Healthcare organizations cannot afford to ignore consumers in 2019, as a number of major trends shape the future of care delivery (and a number of other trends warrant more critical thinking).

This article was first published March 18, 2019, by MedPage Today.

By Joyce Frieden, news editor, MedPage Today

PHILADELPHIA — The consumer will be where it’s at for population health in 2019, David Nash, MD, MBA, said here Monday at a Population Health Colloquium sponsored by Thomas Jefferson University.

“Whatever business model empowers the consumer, wherever she is,” including at home, will spell success, according to Nash, who is dean of Jefferson’s School of Population Health. “That’s where population health must go.”

Nash noted that back in 1990, Kodak, Sears, and General Electric were the most important companies in the Dow Jones Industrial Average; all those companies have disappeared or almost disappeared today.

“If we ignore the consumer, it will be at our peril,” Nash said, citing home healthcare, telehealth, and the use of wearables among the trends to watch in the coming year.

Nash, who is a columnist for MedPage Today, also cited these other trends to watch:

  • The growth of Medicare Advantage and managed Medicaid. “These are two programs that are working,” he said. “They’re working because they deliver value — high-quality care with fewer errors — and they follow our mantra: no outcome, no income.”
  • Tax reform. “Whatever your politics are [on this issue], park it at the door,” he said. “The sugar high is over, and now we’re in a carbohydrate coma. We’ve got the biggest deficits in American history; if we continue to spend money we don’t have, what will that do to healthcare? I think it will bite us in the butt when [it] comes to the Medicare trust fund.”
  • Precision medicine and population health. “[There is a notion] that precision medicine and population health are actually kissing cousins,” said Nash. “They are inexorably linked.”
  • Continued deal-making. The CVS/Aetna, UnitedHealth Group/DaVita, and Humana’s deals with Kindred Healthcare and Curo Health Services are just some of the more recent examples, he said. And he noted, the healthcare company formed by Amazon, Berkshire Hathaway, and JPMorgan Chase now has a name: Haven. “It’s a place where they’re going to figure it all out and they’ll let us know when they do.”
  • Continued delivery system consolidation. “Big surprise there,” he said sarcastically. “The real question is will they deliver value? Will they deliver synergies?” Nash noted that his own institution is a good example of this trend, having gone from one or two hospitals 5 years ago to 16 today with another two in the works.
  • Population health technology. “The gravy train of public money into this sector will [soon] be over; now the real challenge is for the IT [information technology] systems on top of those legacy companies; can they create the patient registry information and close the feedback loop, and give doctors, nurses, and pharmacists the information they need to improve care?”
  • The rise of “population health intelligence.” “That’s our term for predictive analytics, big data, artificial intelligence, and augmented intelligence … It says we don’t want to create software writers — we want doctors, nurses, pharmacists, and others who can glean the usable information from the terabyte of information coming our way, to [know how to interpret it].”
  • Pharmaceutical industry disruption. “This is really under the thumb of consumers … It’s all about price, price, price,” Nash said. “We’ve got to find a way to rationalize the pricing system. If we don’t, we’re going to end up with price controls, and as everybody in this room with a background in this area knows, those don’t work either.”
  • More venture capital money. Nash described his recent experience at the JPMorgan Chase annual healthcare conference, where people were paying $1,000 a night for hotel rooms that would normally cost $250, and being charged $20 just to sit in the lobby of one hotel. “What was going on there? It was more private-sector venture money coming into our industry than ever before. [These investors] know that when there’s $1 trillion of waste in an industry, it’s ripe for disruption.”
  • Workforce development. This is needed for the entire industry, said Nash. “More folks know a lot more [now] about population health, quality measurement and management, Lean 6 Sigma, and improving processes and reducing waste. The only way we’re going to reduce that waste of $1 trillion is to have the right kind of workforce ready to go.”

Lawton Burns, PhD, MBA, director of the Wharton Center of Health Management and Economics at the University of Pennsylvania here, urged the audience to look critically at some of these possible trends.

