Curing Type 2 Diabetes with Surgery: It Works — Now Let’s Figure Out Why
During my endocrinology training, I was captivated by a phenomenon I’d seen on the wards, and had just started to read about in the literature: type 2 diabetic patients receiving bariatric surgery exhibiting rapid, seemingly instantaneous improvements in their glycemic control, apparently related to profoundly reduced insulin resistance as a consequence of the surgery.
The first teaching seminar I gave as a fellow, at Endocrinology Grand Rounds, asked the distinguished medical faculty who gathered in the Ether Dome, “Is Diabetes a Surgical Disease?”
At the time, the answer was, “Yes?” Now, two recent reports presented today at the ACC, and simultaneously published in the NEJM (here and here), seem to upgrade this answer to “Yes!”
Both reports conclude that bariatric surgery surpasses medical therapy as a treatment for type 2 diabetes, and are fascinating not only because of the immediate clinical implications (as discussed by Matt Herper here, and in anNEJM editorial comment here), but also because there’s some really cool underlying science that nobody seems to understand.
The fundamental paradox is the same mysterious clinical phenomenon that so intrigued me years ago: the drastic improvement in diabetic function that occurs significantly before most of the weight is lost.
The authors of the first study note, “Reductions in the use of diabetes medications occurred before achievement of maximal weight loss, which supports the concept that the mechanisms of improvement in diabetes involve physiologic effects in addition to weight loss, probably related to alterations in gut hormones.”
The authors of the second study were also struck by the rapid improvement in glycemic control they observed, reporting that all patients treated surgically were able to discontinue all their diabetes medicines within fifteen days of their operation – a remarkable result (and entirely consistent with my own clinical experience). Almost all of the surgically-treated patients remained free of diabetes after two years, while none of the medically-treated patients were as fortunate.
As the authors write, “there was no correlation between normalization of fasting glucose levels and weight loss after gastric bypass and biliopancreatic diversion, findings that are consistent with results of previous studies, which suggests that such surgeries may exert effects on diabetes that are independent of weight.”
The authors also point out this result is in contrast with gastric banding procedures (which constrict the stomach but don’t otherwise alter the anatomy); the improvement in diabetes seen in those patients does appear to correlate more directly with weight loss.
The intriguing scientific question is how can bariatric surgery result in an almost immediate improvement in the insulin resistance profile of diabetic patients? To my mind, this is among the most important unanswered questions in endocrinology, and medical science more generally. While the effect is generally attributed to “gut hormones” (as the authors of the first study write), the biology beyond that gets a bit murky.
To be sure, some companies are working on it – the example that springs first to mind is NGM Biopharmaceuticals, a small Bay-area biotech (with which I have no personal nor professional connection) founded in 2008 as an ambitious science play by The Column Group, Rho Ventures, and Prospect Venture Partners. I’m sure others are working on this challenge as well.
A final point – as attracted as we are to the view of basic science driving clinical medicine, the experience with gastric bypass surgery arguably exemplifies the reverse, and represents a triumph of empiricism, as well as a reminder of the value of human physiology (see here), and more generally, the importance of studying people (and not just parts of people).
It also would not be the first (nor will it be the last) time that medical sophisticates learned a valuable lessons from those laboring – often, as in the case of many bariatric surgeons, with inadequate respect – on the front lines of patient care.
TRACKED SINCE BIRTH: THE RISE OF EXTREME BABY MONITORING
DOES TRACKING A BABY’S EVERY MOVEMENT, CRY, AND WET DIAPER MEAN HAPPIER PARENTS AND HEALTHIER INFANTS, OR ARE WE TURNING OUR KIDS INTO TAMAGOTCHIS FOR NO REASON?
For the first 10 months of her life, her mother, Yasmin, kept detailed records of Elle’s sleep patterns, feedings, and diaper changes, noting the data points with a pencil and paper on a clipboard. A few months in, she digitized the logs, graphed the data, and became a more knowledgeable parent.
“It helped me feel confident,” she told Fast Company.
