be a $28 billion organization with 160,000 employees. The size and scale of these mergers is pretty stunning. While the announcement of these and the other recent mega-mergers has forced many into their board room to determine what the deals mean to them, the consensus at the conference was this: There are a number of different paths forward to achieve scale. Some, like Baylor Scott & White in Texas, have aggressive regional expansion plans. Others are betting on partnerships to provide the same or even more value. Taking a pulse of the room, two things were clear. The first is there is no definition of scale any more in this market. The second is that, despite this flurry of mergers, “getting really big” is not the only destination.
2. You Must Pursue “Smart Growth” and Find New Revenue Streams
Running counter to the merger narrative in the market, Salt Lake City-based Intermountain provided a good overview of the movement to what is called an “asset light” strategy of “smart growth.” This is a radically contrarian approach to the industry norm, which is the capital intensive bricks and mortar playbook of buying and building. As part of their strategy, Intermountain will open a “virtual hospital” delivering provider consultations and remote patient monitoring via telehealth. The system will also launch a number of healthcare companies every year, leveraging their considerable resources in a manner they believe will produce a higher yield. Other health systems outlined a similar stream of initiatives they have in motion to diversify their revenue streams and expand their business model into higher margin, higher growth businesses. One example is Cincinnati-based Mercy Health, which achieved strong growth and leverage via their investment in a revenue cycle management company. Advocate in Illinois formed a partnership with Walgreens. Together, they now operating 56 retail clinics and Advocate has made a significant impact on driving new patients and downstream revenue to their system. The bottom line is all now recognize that they must think and act differently to be able to continue to fund their clinical mission and serve their community.
3. You Must Measure and Manage Cost and Margins
While some are moving aggressively to get scale, everyone is looking to more effectively use the resources they have and get more operating leverage. Margin compression was a consistent theme, with many systems now moving into consistent, stable operating models around managing margins versus launching reactionary initiatives when they find a budget gap. What is emerging is a new discipline and continuous process around managing cost and margins that is starting to look similar to the level of sophistication we have seen in the past for revenue cycle management. To that end, there has been major movement in the market to implement advanced cost accounting systems, often referred to as financial decision support, which provide accurate and actionable information on cost and help organizations understand their true margins as they take on risk-based, capitated contracts. Some during the conference referred to it as the “killer app” for the financial side of driving value. Regardless of what you call it, all are moving aggressively to understand the denominator of their value equation.
4. You Must Become a Brand
Investing in and better leveraging their brand has become a strategic must for health systems. The level of sophistication is growing here as providers shift their mental model to viewing patients as “consumers.” Aurorain Wisconsin cited their dedicated Consumer Insights Group and outlined their “best people, best brand, best value” approach that has been incredibly effective both internally and externally. At the same time, the bigger investments for many health systems relative to brand are more on brand experience than brand image, with a focus on understanding and radically rethinking the consumer experience. As an example, at Danville, Pa.-based Geisinger, close to 50 percent of ambulatory appointments are scheduled and seen on the same day. And every health system is making meaningful investments in their “digital handshake” with consumer, creating and leveraging it via telehealth as well as mobile applications to enhance the customer experience.
5. You Must Operate as a System, Not Just Call Yourself One
One clear theme at #JPM18 is different organizations were at different points along the continuum of truly operating as a system vs. merely sharing a name and a logo. There are a number of reasons for this, but you are increasingly seeing tough decisions actually being made vs. just kicking the can down the road. There has been a great deal of acquisitions over the last few years coupled with a new wave of thinking relative to integration that is more aggressive and more forward-looking. This mental shift is actually a very big deal and perhaps the most important new trend. Many health systems are heavily investing in leadership development deep into their organization to drive changes much faster.
6. You Must Act Small
The word “agile” is quickly becoming part of everyone’s narrative with health systems looking to adopt the principles and processes leveraged in high tech. Chicago-based Northwestern Medicine is an example of an organization that has grown dramatically in the last five years, now approaching $5 billion in revenue. At the same time, they have still found a way to operate small, leveraging daily huddles across the organization to drive their results. The team at Raleigh, N.C.-based WakeMed has achieved a dramatic financial turnaround over the last few years, applying a similar level of rigor yielding major operational improvements in surgical, pharmacy and emergency services that have translated into better bottom line results.
7. You Must Engage Your Physicians
Employee engagement was a major theme in many of the presentations. With the level of change required both now and in the future, a true focus on culture is now clearly top of mind and a strategic must for high-performing health systems. That said, only a handful articulated a focus on monitoring and measuring physician engagement. This appears to be a major miss, given that physicians make roughly 80 percent of the decisions on care that take place and, therefore, control 80 percent of the spend. One data point that stood out was a 117 percent improvement in physician engagement at Northwestern. Major improvements will require clinical leadership and a true partnership with physicians.