“You need to look for evidence for everything you hear,” said Burns, who coauthored an article with his colleague Mark Pauly, PhD, about the need to question some of the commonly accepted principles of the healthcare business.

Some of the ideas that merit more critical thinking, said Burns and Pauly, are as follows:

  • Economies of scale
  • Synergy
  • Consolidation
  • Big data
  • Platforms
  • One-stop shops
  • Disruption
  • Killer apps
  • Consumer engagement

“I’m not saying there’s anything wrong with those 10 things, but we ought to seriously consider” whether they’re real trends, Burns said. As for moving “from volume to value” in healthcare reimbursement, that idea “is more aspiration than reality” at this point, he said. “This is a slow-moving train.”

Burns also questioned the motives behind some recent healthcare consolidations. In reality, “most providers are positioning themselves to dominate local markets and stick it to the payers — let’s be honest,” he said. “You have to think when you hear about providers doing a merger, you have to think what’s the public rationale and what’s the private rationale? The private one is [often] more sinister than you realize.”








Paul Allen

We are about to enter the era of deep medicine, where we understand cell pathways and how to change them. I’m a two-time cancer survivor.

We are about to enter the era of deep medicine, where we understand cell pathways and how to change them. I’m a two-time cancer survivor. First I had Hodgkin’s, a young person’s cancer. And then non-Hodgkin’s lymphoma. Right now they just hit you with everything they’ve got, like carpet bombing. And then my mother passed away of Alzheimer’s. Those things are motivating experiences that make you want to understand things better and then make a difference. In maybe 20 or 30 years, we will use things like stem cells to change disease outcomes — your own immune system, designed by evolution, to attack sick cells and things like that. It seems inconceivable now — we have thousands of types of cells, so there are trillions of combinations — but health care would be much more personal. And the costs will potentially decline.


Precision Medicine Has Bipartisan Support, Proponents Assure Amid Trump Administration Transition


Precision Medicine2

At a cocktail reception in Boston last week ahead of an annual meeting on personalized medicine, attendees milled around not talking about the latest advances in genomics or the challenges of companion diagnostics development. They were too preoccupied with the impact of the Presidential elections the week before.

Will the new administration value genomics research and personalized medicine projects going on around the country that depend on government funding? How will a change in administration and priorities impact projects such as the Precision Medicine Initiative (PMI) and the Cancer Moonshot? Who will head up the US Department of Health and Human Services, the National Institutes of Health, and the US Food and Drug Administration? And will these new government officials continue efforts of the last administration to advance data sharing, privacy protections, and integrated systems critical for the implementation of personalized medicine?


The Overhyping of Precision Medicine


Science has always issued medical promissory notes. In the 17th century, Francis Bacon promised that an understanding of the true mechanisms of disease would enable us to extend life almost indefinitely; René Descartes thought that 1,000 years sounded reasonable. But no science has been more optimistic, more based on promises, than medical genetics.

Recently, I read an article promising that medical genetics will soon deliver “a world in which doctors come to their patients and tell them what diseases they are about to have.” Treatments can begin “before the patient feels even the first symptoms!” So promises “precision medicine,” which aims to make medicine predictive and personalized through detailed knowledge of the patient’s genome.

The thing is, the article is from 1940. It’s a yellowed scrap of newsprint in the Alan Mason Chesney Archives at Johns Hopkins University in Baltimore. The article profiles Madge Thurlow Macklin, a Hopkins-trained physician working at the University of Western Ontario. Macklin’s mid-century genetics is not today’s genetics. In 1940, genes were made of protein, not DNA. Textbooks stated that we have 48 chromosomes (we have 46). Looking back, we knew almost exactly nothing about the genetic mechanisms of human disease.