Elle wasn’t a very good sleeper, even for a baby. The pediatrician told Yasmin she needed to let her daughter “cry it out” until she fell asleep, but that never worked. For the sake of her sanity (and sleep), Yasmin took problem solving into her own hands. She wanted answers: Did she put Elle to bed too early? Too late? Give her too many naps? Parsing data, she thought, would help her figure it out. “That was the kind of stuff we were looking for,” she said.
Unfortunately for the Lucero family’s sleeping habits, Yasmin never found a definitive answer. Per the data, Elle was just fussy.
The results suggested Yasmin couldn’t engineer better naps, as she’d hoped. Just knowing that, however, made her feel better. “If you come to the conclusion that you have no control, then it’s okay to relax and just do whatever is convenient for you at the moment,” she explained. (Of course, many parents come to this conclusion at the moment of birth, without all that tedious data tracking.) But for Lucero, a conclusion–any conclusion at all–was all she wanted.
Many new and sleep-deprived parents crave that peace of mind and would kill for a data set that helped them determine if putting little Emma down an hour earlier would mean a restful night for the whole family. But unlike Yasmin, most people aren’t trained statisticians. Tired moms and dads with no mathematical background aren’t about to write down hundreds of data points, and might not know how to analyze that information anyway. Twenty-two months into Elle’s life, even Yasmin has semi-abandoned the project, and keeps much less rigorous records now.
In the imminent future, though, any curious parent with an iPhone will have access to helpful analytics, thanks to the rise of wearable gadgets for babies. Following the success of self-trackers for grown-ups, like Jawbone and Fitbit, companies likeSproutling, Owlet, and Mimo want to quantify your infants.
Mimo Onesie
These devices connect to a baby via boot, anklet, or onesie, and record his or her heart rate, breathing patterns, temperature, body position, as well as the ambient conditions of the room. They aim to replace baby monitors, which give an incomplete picture of a sleeping child. There’s also the nascent “smart diaper” market, led by Pixie Scientific, which scans dirty diapers for signs of infection.
In addition to alerting parents of any concerning findings, these companies encourage a big-data approach to parenting. By gathering information on your kid’s poop, sleep, and eating schedules, the idea goes, you can engineer a happier, healthier baby. The accompanying app for the Sproutling monitor, for example, looks at patterns specific to your child and its environment to offer insights–the kind that Yasmin craved–that might help the child sleep better. It might find that little Jake naps better in complete dark, for example.
The Sproutling monitor
In theory, all this data will lead to more rested, relaxed parents and healthier kids. As of now, parents do a lot of this in the dark. “There’s no owner’s manual,” Sproutling CEO Chris Bruce told Fast Company. His company hopes to change that. “It’s smart technology that helps raise the parenting IQ.”
When Bruce talks about “parenting IQ,” he doesn’t just mean his customers. Sproutling and its cohorts want to use their arsenals of data to better inform research. “The promise of big data is that we can monitor every single environmental parameter and we can find correlations and detect patterns,” added Bruce, calling big data the “holy grail” of his business. Both Owlet and Sproutling indicated that they will offer up their intel–anonymously!–to researchers so that all future parents can better understand babies.
Parents like Yasmin, who haven’t had a full night of sleep in months, are desperate to have that information. She didn’t want to know average sleep patterns–information available in baby books–she wanted bell curves. Yasmin knew her baby wasn’t normal, but she didn’t know how abnormal and her own analyses couldn’t clarify that, either. “I wasn’t finding the exact data I wanted to see,” Yasmin said, after scouring the Internet for answers.
An aggregation of Yasmins, however, can provide those insights. At least that’s the hope.
What sounds like a lot of progress for parenting also means handing a digital record of your baby over to an iPhone app. Are the benefits worth that?
While these apps could improve infant health by telling a parent the exact right nap or changing time, the app in large part benefits parents. Anxious first time moms and dads who worry about every little movement (or non-movement) can monitor their children more closely than ever. “You see your baby lying there and you don’t see them moving,” Bruce, who has two young daughters, said of his experience with old-school video monitors. “You can’t see them breathing; your first thought is: ‘Oh my God, something is wrong.'”
Unlike a basic $35 baby-monitor, the $250 Owlet bootie and accompanying app can alert parents if anything serious has gone wrong, like if a kid stops breathing, or if his heart stops beating. That means no more unnecessary freakouts for the over-protective and inexperienced dad like Bruce, which leaves more time for him to do other dad things.
