Martin Entwistle is Executive Director of theDavid Druker Center for Health Systems Innovation, a multidisciplinary group whose mission is to catalyze, invent and deploy innovations in health and wellbeing. Using a human-centered design approach and leveraging technology the center works to create scalable solutions that address the pressing health challenges of our time.

Entwistle spoke with me about the current projects at PAMF’s Innovation Center and how technology is empowering individuals to develop health-promoting habits.

What projects are you currently working on at the PAMF Innovation Center?

We are focused on two big initiatives. The first is a system called EMPOWER, a goal tracking, behavior modification, teachable-moment education system for people with chronic disease.  The second, linkAges (look for part 2 of this post), is a system to help seniors remain in the community as they age and be closely supported by caregivers.

It has become increasingly important to get upstream on health issues and look for ways to get people engaged in preventive action, to focus on health and wellbeing and not just wait for an acute health event to occur and then for us to intervene.  One of our key programs, Personal Healthcare Programs, is designed to change this traditional dynamic of treating the sick, versus managing health conditions. Employers that carry insurance for employees were a good target because they have a strong motivation to support their staff to be fit and well. The EMPOWER provides a seamless transition to more active management for individuals diagnosed with active disease.

Applying EMPOWER to support prevention programs and assist people to self-manage has been one of our early successes, as has been the realization that many features developed for prevention programs are equally valuable for disease management. Managing disease includes taking medications as prescribed, as well as lifestyle and helping people keep on track with their goals.

Using EMPOWER, we track information day-to-day related to an individual’s personal goals in prevention and disease management. We’re able to do this using tracker devices linked to smartphones that send data to EMPOWER.  In addition to trackers, we use devices that consumers already have like blood pressure and glucose monitors and tie them into EMPOWER.  A nurse has access to this data, sees what is happening with patients, then helps keep them on track with their care plan, using both direct interaction and EMPOWER tools to provide automated “teachable moment nuggets” giving nudges and reminders.

Our first EMPOWER pilot was completed in 2010 supporting 200 patients with diabetes. More recently we ran a pilot with 150 patients with uncontrolled hypertension from one of our PAMF clinics. Patients were recruited and equipped with a blood pressure monitor, pedometer, weight scale, iPhone, and Bluetooth device for transmitting blood pressure readings. Patients used an EMPOWER iPhone app to upload their blood pressure and their weight. Their data was tracked by a designated nurse care manager who formulated a personalized Action Plan, with goals such as increasing the number of steps taken per day, changing their diet, or reducing cigarettes smoked per week.

Because patients are receiving real-time feedback as well as continuing education and support without having to make frequent doctor visits, they are better equipped to self-manage. A patient may observe trend data and see that their efforts are indeed lowering their blood pressure. This may give them confidence that their actions can positively impact their blood pressure and consequently motivate them to take other steps.

How do you measure the success of your prevention programs?

We’re on a quest to understand how you get sustained, positive engagement from patients over time. We are working hard to reach and involve the people who are reluctant to engage. We’re not just interested in a whizzy piece of technology that’s exciting for a few weeks but then patients get bored and stop using it. We want to get people involved in challenges, like working as a group at work and helping each person in the group make progress toward goals that are both meaningful and helps them improve their health and well-being. At the end of the day it’s all about sustained changes in behavior. Of course we have to see if they are still doing it in 12 months. That will be the real test!

What healthcare innovations do you see on the horizon in 5-10 years?

We’re seeing a significant shift in the way we consume health care; it’s becoming more like retails, food and entertainment where service, choice, convenience and price are all important. In the current model you visit the doctor when you are sick and take action to fix your medical problems.  We do this really well. But people don’t want to consume health care in that way. They want to interact with a doctor at their convenience, from their desk, or during a few free moments. They are looking for support in their quest to be healthy and well. So our system needs to go outside the bricks and mortar of health care.  A lot more of healthcare has to be conducted within the community versus within facilities, and to engage with patients as consumers who have choices for care outside the traditional medical system.

We want people to be supported in their day to day lives in the community, covering all aspects of health and welfare, from ensuring people are not lonely or isolated to ensuring they continue to exercise and eat better. A key question we thread though all our health care innovations is: how can we provide the right level of support to people to help them achieve their personal goals for holistic health and welfare in the context of their day to day lives?