These genetic promissories echo down the decades with an eerie resonance. In 1912, Harvey Ernest Jordan—who would become dean of the University of Virginia medical school—wrote: “Medicine is fast becoming a science of the prevention of weakness and morbidity; their permanent not temporary cure, their racial eradication rather than their personal palliation.” (By “racial” here Jordan simply meant any large, loosely related population.) “Fast” is relative; 99 years later, in 2011, Leroy Hood wrote: “Medicine will move from a reactive to a proactive discipline over the next decade.”

Nonacute Care: The New Frontier


Image result for New Frontier

What happens outside the hospital is increasingly important to success, so healthcare leaders need to influence or control care across the continuum.

If you’re running a hospital, one irony in the transformation toward value in healthcare is that your future success will be determined by care decisions that take place largely outside your four walls. If you’re running a health system with a variety of care sites and business entities other than acute care, the hospital’s importance is critical, but its place at the top of the healthcare economic chain is in jeopardy.

Certainly, the hospital is the most expensive site of care, so hospital care is still critically important in a business sense, no matter the payment model. But if it’s true that demonstrating value in healthcare will ensure long-term success—a notion that is frustratingly still debatable—nonacute care is where the action is.

For the purposes of developing and executing strategy, one has to assume that healthcare eventually will conform to the laws of economics—that is, that higher costs will discourage consumption at some level. That means delivering value is a worthy goal in itself despite the short-term financial pain it will cause—never mind the moral imperative to efficiently spend limited healthcare dollars.

So no longer can hospitals exist in an ivory tower of fee-for-service. Unquestionably, outcomes are becoming a bigger part of the reimbursement calculus, which means hospitals and health systems need a strategy to ensure their long-term relevance. They can do that as the main cog in the value chain, shepherding the healthcare experience, a preferable position; but physicians, health plans, and others are also vying for that role. Even if hospitals or health systems can engineer such a leadership role, acute care is high cost and to be discouraged when possible.

21st Century Cures Act: 4 health industry impacts summarized


On Wednesday, the Senate voted 94-5 to pass the long-awaited 21st Century Cures Bill. As it has backing from the current White House administration, President Barack Obama is expected to sign the legislation into law.

The law has been called the “most important bill of the year” by Senator Lamar Alexander (R-TN), as Politico Pulse reported Tuesday. The bill, while bipartisan, is not without controversy. While the House version of the legislation passed swimmingly with a vote of 392-26, the bill did have its share of opponents in the Senate– including Sen. Elizabeth Warren (D-MA) and Sen. Bernie Sanders (I-VT) – who think the bill is too favorable to pharmaceutical companies. Both Sanders and Warren were among the five Senators to vote against the measure.

And as Modern Healthcare’s Merrill Goozner notes in an editorial, it’s likely the true impact of the bill won’t be known right away but will be realized as the years pass. “The final details of the 996-page legislation…weren’t known until five days before it passed,” Goozner wrote.

About three years of work and efforts from 1,400 lobbyists for 400 companies went into the making of this $6.3 billion package. It seeks to deliberately speed medical research and treatments. Because seemingly no healthcare legislation can be a reasonable length (it’s about 90 pages longer than the ACA) and because nothing in healthcare is simple, we’ve summarized some of the notable implications of the bill in four buckets: Health IT, mental health, FDA reform and research and care funding.

Regulatory, Legal Uncertainties Are Barriers To Value-Based Agreements For Drugs

Regulatory, Legal Uncertainties Are Barriers To Value-Based Agreements For Drugs


The past several years have seen an increasing number of new and innovative therapies entering the drug market. Many of these are precision medicines developed to treat a narrowly defined patient population, often with a previously unmet need. These treatments have demonstrated success in improving quality of life and other important health outcomes among indicated patients in clinical trials, but there is uncertainty about patient response rates in real-world settings. These uncertainties have led payers to express concerns about the costs of some new medicines and to implement policies to control patients’ access to those medicines, such as higher cost sharing, health technology assessments, and step therapy (which requires patients to try certain, often less expensive medications before progressing to costlier drugs). This creates a potential problem, as delays in receiving health care, whether due to step therapy or other factors, can be detrimental to patient health outcomes.