But, to an extent, these apps take advantage of parent anxieties. “SIDS is the number one cause of infant death. That’s really scary to parents,” Jordan Monroe, a cofounder of Owlet, told Fast Company. Monroe has no kids, but while talking to friends and friends of friends with babies, he found that to be a common worry.
Those fears don’t come from a place of reality, though. According to the Center for Disease Control, 4,000 infants die each year from Sudden Unexpected Infant Death. Only a fraction of those deaths occur because of “accidental suffocation and strangulation in bed,” according to the CDC report. And even SIDS–which causes about 2,000 deaths a year–might stem from underlying brain issues, according to recent research. Monitoring a child’s breathing with a high-tech bootie won’t cure SIDS.
As anyone who has ever had any contact with a hypochondriac knows, those facts don’t really matter. Parents will continue to worry. And, as we saw with Yasmin, certainty has a lot of value. A certain type of parent, like TechCrunch’s Leean Rao, thinks that $250 for Owlet or $200 for Mimo’s version–Sproutling hasn’t yet announced pricing–is a reasonable price to pay to worry about one less thing. In her review of Sproutling, she writes:
As a relatively new parent myself, I would have loved to be able to use some of the data from a wearable to help determine optimal sleep patterns for my child. I’m not sure if it would have helped my daughter sleep through the night earlier in her development, but to me as a fledgling parent, knowledge is power.
Of course, the dollar amount is only a part of the price parents pay with these apps. They give up their children’s data and possibly privacy. “We’re creating the largest data set of infant health data,” Monroe said–a chilling statement in certain contexts. Trackers could turn around and sell their troves to insurers or be forced to hand them over to the government. The information is also vulnerable to hackers.
These companies say they take security issues seriously. “Security encryption has been designed in our system from the get-go,” said Bruce. Anonymous sharing with researchers is both opt-in and anonymous for Sproutling users. But, even Bruce admits that our cultural acceptance of privacy changes every day. What seems innocuous today might feel invasive tomorrow (or vice versa).
Is that risk worth the stated benefits? At this point, it’s not clear these monitors offer many health solutions. The breathing and sleeping alerts will calm (and draw) a lot of parents. But, none of these companies see that as the “holy grail.” The main sell is the tracking. And what does that do for parents and babies?
Arguably, it means finding those little tweaks that make life easier. But, as Yasmin discovered, sometimes babies fuss just because. Numbers don’t always offer solutions, as technical theorist and staunch critic of the self-quantified movement Evgeny Morozov wrote in his book To Save Everything, Click Here: The Folly of Technological Solutionism. “Self-trackers gain too much respect for the numbers and forget that other ways of telling the story–and generating action out of it–are possible.”
While pediatricians typically ask new parents to chart and report feedings and bowel movements for a few weeks after bringing babies home to make sure all systems are go, obsessive tracking beyond that could get in the way of parenting, some doctors say. “Often, when babies have regained their birthweight and are 10-14 days old, I instruct families to dial the tracking down,” Dr. Wendy Sue Swanson wrote on her blog. She adds:
I want new parents to gain confidence and appreciate the homeostasis with following a baby’s natural routine. Relying only on the numbers may cause parents to miss out on the nearly unspeakable experience of parenting a new baby and all that a baby intimately communicates from the beginning. It’s better to look up at the sky to know if it’s raining than to consult the weather report on your iPhone.
After all, do you really want to treat your child like a Tamagotchi?
despite the noise regarding safety, quality and health reform, and in particular payment reform from fee-for-service to value-based-payment, the truth is that practically all providers and provider organisations are simply focused on one thing: MAXIMIZING REVENUE
It’s fun to read about cool technology, big data, and innovation incentives, but the reality is that in the trenches, many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago.
Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience.
Health policy discussion these days focuses extensively on the idea that medicine is changing, moving (maybe slowly, maybe rapidly) from a fee-for-service to a fee-for-value world, where providers and hospitals own risk, and are incentivized to reduce costs and improve care, a win-win situation for all.