Luke Doiron is chief commercial officer at Conversant Bio, a leading human tissue specimens supplier to pharmaceutical, biotech and research facilities. Housed at the HudsonAlpha Institute for Biotechnology in Huntsville, Alabama, Conversant Bio puts viable tissue or cell samples into the hands of the world’s top researchers seeking treatments for cancer and other life threatening diseases.

As its name suggests, Conversant Bio supports a conversation between patients, medical professionals and the research community to accelerate breakthrough research. In his previous career as a pharma investment banker Doiron saw that it could take weeks or months to obtain high quality biospecimens.  Along with CEO Marshall Schreeder, Doiron discovered that lack of access to human tissue was routinely delaying and disrupting critical biotech research.

Doiron sat down with me to discuss recent advances in cancer research, and how Conversant Bio’s services are helping to catalyze advancements in treatments and cures for life threatening disease.

What is the key solution that Conversant Bio offers to its clients?

Conversant Bio provides researchers with blood and tissue samples from cancer and autoimmune diseases to help them discover new medicines and diagnostic tests. Our business is logistics: get precious, hard to find material into the hands of researchers so they can work on and accelerate the drug discovery process.

If you’re a cancer researcher you need blood samples before or after treatment to look for biomarkers that might explain why a patient gets cancer or responds to a particular drug. Researchers also use samples to analyze how a patient’s disease might be affected by a new drug before they test it on actual cancer patients in the clinical setting.

How is Conversant Bio different from similar research sample and specimen providers?

We are the only company in the world that can deliver same-day and next-day oncology blood, bone marrow and solid tumor tissue samples anywhere in the U.S. There are a few competitors that source from other countries where regulations are much less stringent and costs are low. However only in the U.S. do we have access to the latest and greatest medicines and research techniques. If you’re a researcher investigating new and novel treatments  you want to use blood from patients using today’s standard of care treatments.

Oncologists typically draw blood at every visit so we’re able to collect blood samples on the spot without disrupting the normal flow of medical care.  Nurses stationed at the cancer centers ask donating patients to fill out an Informed Consent Form and then capture the unused blood samples. We currently work with over 50 medical oncology centers in the U.S. and have over 500 doctors in our network – oncologists, surgeons and rheumatologists.

How did you choose the company name?  Why “Conversant”?

On average, it takes 12 years and $1.2 billion to create a drug, and about 90% of drugs fail to get through the FDA process. We see bridging this gap as an important role. We want to facilitate a conversation between researchers, patients and doctors.  Doctors don’t see things from the researcher’s perspective.  Researchers don’t understand doctors.  Patients don’t get researchers or doctors. We facilitate the conversation between these three distinct groups.

Why are the blood samples you provide so valuable to cancer researchers?

The way drugs used to get developed was using cell lines. Researchers find a genetic target – a potential route to kill cancer through a cell line.  They take the cell line and grow a new cell line in a petri dish. Then they expose their compound to the cell line and if it kills the cancer cell then that’s promising. But what we know is that cancer mutates.  Most cell lines have been transformed and have been manipulated in a petri dish to grow forever.  However these are not native cells so they’re not a representation of what happens in nature.

Many years of cancer research have been built upon cell lines but researchers need to know the current state of the cancer which has been transformed over time.  What researchers have come to realize is that they need cancer cells from lots of people who currently have the disease. Primary samples have become the second step and a major reason why researchers need the products we provide.

For more information visit www.conversantbio.com

Marsha Summers started Quantum Medical Solutions to help doctors in private practice separate billing from patient care. After 25 years of business she continues to work primarily with small practices, handling billing, CMS credentialing, HIPAA compliance, human resource and a host of other services.

“I see myself as a physician advocate,” says Summers. “I try to find ways to help them survive in private practice.” Rather than stand back and watch the changing business of healthcare bankrupt physicians, she helps them discover their options, build a referral base, and shorten the reimbursement cycle by avoiding critical coding errors, etc.

I spoke with Summers about the importance of preserving private practices and quality doctor patient relationships, and how physicians can learn to thrive in a “hybrid practice.”

What are the biggest challenges facing private practice physicians today?