Performance-based risk-sharing arrangements (PBRSAs) and value-based agreements (VBAs) have received attention of late because of the flexibility they give private payers, providers, and biopharmaceutical companies to better understand the value of new medicines and align payment with it. By tying payment to real-world outcomes, these arrangements—collectively referred to in this post as VBAs—have the potential to support patients’ prompt and affordable access to new, innovative treatments while also addressing payers’ cost concerns.

Despite considerable interest from stakeholders on both sides of the negotiations, there were few successful examples of VBAs in the U.S. until very recently: Between 1993 and 2013, there were fewer than 20 VBAs executed in the U.S. However, more of these arrangements have recently been announced, although they remain rare, and payers are expressing increased interest.

The academic literature provides information about some of the existing agreements and suggests possible barriers to their execution, but it leaves many questions unanswered. We conducted two-part interviews with a group of five stakeholders regarding their experience with these types of contracts. All respondents had direct experience developing and negotiating VBAs, four as representatives of private insurers and pharmacy benefit managers, and one on behalf of a large pharmaceutical firm launching branded products.

The interviews focused on respondents’ overall perceptions and expectations of VBAs, barriers to adoption, and possible solutions to those barriers (see note 1). In order to solicit unbiased responses, the interviews were double blinded: the sponsor of the research was not revealed to interviewees, and the identity of respondents is not known by the sponsor. We conducted the initial interviews during the summer of 2015 and followed up with the respondents this fall (2016) to understand how perception of VBAs and the barriers to them may have shifted.

What’s up with Apple in healthcare?


In recent months, Apple has been sending out smoke signals suggesting a major thrust into healthcare. The tech giant has bolstered its health team with four recent high-profile hires and forged partnerships with large healthcare systems. These include a clinical trial partnership with Beth Israel Deaconess Hospital and a precision medicine initiative with Scripps Translational Science Institute, according to Politico.

The company has also partnered with IBM, Johnson & Johnson and Medtronic on cognitive computing platform called Watson Health Cloud. The platform offers tailored data analytics services to clinicians.

With a current health team of about 100 strong, including medical device and medical sensor experts, the Cupertino, CA company appears poised to move beyond fitness apps to fully regulated medical technologies and clinical support systems.

In August, Apple confirmed its first digital health acquisition, personal health record startup Gliimpse. The Redwood, CA-based firm, which has raised about $1 million in seed funding, hopes to advance interoperability by aggregating health data into a single digital patient record.

Biomarkers: Top challenges and opportunities in managed care


Image result for Biomarker


Mark Zuckerberg and Priscilla Chan’s $3 billion effort aims to rid world of major diseases by end of century

Facebook co-founder Mark Zuckerberg and his wife, Priscilla Chan, on Wednesday announced a $3 billion effort to accelerate scientific research with the wildly ambitious goal of “curing all disease in our children’s lifetime.”

The many components of the initiative include creating universal technology “tools” based on both traditional science and engineering on which all researchers can build, including a map of all cell types, a way to continuously monitor blood for early signs of illness, and a chip that can diagnose all diseases (or at least many of them). The money will also help fund what they referred to as 10 to 15 “virtual institutes” that will bring together investigators from around the world to focus on individual diseases or other goals — an idea that has the potential to upend biomedical science.

Being a scientist in academia today can often be a solitary endeavor as the system is set up to encourage colleagues to keep data exclusive in the hopes that this strategy helps them be more competitive at getting publications and grants. But as more Silicon Valley entrepreneurs like Zuckerberg are seeking to make their mark in the biological sciences, they are emphasizing the power of collaboration and openness.

A centerpiece of the new effort, called Chan Zuckerberg Science, involves creating a “Biohub” at the University of California at San Francisco (UCSF) Mission Bay campus that will bring together scientists from Stanford, the University of California at Berkeley and UCSF.

Zuckerberg and Chan, among the world’s 10 wealthiest couples, with a net worth of $55.2 billion, emphasized that their timeline is long — by the end of the century.