It’s possible such change is happening – somewhere, or in some parts of some organizations.Yet, most providers with whom I’ve been speaking tell a starkly different story. The view from the front lines suggests that hospitals and care delivery systems are obsessing like never before on doing whatever they possibly can to maximize their revenue. They are consumed, utterly consumed, by this objective.
It’s touching to read accounts from Ashish Jha and others describing benevolent CEOs concerned about patient care and safety; the hospital executives I’ve been hearing about tend to talk a good game about safety, and may even genuinely care about quality, but they are focused on, driven by, and hired for their skill at maximizing revenue – a prime directive that quickly percolates its way through the entire care system.
I know of examples at non-academic centers where doctors are refusing to see patients who don’t carry “good” insurance, citing miserable rates of reimbursement – rates they point out can be lower (sometime much lower) than what professional trainers often make.
At academic centers, publishing papers is certainly encouraged, but making your “RVUs” (i.e. seeing enough patients) is prioritized – and failing to do so can get you canned.
Hospital records are routinely reviewed in detail to ensure every opportunity for “revenue capture” has been identified.
The reason to highlight what seems to me the current state of medicine (and yes, this is anecdotal, but I suspect that if anything, this description understates the magnitude of the situation) isn’t so much to critique it as to surface it, and remind readers what healthcare actually looks like today — a reality that seems far more Hobbesian than what’s often imagined, presented, and discussed.
It’s fun to read about cool technology, big data, and innovation incentives, but the reality is that in the trenches, many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago. Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience.
It’s hard to envision this is sustainable – you can only increase the speed of the treadmill so much.
Rather, the question is what comes next for medicine – how will care be delivered, and who will be delivering it?
PATIENTS with type 2 diabetes spend an extra hour a year with their GP compared to other patients, according to new data which has prompted renewed calls for an improved approach to funding for management of the condition.
The findings, from the latest Bettering the Evaluation and Care of Health (BEACH) study, published this week, showed the average patient spent 1.6 hours a year with their GP, while those with diabetes spent an average of 2.6 hours.
The report, General practice activity in Australia 2012–13, noted those with diabetes also spent time with a range of allied health professionals as well as practice nurses.
With the management rate of the condition increasing by 33% over the past decade, the authors said type 2 diabetes was “very resource intensive” and was “bound to increase in future”.
BEACH director Associate Professor Helena Britt said type 2 diabetes now accounted for 8% of GPs’ workload and that patients with the condition visited their doctor an average of eight times a year compared to the national average of 5.6 annual visits.
Patients with diabetes had their condition managed at half of their GP consultations, according to the report.?
Brisbane GP Dr Gary Deed said the data confirmed the need to improve funding models for the management of diabetes in general practice.
Dr Deed, who is a director of Diabetes Australia’s Queensland arm and chairs the RACGP’s National Faculty of Special Interests Diabetes Network, said he hoped the Coalition government would undertake a consultation with GPs “at the coalface” as part of efforts to develop a long-term approach to diabetes management. ?
With the majority of patients also having at least two other comorbidities, he said a block funded model, such as the one being trialled under the Diabetes Care Project, created problems with regard to funding of the patient’s whole care.?
Meanwhile, the report found GPs made 7.6 million more referrals in 2012–13 than they did a decade ago with the increase split almost evenly between referrals to medical specialists and allied health services. A total of 126.7 million GP services were claimed through Medicare in 2012-13.?
The report also stated that despite spending on average three hours less per week providing direct clinical care than a decade ago, GPs were dealing with an increasing number of health problems during each consultation.
“Dementia is our most-feared illness, more than heart disease or cancer,” Perlmutter says. “When you let Type 2 diabetics know they’re doubling their risk for Alzheimer’s disease, they suddenly open their eyes and take notice.
Gluten is addictive – it takes a couple of weeks to escape withdrawal
MIT’s Hacking Medicine program believes that entrepreneurship is best suited to tackle health’s largest problems
he best healthcare solutions alleviate suffering at scale, often via technology to de-skill medicine, increase quality and lower costs, thus broadening access
Clinicians often get in habits and practices that are hard to change
Be a missionary, not a mercenary. Find a mission and customer with whom you truly empathize. The rest will come if you use that as your compass.
