The New Complex Patient: The Shifting Locus of Care and Cost. Does Technology Keep Patients Out of Hospitals?

Transcription

1 The New Complex Patient: The Shifting Locus of Care and Cost Does Technology Keep Patients Out of Hospitals? Lee H. Schwamm, MD Executive Vice Chairman, Department of Neurology, Director of Stroke Services & Mass General TeleHealth Massachusetts General Hospital Professor of Neurology, Harvard Medical School, Co-Director, Institute for Heart, Vascular and Stroke Care

2 Disclosures PI of NIH/Gnenetech funded MR WITNESS trial of extended window thrombolysis in wake-up strokes Int l Steering Committee, DIAS4 trial of IV desmoteplase 3-9 hr after stroke onset DSMB, Penumbra 3D trial Stroke System consultant to the MA DPH/CDC Chair, AHA Get with the Guidelines Stroke CWG PI of HRSA funded TeleStroke Survey

3 Overview To control costs we will need to focus on value Avoid costly hospitalizations or prolonged dependency Pool risk across the continuum, so that we remove perverse incentives that prevent increased upfront investment to reduce long-term costs Increase access to care and encourage use of low cost preemptive interventions through remote monitoring, telehealth visits and adherence to recommended therapy Provide access-on-demand for physician-to-specialist consultation in urgent situations to promote golden hour treatments that are effective 3

4 Stroke is a High Incidence, High Cost Condition ~800,000 new strokes each year in the US The direct cost of stroke in 2010 was $20.6B, with total costs of $36.5B, with a mean lifetime cost of ischemic stroke in the US estimated at $140,048 Between 2012 and 2030, total direct medical stroke related costs are projected to triple, from $71.6 B to $184.1 B, with the majority among 65 to 79 yr-olds Severe strokes (NIHSS>20) cost 2x mild strokes Data from Sweden show that healthcare costs associated with stroke survivors with spasticity are 4-fold higher than for stroke survivors without spasticity 4

5 Why Act Now? Stroke is a common and expensive disease, with both early mortality as well as lifelong costly disability Avoiding disability can reduce long term costs and societal burden due to stroke Risk of stroke doubles every decade after 45, with an impending avalanche of stroke and dementia, because up to 50% of dementia is caused by cerebrovascular disease Proactive discussions about care after an unexpected catastrophic event (e.g., stroke) must occur during routine primary care and become more publicly accepted 5

6 Cycle of Stroke Care: Where are the costs? EMS transfer Stroke center Home Self-present Hospital ED- based Patient history, vitals, CT scan Triage decision: ED physician/ neurologist Inpatient Rehab Facility PCP followup Transitional Residential Living Skilled Nursing Facility

7 Cycle of Stroke Care: Where are the opportunities? 6. Remote monitoring 1. Smarter triage Home EMS transfer Stroke center Comprehensive or high volume Stroke centers 2. Cost-effective early Rx: IV tpa and Stroke Units Self-present 5. Medical Home Hospital 3. Early supported DC to Home Inpatient Rehab Facility PCP followup Transitional Residential Living Skilled Nursing Facility 4. Flexible postacute levels of care

8 Acute Stroke Triage: Hospital Setting Prehospital triage EMS transfer Stroke center Site of stroke Self-present Hospital Patient history, vitals, CT scan Triage decision: ED physician/ neurologist Negative CT Positive CT ICH EMS, Emergency Medical Services; HS, hemorrhagic stroke, IS, ischemic stroke; tpa, tissue plasminogen activator

9 Can Technology Help Solve the Problem? Technology can bridge the gaps in time and distance that separate patients and providers Technology can transform data into information and support more effective decision making Technology can offer lower-cost alternatives to in-person visits Technology can t magically reallocate healthcare providers from one discipline to another, or one activity to another, so thoughtful planning will be required to realign resources and compensation to demand as trends shift over time 9

10 10 What is Disruptive Innovation?

11 How Does TeleHealth Change Care? Schwamm LH. Health Aff airs Feb;33(2):200-6

12 Achieving Telehealth s full potential Telehealth is a disruptive technology Telehealth must be integrated into traditional ambulatory and hospital-based practice Telehealth should address the IOM domains of quality and therefore be safe, effective, patient-centered, timely, efficient, and equitable

13 Seven Critical Strategies Understanding patients and providers expectations Untethering telehealth from traditional revenue expectations Deconstructing the traditional health care encounter Being open to discovery Being mindful of the importance of space Redesigning care to improve value in healthcare Being bold and visionary

14 Systems of Care (A,B) vs. Alternative Models (C,D) 14 Silva et al. Stroke Aug;43(8): Figure depicts various organizational models