Fewer doctors are going into private practice these days; it’s a dying breed. Doctors are dispirited. 84 percent say they wouldn’t recommend medicine to their kids. More and more doctors will become employees of large medical centers and foundations.

Doctors making big money is a myth; their expenses are very high: malpractice premiums, EMR implementations and medical education costs, with $150,000 loans coming out of medical school and residency. The physicians I know have all cut costs as much as they can. I’ve lost 25% of my clients because they felt they could no longer survive in private practice.

Many geographical areas where physicians practice don’t have the wealthier clients with private insurance and money for concierge services. These physicians have lots of Medicare patients and a shifting referral base. Plus doctors are spending 20% more time on bureaucratic paper work. They are seeing fewer patients and taking on more administrative duties.

How has the insurance industry evolved since you started Quantum Medical Solutions?

Every year premium costs are higher, benefits go down, and reimbursements to doctors go down. Reimbursements have dropped about 15 percent in the past 4 to 5 years alone.

I recently met with a thoracic surgeon. When he cracks open a patient’s chest, and puts the circulatory processes on a pump to perform an artery bypass, then brings that patient back to life again and assumes a period of 90 days without any further billing, guess what Medicare pays? About $1,000. Two months ago I had an oil leak in my car. I was quoted $1600 to repair that. How can that possibly make sense?

And with the newer insurance exchanges under Obamacare, the private insurers will take at least a 30% cut in reimbursements and more.  It is death by insurance companies for private physicians.

Today, insurance companies contract with independent practice associations (IPAs), which function as middlemen between doctors and insurance companies. The IPA sells health plans to employers and advertises their network of specialists. This is managed care. The IPA gets their money from insurance carriers and they decide what to pay to reimburse physicians.

What can physicians do to survive in private practice?

First, understand that we live in a world of duality and in every problem there’s an opportunity. There must be a complete rethinking about private practice. The old model won’t last. They need to think about hiring physician assistants and nurse practitioners, seeing fewer patients, or dealing with fewer insurance companies.

Some doctors are reimbursed as little as $30 for an office visit. They’ll have to have a hybrid practice and take more cash paying patients, or increase patient volume. A hybrid model would be where they take PPO patients but drop certain insurance plans.

They might be paid on a cash basis, or they would bill only certain insurance companies that make decent reimbursements.
The majority of physicians don’t put money at the top of their satisfaction list. They list patient interaction, patient relationships and helping give patients a better quality of life as the most satisfying element of being a physician. To retain that satisfaction, the hybrid practice will have to become further defined and refined. Those who stay in private practice will have to be more entrepreneurial than ever before.

Are private practice specialists an endangered species? Given the mounting challenges of insurance reimbursements, government regulations, patient perceptions and administrative costs, Dr. Robert S. Forster, M.D. may be part of a diminishing breed.

Dr. Forster is an orthopedic surgeon with 25 years treating patients in private practice.  The realities of primary care and specialization have changed dramatically since he started out, when the autonomy of the job and personal relationships with patients outweighed the difficulties of running a business, complying with government regulations and fighting for  health insurance reimbursements.

Today, the disparities in medical coverage, excessive power of insurance providers, and pressures of running a small business and administrative overload are driving even more private practitioners to join HMOs and medical groups, on salary, or leave medicine altogether.

Despite the challenges of private practice, Dr. Forster chooses to persevere in the work he loves. I asked him about the day-to-day struggles and rewards of seeing patients, helping them improve their quality of life and sustaining a business. He offered a candid diagnosis of our nation’s present healthcare system and coverage. His prescription? More empowered patients and physicians.

What do you love about practicing medicine?

Most doctors I know enjoy taking care of people. The big thing about medicine is it incorporates science, investigation, being inquisitive and applying scientific principles, all in the pursuit of helping to make people better — make their lives better.  When I see people who were incapacitated or crippled by some form of a disease and later they walk into the office with a big smile on their face and say, “I’m so happy”– that’s the kind of thing that really makes practicing medicine worth it.