Entrepreneurship is not academic, though one should try to be strategic you don’t need an MBA.
The most important aspect of entrepreneurship is the entrepreneur’s mindset: to have a mission, clear use case and the persistence to solve it creatively.
Broad realization that technology can be used to scale medicine at a broader systems + population health
Changing healthcare reformsin the US is aligning incentives for better systemic healthcare
Large entrenched healthcare institutions are having a tough time adapting versus more agile startups
Start up costs have plummeted, so it’s more capital efficient than ever
The ubiquity of mobile computing and low cost diagnostics and sensors make health data liquidity and tracking easier than ever
Rising middle classes and health infrastructure in emerging economies are expanding access and demand globally
Why it’s the best time to be a healthcare entrepreneur
We caught up with Zen Chu, the founder of HackingMedicine and the current Entrepreneur in Residence at MIT to ask him some burning questions about digital health and entrepreneurship. Hear more from Chu at our sold out Healthcare Bootcamp in Boston tomorrow, along with thought leaders from athenahealth, MC10, IDEO and others.
What was the impetus for starting HackingMedicine?
We started MIT’s HackingMedicine program to push a philosophy that entrepreneurship is best suited to tackle healthcare’s largest problems. Housed within the Trust Center for MIT Entrepreneurship, it serves as a place to welcome non-healthcare engineers and entrepreneurs and connect them to Harvard Medical School and connect them to Harvard Medical School, the Health Sciences & Technology joint graduate program between MIT and Harvard, and Boston’s wonderful teaching hospitals. Our content and most programs are open to everyone and the mission is to infect more entrepreneurs to tackle healthcare problems.
How do we better engage clinicians in technology innovation in healthcare?
The best healthcare solutions alleviate suffering at scale, often via technology to de-skill medicine, increase quality and lower costs, thus broadening access for more people around the world. Clinicians often get in habits and practices that are hard to change. Our Healthcare Hackathons have brought hundreds of clinicians and health professionals together with entrepreneurs, engineers and hackers. We have now moved over 1500 participants through hackathons on 4 continents and we believe the process we have developed and freely teach is one of the best ways to identify unmet healthcare needs and bring diverse perspectives together to create high impact and creative solutions.
What is the number one piece advice you have for entrepreneurs?
Be a missionary, not a mercenary. Find a mission and customer with whom you truly empathize. The rest will come if you use that as your compass.
How do you ‘teach’ entrepreneurship?
Learn through doing. Entrepreneurship is not academic, though one should try to be strategic you don’t need an MBA. Classes and books can only go so far and every startup or technology is it’s own beast depending on the team and challenge. I think the most important aspect of entrepreneurship is the entrepreneur’s mindset: to have a mission, clear use case and the persistence to solve it creatively.
You’ve said it’s the most exciting time to be an entrepreneur? Why now?
This is truly the best time in the history of the world to be a healthcare entrepreneur:
Broad realization that technology can be used to scale medicine at a broader systems + population health
Changing healthcare reforms in the US is aligning incentives for better systemic healthcare
Large entrenched healthcare institutions are having a tough time adapting versus more agile startups
Start up costs have plummeted, so it’s more capital efficient than ever
The ubiquity of mobile computing and low cost diagnostics and sensors make health data liquidity and tracking easier than ever
Rising middle classes and health infrastructure in emerging economies are expanding access and demand globally
A provisional article published in the peer-reviewed journal BMC Public Health suggests that mHealth technology supporting exercise prescription interventions can be effective.
The findings are based on a Canadian study of 149 adults with at least two metabolic syndrome risk factors, one group using the intervention and one control group.
“Mobile health technologies have proved to be a beneficial tool to achieve blood pressure and blood glucose control in patients with diabetes,” argue the authors, who are currently completing their analyses and will be submitting their data for publication in the next few weeks. “These technologies may address the limited access to health interventions in rural and remote regions. However, the potential as a tool to support exercise-based prevention activities is not well understood.”
