Bryan Sivak discusses the inextricable link between healthcare’s two most influential trends

Oxeon Associate Liam Gallagher recently sat down with Bryan Sivak, former Chief Technology Officer of the U.S. Department of Health and Human Services, to discuss some of the biggest risks facing emerging models within healthcare. Topics covered include the challenges of employer-sponsorship, consumerization, and end-of-life care. Liam Gallagher joined the Oxeon team by way of Williams College where he majored in Chemistry and English. Eventually, he hopes to apply his experience on the business side of healthcare as a physician.

[dropcap]LG:[/dropcap] Bryan, you and I spoke earlier this year about the two big transformations in healthcare: consumerization and accountable care. I’d been stuck on this concern that value-based tools, like telemedicine, were really being adopted to drive patient acquisition and retention, a primarily volume-driven, fee-for-service strategy. As a skeptic at heart, I was really enjoying the question, and then you ruined my fun with a great explanation of how these two transformations are inextricably connected.

[dropcap]BS:[/dropcap] Well, when providers are taking on risk for a population of patients, they’re accountable for future healthcare costs. The proactive strategy for these groups is to invest in the health of the population with preventative medicine and better-coordinated care to make for a healthier group in the future. For that to be a feasible investment model, you’ve got to hold on to your population of patients for their years of relatively healthy living. That’s why patient retention, which might seem like a FFS strategy, is actually key to the success of accountable care models. So, telemedicine and patient-centric models might be doubly valuable to accountable care. From the clinical side, they drive improved outcomes in a cost efficient way. On the experience side, they’re very convenient and might improve patient retention.

That connection is part of the challenge with employer health plans. When an employer thinks about investing in the health of a particular employee with rich benefits, the decision is going to depend on the long-term employment of that employee. Especially today, that employee is likely going to jump ship at some point, and the employer will lose any resources it’s invested in his or her health. That’s one of the biggest challenges in the employer-sponsored framework we have in this country, and maybe why that framework doesn’t make the most sense.

[dropcap]LG:[/dropcap] If customer segmentation in healthcare happens along the lines of the retail world – say like Nordstrom's, Macy’s, and JCPenney, – do you see a risk of creating consumer-selected "classes of care”? Of course, there’s already inequality in access to good healthcare today, but do you see consumerization of health improving or worsening that?

[dropcap]BS:[/dropcap] With healthcare in particular, you’re likely going to find that people who are better off socioeconomically are going to invest more of their time and available resources in their health than those with less resources. It’s unfortunate because that’s probably the opposite of what the need is. One of the possible exciting outcomes of accountable care is that investments are made in helping people in lower socioeconomic strata become healthier simply because there’s a greater potential to save. But, in order to realize those savings, the model of medicine will need to change fundamentally.

A lot of provider networks voice a desire to change today, but are making so much money on the current system that it’s very difficult for them to envision taking on risk and not losing their shirts. And, to date, there have not been a large number of providers that have picked up risk and made money. There’s a lot of progress to be made on that front. That said, there’s no argument that the way the system is set up today is not sustainable.

[dropcap]LG:[/dropcap] We had an OxTalk, what we call our Ted-style learning lunches, with Heidi Allen, one of the investigators on the Oregon Medicaid experiment. The answer, I think, a lot of people were hoping to get from the study was that access to healthcare was enough by itself to improve health and reduce costs. The results showed that the patients did get healthier, but it certainly cost more. Does that point the finger at what we’re actually paying for when we spend on healthcare?

[dropcap]BS:[/dropcap] Sure, the people in the Oregon experiment were suddenly given access to healthcare, but they weren’t given adequate training on how to actually use that access. If you had never been to a doctor before, would you know to seek out a relationship with a PCP or where to even start? I would like to know what the result would have been if they had sub-selected a group of those given coverage and also educated them on how to navigate the system appropriately. Would that reduce costs over time because people are given access and trained to use it in the best way?

[dropcap]LG:[/dropcap] The other way you might approach the challenge could be to incent proper utilization. There may not be much cost-tolerance with Medicaid beneficiaries, but couldn’t you make going to a PCP a much more convenient and enjoyable experience than the ER?