Orthopedics has changed in the last 5 years. There’s always movement forward in terms of new technologies, new procedures, new innovations. The ability for an orthopedist to take care of an individual now is much better than it once was.  We can perform  minimally invasive surgery such as arthroscopy and limited incision joint replacements as well as enlist new structural bio materials that promote healing. The problems that previously required  extensive surgical procedures and long periods of time for convalescence are much faster and easier now.  Pain management has improved through incredible advances in pharmaceuticals and our understanding of pain.  People are much more rapidly returning to work and hobbies.

What is a typical day in your practice?

On an average day I’ll see between 15 and 35 patients. With ER coverage that may increase because we’ll have to book in 4 to 5 patients. Potentially, there may be emergency surgery that day or that evening on someone who has come into the ER.

Typically in medicine, and particularly in orthopedic surgery your schedule for the next day involves seeing some returning patients and some new patients, and I can get a feel for how much time will be involved. But there’s always the unknown. There are the patients who are referred by primary care physicians.  We treat them on an urgent or emergency basis; we do follow-ups or evaluations and hospital visits. And there are patients with complications. A typical day could involve 1 or 2 catastrophic problems that are going to take several additional hours to sort through.

How do you cope with the demands of insurance providers?

Most physicians want to take care of their patients. They don’t want to make millions or become part of a corporation. The trouble is that to make a living one has to deal with  insurance companies that  have a singular goal to make money; that is, to take in more than they pay out.  The companies do not have a human interest in customers, despite their advertisements, but rather the pursuit of the bottom line. Physicians are the low hanging fruit and the easiest to eliminate. In medicine there is no collective bargaining and an individual practitioner can be pressured to accept continually decreasing rates of reimbursement or stop seeing patients with less than acceptable insurance.

The problem is that insurance companies uniformly set rates that are the same across the industry and there will not be a preferable insurer. To delay a payment they will indicate that the claim we submitted for a service wasn’t labeled correctly, that it didn’t have the right code. They’ll find varieties of reasons for not paying and when it comes to authorization they may delay or try to postpone or put off requests for patient procedures. There’s a big element of distrust between physicians and insurance companies.

Over the last 20 years insurers have gained power. Patients are fearful of losing insurance coverage and will stick with whatever their insurer offers.  Insurers can no longer refuse to insure patients because of a pre-existing condition but they can still charge what they want. The insurer has to cover patient costs and reimburse doctors, but they don’t have to do it quickly. The most profitable way for insurance companies to make more money is to slow down reimbursement payments. In this country the plan of the insurer is to delay authorization and pay out as slowly as possible in order to hold on to revenues for as long as possible, or deny claims altogether.

The biggest problem that exists today is that people don’t know what they don’t know.  The perception is that the vast amounts of money spent in healthcare should insure that providers will always be available.  The reality is that physicians and other healthcare providers incomes have really dropped, and with continually increasing costs for in-office administration and staff salaries, the profitability is at the margin of business failure.  Doctors are starting to quit their practices because of insurers’ reimbursement practices.

How do the disparities in medical coverage affect your practice?

Typically in our practice we rarely see uninsured patients unless they come through the ER. We actually receive a stipend to cover the ER at the hospital. But that became an issue because there are so many uninsured and minimally insured patients, and as doctors we have the responsibility to take care of those individuals no matter what. Hospitals can at least bargain with government agencies and make up for some cost deficits by charging more for services to paying patients.

The reimbursement through Medicare is so low that we cannot afford to see those patients without actually losing money due to the administrative costs.  Provider networks and HMOs are the mainstay for revenue with a very few select insurers that continue to pay high reimbursement but allow cash payments from patients.  Medicare is the common denominator and insurers use Medicare reimbursement rates as a base payment.  They will pay at Medicare rates or slightly above and some below.  And we are given or not given bonuses based on how little the orthopedists cost the system.

The big element that is missing in healthcare, as has happened in the banking industry, is regulation.  Physicians no longer have input and to believe that a corporation will do the right thing is self-deception.  The Affordable Care Act is exactly the smoke screen that insurers needed to allow them to hike rates to customers and drop payments to providers.  Even as the legislation claimed to monitor “administrative costs” and payment toward patient care, the industry was very good about hiding the true profits.

What changes and challenges will ICD-10 bring?