The study was undertaken to “investigate the effects of a tailored exercise prescription alone or supported by mobile health technologies to improve metabolic syndrome and related cardiometabolic risk factors in rural community-dwelling adults at risk for cardiovascular disease and type 2 diabetes,” states the article. The authors hypothesized that the primary outcome, systolic blood pressure, and secondary outcomes would be improved in both groups, but to a greater extent in the mobile health intervention group at 12 weeks and that these changes would be better maintained at 24 and 52 weeks in the intervention group with mobile health support, compared with the active control group.
The results of the study “will contribute to the current literature by investigating the utility of mobile health technology support for exercise prescription interventions to improve cardiometabolic risk status and maintain improvements over time, particularly in rural communities,” concludes the provisional article, which serves as a protocol paper.
Study participants were recruited from rural communities in Ontario, Canada. Participants were randomized to either: an intervention group receiving an exercise prescription and devices for monitoring of risk factors with a smartphone data portal equipped with a mobile health application; or an active control group receiving only an exercise prescription.
In addition to the exercise prescription, the intervention group received a mobile health technology kit for self-monitoring of biometrics and physical activity. The kit included a smartphone (Blackberry Curve 8300 or 8530) equipped with Healthanywhere health monitoring app (Biosign Technologies), a Bluetooth-enabled blood pressure monitor (A & D Medical), a glucometer (Lifescan One Touch Ultra2) with Bluetooth adapter (Polymap Wireless) and a pedometer (Omron).
Using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, the review revealed a recent increase in studies conducted to determine the effectiveness of mHealth interventions for the promotion of physical activity. Yet, quantity, not quality, seems to prevail, the authors argued.
To learn more:
– read the article in BMC Public Health
Yet another BBC documentary on obesity, this time featuring an emaciated looking surgeon who specialises in removing skin lesions. It was an excellent exposition of how broken and inappropriate it is to apply a reductionist, scientific lens to a problem of this kind.
A bunch of Imperial College scientists banging on about grellin and PPY and twin studies and epigenetics and fMRI and finishing up with a mandatory reference to bariatric surgery as the only successful intervention that actually changes the way your mind thinks about food.
If only there was a more expensive and complicated way to intervene?
Are we going to get to the point where bariatric surgery becomes a standard procedure, like desexing a dog?
The more of these programs I watch, the more distasteful and disappointing they seem.
If the end goal is to stop people eating crap, and also feel fuller quicker, then there has to be a better, more positive, less invasive way to achieve this than with surgery or a pill.
GE are using their market power to experiment with different health care delivery
Pushing strongly for the introduction of medical homes
Early results are promising: patients enrolled in medical homes had 3.5 percent fewer visits to the emergency room and 14 percent fewer hospital admissions over the four years from 2008 through 2012
As Some Companies Turn to Health Exchanges, G.E. Seeks a New Path
CINCINNATI — Although the new federal health care law is designed to help people buying individual policies, even people with employer-provided policies are beginning to see changes in their coverage as companies rethink health care for their workers, discontinuing it in a few cases and redesigning it in many others.
They are motivated by a need to rein in health care costs, which continue to rise faster than overall inflation, but the federal health care law is also changing how some view their obligations to their employees.
Some major firms, like Walgreen, the drugstore chain, are giving those who qualify money to buy insurance on a private health exchange. Aon Hewitt, a benefits consultant that will oversee health plans on Walgreen’s behalf, said 18 large employers had signed up so far, including Sears and Darden Restaurants.
But here in Cincinnati, General Electric is taking the opposite approach.
One of the largest employers in the nation, it spends more than $2 billion a year offering coverage to 500,000 employees and retirees and their families. And it is using its considerable clout in places like this — where its giant aviation business gives it a major presence — to work directly with doctors and hospitals to improve care and reduce costs.
“I don’t know anybody who isn’t trying almost everything,” said Helen Darling, president of the National Business Group on Health, which represents employers providing benefits. “We’re going to see a lot of activity in the next couple of years.”
Over the last few years, G.E. has pushed for the creation of so-called medical homes, in which an individual medical practice closely coordinates a patient’s care by having access to all of the patient’s medical records.
In Cincinnati, about 118 doctors’ practices have converted to medical homes, and all five of the major health systems are making their primary care practices move in that direction. G.E. has also pushed for greater transparency of results.
“If we don’t take accountability ourselves for figuring this out, we’re part of the problem,” said Sue Siegel, a senior executive at G.E., who sees transformation of health care both as a business opportunity and a business necessity.