[dropcap]BS:[/dropcap] Well, seeing a PCP is already more enjoyable than the ER. It’s still necessary to communicate that the PCP is even an option. How do you tell someone who has only used the ER that now you can go to a Minute Clinic and you don’t have wait? There are other factors than cost and access that have to be taken into account and I think that education is a huge one.

[dropcap]LG:[/dropcap] When people are healthy, it seems like there’s a neat alignment of costs, outcomes, and experience driven by accountability for downstream costs. What happens when people do get sick, terminally so, and that feedback loop no longer exists? I guess the question is whether transformation of our care model or a cultural transformation around end-of-life?

[dropcap]BS:[/dropcap] Have you read Atul Gawande’s Being Mortal?

[dropcap]LG:[/dropcap] I have – it’s basically required reading at Oxeon.

[dropcap]BS:[/dropcap] I’m a huge fan in general of Gawande, but that book, in particular, was one of the most important things I’ve read in the last decade. To me, it very clearly illustrates the way both physicians and the rest of society need to change the way we think about end-of-life. The thing that really stuck with me was his point that physicians are trained to treat disease as an enemy to be eradicated at all costs. It makes perfect sense, but at the end of the day, death can only be deferred so long. The question Gawande learned to ask, partially through his father’s illness but also as a public health guy, is how can we maximize the enjoyment of the time that is left? Is being stuck in the ICU for the next six months attached to five machines an existence that makes sense? Maybe for some people it is, but in general, people are never really given that choice in a way that is accessible. To answer your question about whether it’s a cultural transformation or clinical transformation that’s necessary: I think it’s both.

The interesting side effect of providing patients with the information to enable them to actually make a decision between the ICU and their homes is that it will inevitably reduce costs. Some huge percentage of total healthcare costs is in the last six months of a person’s life because the medical default at this point is to treat aggressively until the end. With the cultural changes underway, I think that if you enable patients to decide, you’re going to see at least some choose the option that ultimately costs the government less.

I was talking to my friend the other day, whose father has cancer. The decision they were facing was between an operation that would give him maybe a few more months to spend with his family in an idyllic setting, or not do it and have shorter period of time without the family trip. He chose to do it, and you can’t fault that choice because ultimately he made his decision based on what would make a better day or few months.

[dropcap]LG:[/dropcap] There’s definitely a lot of tricky calculus in these decisions as well. It’s hard to evaluate a treatment that might give you 50% odds at living a year longer, 20% at two years, and 1% at five years. How do you weigh those complicated odds, against the other 50% odds you don’t live longer and endure more pain?

[dropcap]BS:[/dropcap] Maybe, that’s the wrong way to ask the question. It doesn’t have be a trade off between a procedure and time. The point that Gawande makes is that it’s all about the quality: which option is going to allow me to find the most enjoyment. Part of the challenge is that we all know of someone who’s taken the long-odds operation and it’s saved their life. It’s easy to hear those stories and hold out hope, but the odds are the odds.

[dropcap]LG:[/dropcap] One piece of evidence for your point that we’re overly focused on how long and not how well is that treatments are evaluated primarily on their ability to fend off death. It’s exciting to imagine a world where the success of a clinical trial is measured in the quality of life delivered, but pulling that off seems tricky.

[dropcap]BS:[/dropcap] Tricky because it’s subjective. Your enjoyable day might look very different than mine. Maybe, my great day is one I spend surfing and, if I can’t surf, I’m not interested. Yours could be spending it in your home with family, maybe not even talking.

It’s where healthcare and medicine get really tricky. On one level, it’s a science, but at the same time, there’s an art to it. My dad’s a doctor, and I’ve talked to him about this in the past. One of the things he’s pointed out is that you can have algorithms and pattern matching for lots of things in medicine, but at the end of the day, a lot of skill as a physician comes down to this art of medicine: the way you talk to someone and the way you listen to someone. That’s something that’s often lost in a lot of our conversations because it’s easier to think of medicine as a science and set of rules about how to diagnose and treat. At the end of the day, though, it misses the art and human interaction that’s at the heart of healthcare.