This transition to ICD-10 theoretically should not be a big thing. For people who write software it means they put in a lot of work to actually change things over smoothly. Twenty years ago, when I first started my practice, the Orthopedic Surgery Academy had created a whole series of codes that were very specific  to orthopedics. Our codes were replaced by Medicare’s version, which didn’t fully encompass the problems that we see. For example, say you had pain resulting from an injury in your hip muscles, considered lower extremity tendonitis; the previous ICDs didn’t allow you to be that specific.

ICD-10 has quadrupled the number of code numbers, from 15,000 to 72,000 codes, but it’s because things are much more specific (i.e., your left side, right side, something chronic, acute, specific muscle, tendon, joint, etc.).  So in many ways it’s better and more comprehensive. Because medicine is becoming very compartmentalized, it’s not a bad thing to have a clear understanding of the incidence and treatment for various diseases.  It will be work, but like the millennium transition a necessary step.

EHR or electronic health records are another example of good medicine at a cost.  The government’s concept of efficiency and cost savings was entirely off the mark.  Medical practices are spending hundreds of thousands of dollars to achieve the specified requirements and at virtually no cost savings.  The beauty of the EHR is the portability of health care records and the ability to drastically limit errors in treatment that have occurred because patient health care records were not available.  Again the healthcare system is spending billions on computer code and there is no real tried and true methodology.  Private vendors are working by trial and error and at great cost. This is exactly the issue with the rollout of the ACA.

What changes would you like to see in our nation’s healthcare system?

Physicians don’t really have the ability to talk to an individual. They must see a lot of patients to remain solvent and it is much more expedient to just prescribe a medication. When it comes to talking to the patient about lifestyle changes such as exercise, and modified diet, primary care physicians and specialists don’t have the time. It’s a shame because there are so many ways we now know where the patient would do better without surgery or hospitalization, but the patients want to come in and get something quick and fast; and they do not want a lecture; they just want to get it done. They see it like dropping their car off at the shop.

I believe that our healthcare could be much better if there was a real universal healthcare program in this country with the option for individuals to buy additional coverage. There must be regulation as to how resources are used, just as in triage on the battlefield it is not possible to provide everything for everyone, but it is much more effective to supply insulin to an impoverished individual and prevent them from coming to the hospital in the last several years of their life, with costs of hundreds of thousands of dollars a day.

A tiered system would allow private insurance companies to exist, but provide real coverage above the universal care minimum. It would eliminate the smoke and mirrors of the corporate greed by creating true competition. People who are responsible and understand the value of healthcare could set aside money and buy the plan that they can afford and desire, but knowing that the basics of health care are already provided.  Being out of work should not mean being uncovered for basic healthcare.  Compensation for physicians will have to be made reasonable to continue to attract good candidates.

The road to becoming a physician is extremely difficult as it involves at least 6 years of intense post graduate training with high debt and high stress.  Just as we would like to believe that the pilot flying our plane is dedicated and concerned for our welfare, we understand that they must be compensated appropriately to attract the individual that will.  Healthcare is equally a concern with respect to the counseling and skill that will be needed to care for all of us throughout our lives. The vast amount of money that is spent on administration of healthcare needs to be funneled back to providing care. This will require real regulation or allowing the market place to be truly free and allow physicians and other providers to collectively negotiate with insurers.

The thrust of healthcare needs to be redirected toward preventative care, but with the realization that disease and injury will still need to be addressed by treatment.

An alternative to Universal Care or private practice is corporate medicine to compete with corporate insurance.  Physicians in the corporate world are a commodity and placed in much the same position as engineers working for industry.  The difference is that physicians have traditionally been an ongoing resource and stable touch point for patients, whereas in the corporate world, as long as the patient sees some provider the job is done.

You do not choose your surgeon or specialist, you have one provided.  Your PCP will see you in the office if time allows, but you may see another and the job is done.  Individuality and responsibility for care of your patients is replaced by the job.  But —– you have “the company” to do the negotiating and making the decisions to get the money, and you take home a pay check each month.  I believe that corporate medicine can work but it requires the innovative business leadership that companies such as Google and Apple have demonstrated in dealing with employees.

It is sad that the physician is being replaced by the healthcare provider. Robots will do the surgery and computers can provide all of the necessary diagnostics and we can text each other about our ills rather than talk to one another.  And the corporations will keep on doing what they do best.