“We have to be involved in the solution,” she said. “We can’t just wait for someone to tell us that it is going to be fixed.”
What distinguishes the effort by G.E. is its direct focus on hospitals and doctors. Companies looking to the private exchanges are largely hoping to save money and want to be freed from the headache of administering health benefits.
In Walgreen’s case, the company says it doesn’t plan to lower its share of its workers’ health care costs but hopes to foster more competition among insurers, leading to better prices and more choice for employees.
In Cincinnati, G.E. took on both a cheerleading and coordinating role. In early 2010, Jeffrey R. Immelt, its chief executive, addressed local business leaders and urged them to think strategically and align their efforts to make more of a difference. There were already significant efforts under way to foster medical homes, for example, and G.E. pushed to find more financing to expand the concept to more medical practices and keep the focus on that initiative.
“The ever-present vigilance of the employers help nudge things along,” said Craig Brammer, chief executive of three area health care coalitions, including the Greater Cincinnati Health Council, which is made up of the area’s hospitals, health plans and employers.
The city’s health systems say they recognize that insurers and employers are increasingly going to reward them for better tracking their patients in and out of the hospital. “We are clearly gearing up to change directions from fee for service for what I’ll call payment for value,” said Will Groneman, an executive vice president for TriHealth, one of the systems.
The medical home also appears to resonate with employees. When Mary Farris, a 44-year-old marketing executive for G.E., found herself going to a local urgent care center because she could never get an appointment with her physician, she switched to a practice that had become a medical home.
What strikes Ms. Farris was how much time the doctor and medical assistant spent gathering her medical history and making sure there weren’t additional medical issues. While she came in for a spider bite, the focus was on her well-being as a working mother whose father was seriously ill at the time. “The picture was more on all of me as opposed to one isolated incident,” she said. “Somebody was trying to connect the dots.”
In Cincinnati, there are beginning to be grudging signs of success. Early results are promising: patients enrolled in medical homes had 3.5 percent fewer visits to the emergency room and 14 percent fewer hospital admissions over the four years from 2008 through 2012. G.E. plans to ask an outside firm to do a more detailed analysis.
But employers looking to adapt a similar strategy will find “it’s hard to do,” said David Lansky, the chief executive of the Pacific Business Group on Health, which represents West Coast employers. While “the opportunity is significant,” he said, companies may not have the time or resources to work in too many of their locations, with different hospitals and health plans in each market.
Some companies — Trader Joe’s for example — decided to send at least some employees to the new public exchanges. Trader Joe’s has left coverage for three-quarters of its work force untouched but is giving part-time workers a contribution of $500 to buy policies in the newly created state marketplaces. Because of the employees’ low incomes, the company says it believes many will be eligible for federal subsidies to help them afford coverage.
But a few major employers are taking even more aggressive stances and are trying to reshape how health care is delivered in this country.
They are increasingly looking to make direct connections with health systems, particularly well-regarded institutions that can deliver good care for what can be very expensive back or heart problems. G.E. recently signed an agreement with Hospital for Special Surgery in New York, a high-volume orthopedic hospital, to oversee the care of some employees getting hip and knee replacements. Last year, Walmart contracted with health systems like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need transplants, heart and spine care. The company says it will soon expand the program to other centers of excellence.
The decision doesn’t always sit well with the home team. In Cincinnati, the UC Health System, which includes an academic medical center that also serves the area’s major source of care for the uninsured, says it would welcome a similar opportunity to provide joint replacements for G.E., but executives say they simply cannot afford to offer significant discounts. “We don’t have the resources to cut deals,” said Dr. Myles Pensak, an executive for UC Health.
G.E. is unapologetic. The company says it will continue to try a variety of approaches until it finds a way to tame health care costs even more than the annual growth rate achieved so far of under 3 percent. “You’ll see many, many experiments across the board,” Ms. Seigel said.
accountable care is a system in which hospitals are paid to keep people healthy
the new economic incentives drive a need for data regarding the population being treated
Joel Dudley (Director of Informatics at Mount Sinai Medical School) is running diabetic patient data through an algorithm to cluster them according to phenotype and genotype.