8. You Must Leverage Analytics
Many have reached their initial destination of deploying a single clinical record, only to find that their journey isn’t over. While health systems have made major investments big data, machine learning and artificial intelligence, there was a consistent theme regarding the need to bring clinical and financial data together to truly understand value. Part of this path is the consolidation of systems that is now needed on the financial side of the house with a focus on deploying a single platform for financial planning, analytics and performance. The primary focus is to translate analytics not just into insights, but action.
9. You Must Protect Yourself
As organizations move deeper into data, there is increased recognition that cybersecurity is a major risk. Over 40 percent of all data breaches that occur happen in healthcare. During the keynote, JP Morgan Chase CEO Jamie Dimon shared that his organization will spend $700 million protecting itself and their customers this year. Investments in cybersecurity will continue to ramp up due to both the operational and reputational risk involved. Cybersecurity has become a board room issue and a top-of-mind initiative for executive teams at every health delivery system.
10. You Must Manage Social Determinants of Health in the Communities You Serve
Perhaps the most encouraging theme for healthcare provider organizations was the need to engage the community they serve and focus on social determinants of health. As Intermountain shared: “Zip code is more important than genetic code.” To that end, Geisinger refers to their focus on “ZNA.” They have deployed community health assistants, non-licensed workers who work on social determinants of health and have implemented a “Fresh Food Farmacy,” yielding a 20 percent decrease in hemoglobin A1c levels along with a 78 percent decrease in cost. Organizations like ProMedica Health System in Ohio have seen similar results with their focus on hunger in Toledo. WakeMed has an initiative focused on vulnerable populations in underserved communities that has resulted in a significant decrease in ER visits and admissions and over $6 million in savings.
11. You Must Help Solve the Opioid Epidemic
The opioid issue is one that healthcare professionals take very personally and feel responsible for solving. It came up in virtually in every presentation, and it’s an emotional issue for the leaders of each organization. This is good news, but the better news is that they are taking action. As an example, Geisinger invested in a CleanState Medicaid member pilot that resulted in a 23 percent decrease in ER visits and 35 percent decrease in medical spending, breaking even on their investment in less than 10 months. While many would rightly argue that the economic rationalization isn’t needed for something this important, the fact that it’s there should eliminate any excuse for anyone not taking action.
12. You Must Deliver Value
The Hospital for Special Surgery in New York is the largest orthopedics shop in the U.S. and a great example of how value-based care delivery is taking shape. Perhaps the most revealing stat they shared is that 36 percent of the time, patients receive a non-surgical recommendation when they are referred to one of their providers for a second opinion. This is exactly the type of value-based counseling and decision-making that will help flip the model of healthcare. Some systems are farther along than others. Northwestern currently has 25 percent of its patients in value-based agreements, but other systems have less. As the team from Intermountain re-stated to this audience this year, “You can’t time the market on value, you should always do the right thing, right now.” Well said.
It’s time to get started or get moving even faster.
As the saying goes, “It’s the journey, not the destination.”
AB 72: “Surprise medical bill” legislation by Assemblyman Rob Bonta (D-Oakland) was among the most-talked-about measures of the year in Sacramento. It promises to better protect consumers against unexpected medical bills.
SB 482: Amid a national opioid epidemic, Brown approved legislation that requires doctors to check a patient’s prescription history in a state database before prescribing any potentially addictive drugs.
SB 586: The legislation, a compromise between the Department of Health Care Services and children’s advocates, aims to slow down and improve plans to overhaul the way the state’s most medically fragile children receive care.
SB 908: This bill will allow consumers to learn when their health insurance premium rates have been considered “unreasonable” by state officials. Current law requires that unreasonable rate hikes be posted online by one of the two state agencies that regulate insurers — the Department of Managed Health Care or the California Department of Insurance. But consumers don’t check online, the bill’s supporters argued.
SB 1076: This law, sponsored by the California Nurses Association, was designed to protect hospital patients in “observation” care. It requires that observation units meet the same staffing standards — nurse-to-patient ratios — as those in the emergency room.
While health care has not been central to the 2016 Presidential campaign, the election’s outcome will be a major determining factor in the country’s future health care policy. A number of issues have garnered media attention, including the future of the Affordable Care Act (ACA), rising prescription drug costs, and the opioid epidemic.
Hillary Clinton and Donald Trump have laid out different approaches to addressing these and other health care issues. Central among these is their position on the future of the ACA. Hillary Clinton would maintain the ACA, and many of her policy proposals would build on provisions already in place. Donald Trump, in contrast, would fully repeal the ACA, and although his policy proposals and positions do not offer a full replacement plan, they do reflect an approach based on free market principles.
See where the candidates stand on seven key health policy issues.
Two thirds of voters (66%), including large shares of Democrats, Republicans, and independents, identify access and affordability of health care and the future of Medicare, an issue not being widely discussed on the campaign trail, as top priorities for the presidential candidates to talk about during the campaign. Smaller majorities of voters say the same about Medicaid’s future (54%), prescription drug costs (53%), and the future of the 2010 health care law (52%).