15 15 Müller-Barna. Curr Opin Neurol Feb;25(1):5-10

16 Active European and US TeleStroke Sites Müller-Barna P, Schwamm LH, Haberl RL. Telestroke increases use of acute stroke therapy. Curr Opin Neurol Feb;25(1):5-10. Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. The status of telestroke in the United States: a survey of currently active stroke telemedicine programs. Stroke Aug;43(8):

17 Telemedicine has high NIHSS inter-rater reliability to bedside, on-site evaluation S. Shafqat, et al. Stroke, 1999 greater accuracy than telephone consultation alone in determining rt-pa eligibility B.C. Meyer, et al. Lancet Neurol, 2008 higher rates of rt-pa use, equivalent patient outcomes, and low intracranial hemorrhage rates P. Müller-Barna, et al, Curr Opin Neurol, 2012 cost-effectiveness R.E. Nelson, et al. Neurology, 2011 Telestroke stakeholder representatives at hub and spoke hospitals L.H. Schwamm, R.G. Holloway, P. Amarenco et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/American Stroke Association, Stroke, 40 (2009), pp

18 TeleStroke is Cost Effective 1 Payer Short term increase in costs w/ break even at 90 days Healthcare System Greater value per Healthcare $ spent 1 Neurology Oct 25;77(17): Epub 2011 Sep 14. The costeffectiveness of telestroke in the treatment of acute ischemic stroke. Nelson RE, et al.

19 Cost, Savings and CBO Scoring 66% of the 795,000 new strokes per year are in Medicare beneficiaries. 94% of them live in non-coverage areas. 87% of strokes are ischemic. Therefore 795,000 x 0.66% x 0.94% = 493, ,218 x 0.87% = 429,100 Alternatively, the rate of ischemic stroke hospitalizations among the 40M beneficiaries was 1134/100,000 for age ,000,000/100,000 x 1134 = 453,600 19

20 Estimating Savings from TeleStroke TBD 20

21 It s not about the technology, it s about trust

22 Rethinking Stroke Prevention and Wellness: Cost-Effective and Safe

23 Virtual Visits and evisits Technology MGH Pilots Primary Care Provider reviews patient s pre-visit questionnaire to determine treatment options and assess the need for visit or phone appointment. Videoconferencing Psychiatrist conducts a follow-up Virtual Visit with an adolescent patient with autism for medication management. Telephone Psychiatrist provides consults to oncologists regarding the management of psychiatric conditions for cancer patients. Text Messaging Primary Care physician is alerted of alarm symptom in a patient who is completing an asynchronous evisit via web portal. Electronic Curbside Specialist reviews referral requests and triages to curbside consult answers PCP questions by . 23

24 When was the last time you saw a teller? 24

25 Its not just kids Skyping these days 25

26 Mass General TeleHealth Goals Foster Communication Build Relationships Improve Access and Convenience Enhance Patient Care Improve Healthcare Value Value = Quality Cost 26

27 27 Expanding from TeleStroke (hospital-tohospital) to TeleNeurology (office-to-home)

28 To Infinity and Beyond Cardiology Cardiology Patient At Home Psychiatry Burn Patient at Rehab 28

29 Partnerships MGH TeleHealth Remote Monitoring, mhealth Apps Medical Simulation Clinical Care Education MGH Learning Laboratory MGH Academy

30 MGH TeleHealth Focus Areas Population Health Management Improve quality and decrease expense trend for our risk population Synchronous Specialist Virtual Visits Synchronous Patient Virtual Visits Episodic Care Management Provide specialty consultation to community hospitals, providers, and patients Second opinions to providers and patients Virtual Staffing for Community Hospitals Specialty Consultation to Community Hospitals Coordinated Care Foster collaborative communication and improve quality of care for patients Virtual alternatives to in-person attending staffing 30

31 31 The Telehealth Adoption Curve

32 32 Is Anticipated Loss of Comfort and Productivity a Major Barrier to TeleHealth Adoption?

33 Teleneurology applications: Report of the Telemedicine Work Group of the AAN OBJECTIVE: To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy. METHODS: Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine. RESULTS: Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit. CONCLUSIONS: Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology. Wechsler. Neurology Feb 12;80(7):

34 34 Benefits of and Barriers to Telemedicine Implementation for Neurologic Disease

35 TeleHealth Challenges Reimbursement Licensure and Malpractice Patient and Provider Adoption Technology Platform and Workflow Standardization Impact of EPIC on workflow design Internal competition from traditional face-to-face Finding the clinical balance between traditional vs. virtual visit balance driven by patient need and medical appropriateness Perceived competition from community hospital partners 35

36 Summary To improve value and manage populations, traditional healthcare delivery models need to be disrupted TeleHealth remains a tremendous opportunity for improving neurological care when patients are geographically dispersed, underserved, often of limited mobility and in dire need of treatment Aggregating patients in novel ways will increase the efficiency of the clinical research enterprise and lead to new treatments faster We need to train our residents and faculty in the practice of the future, not of the past 36

37 What does the Future Hold? ? 2025?