This work aims to to replace the general guidelines doctors often use in deciding how to treat diabetics and replace them with risk models—powered by genomics, lab tests, billing records, and demographics—making up-to-date predictions about the individual patient a doctor is seeing, not unlike how a Web ad is tailored according to who you are and sites you’ve visited recently.
The person leading the design of the new computer is Jeff Hammerbacher, a 30-year-old known for being Facebook’s first data scientist. Now Hammerbacher is applying the same data-crunching techniques used to target online advertisements, but this time for a powerful engine that will suck in medical information and spit out predictions that could cut the cost of health care.
With $3 trillion spent annually on health care in the U.S., it could easily be the biggest job for “big data” yet. “We’re going out on a limb—we’re saying this can deliver value to the hospital,” says Hammerbacher.
Mount Sinai has 1,406 beds plus a medical school and treats half a million patients per year. Increasingly, it’s run like an information business: it’s assembled a biobank with 26,735 patient DNA and plasma samples, it finished installing a $120 million electronic medical records system this year, and it has been spending heavily to recruit computing experts like Hammerbacher.
It’s all part of a “monstrously large bet that [data] is going to matter,” says Eric Schadt, the computational biologist who runs Mount Sinai’s Icahn Institute for Genomics and Multiscale Biology, where Hammerbacher is based, and who was himself recruited from the gene sequencing company Pacific Biosciences two years ago.
Mount Sinai hopes data will let it succeed in a health-care system that’s shifting dramatically. Perversely, because hospitals bill by the procedure, they tend to earn more the sicker their patients become. But health-care reform in Washington is pushing hospitals toward a new model, called “accountable care,” in which they will instead be paid to keep people healthy.
Mount Sinai is already part of an experiment that the federal agency overseeing Medicare has organized to test these economic ideas. Last year it joined 250 U.S. doctor’s practices, clinics, and other hospitals in agreeing to track patients more closely. If the medical organizations can cut costs with better results, they’ll share in the savings. If costs go up, they can face penalties.
The new economic incentives, says Schadt, help explain the hospital’s sudden hunger for data, and its heavy spending to hire 150 people during the last year just in the institute he runs. “It’s become ‘Hey, use all your resources and data to better assess the population you are treating,’” he says.
One way Mount Sinai is doing that already is with a computer model where factors like disease, past hospital visits, even race, are used to predict which patients stand the highest chance of returning to the hospital. That model, built using hospital claims data, tells caregivers which chronically ill people need to be showered with follow-up calls and extra help. In a pilot study, the program cut readmissions by half; now the risk score is being used throughout the hospital.
Hammerbacher’s new computing facility is designed to supercharge the discovery of such insights. It will run a version of Hadoop, software that spreads data across many computers and is popular in industries, like e-commerce, that generate large amounts of quick-changing information.
Patient data are slim by comparison, and not very dynamic. Records get added to infrequently—not at all if a patient visits another hospital. That’s a limitation, Hammerbacher says. Yet he hopes big-data technology will be used to search for connections between, say, hospital infections and the DNA of microbes present in an ICU, or to track data streaming in from patients who use at-home monitors.
One person he’ll be working with is Joel Dudley, director of biomedical informatics at Mount Sinai’s medical school. Dudley has been running information gathered on diabetes patients (like blood sugar levels, height, weight, and age) through an algorithm that clusters them into a weblike network of nodes. In “hot spots” where diabetic patients appear similar, he’s then trying to find out if they share genetic attributes. That way DNA information might add to predictions about patients, too.
A goal of this work, which is still unpublished, is to replace the general guidelines doctors often use in deciding how to treat diabetics. Instead, new risk models—powered by genomics, lab tests, billing records, and demographics—could make up-to-date predictions about the individual patient a doctor is seeing, not unlike how a Web ad is tailored according to who you are and sites you’ve visited recently.
That is where the big data comes in. In the future, every patient will be represented by what Dudley calls “large dossier of data.” And before they are treated, or even diagnosed, the goal will be to “compare that to every patient that’s ever walked in the door at Mount Sinai,” he says. “[Then] you can say quantitatively what’s the risk for this person based on all the other patients we’ve seen.”
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