Imagine with me what health care will be like in the future for four very different people.
Andrew’s a 24-year-old Meridian man who is healthy and has no known medical risk factors. He signed up with SelectHealth insurance and downloaded the St. Luke’s Provider Finder app free from the app store on his iPhone. He has selected a St. Luke’s physician and, right after his check-up, downloaded the myChart app through which he can log in to email his physician, check lab results, and schedule visits online.
He filled out a health risk assessment form that showed him his “vitality” score and allows him to monitor his health status. He got information about diet, exercise, and health behaviors.
After his check-up, his doctor wanted him to have a fasting blood sugar and cholesterol blood test. Logging into his myChart account, he noted the appointment made for the lab tests.
Andrew went in for the lab tests and when he returned to work, had an email that indicated his lab results were ready. He logged into myChart, pressed “test results,” and received the results and a note from his physician indicating that his tests were normal.
A couple of months later, Andrew developed sneezing, itching eyes, and a runny nose. Not experiencing relief with over-the-counter medications, he sent a myChart email to his physician explaining his symptoms and lack of improvement with over-the-counter medications.
Within two hours, Andrew received an email from the physician’s assistant who works with his physician, letting him know that a prescription was sent electronically to his pharmacy and explaining that he should contact them for an online video visit if he was not better in a few days. In the fall, Andrew received an email reminder to get a flu shot.
Brenda is a 24-year-old Fruitland resident who is overweight and smokes, is not physically fit, and has a family history of diabetes, hypertension, and heart disease. She works for a company that has chosen St. Luke’s to manage their employee wellness.
St. Luke’s wellness team members visited her workplace and conducted health screenings. Her BMI, blood pressure, blood sugar, and cholesterol were all checked.
Brenda also took a health risk assessment online, prior to the screening, where her vitality score indicated that her health was suboptimal and that she was at high risk for heart disease, stroke, and cancer because of her smoking history, her weight, and her level of physical activity.
After learning how much her risk factors were threatening her health, Brenda told her St. Luke’s health coach that she had wanted to stop smoking and lose weight, but just didn’t know how, and feared stopping smoking would just aggravate her weight problem.
Brenda started a St. Luke’s smoking cessation program and a journey toward improved wellness. A nutritionist took her and others beginning the same journey to the grocery store and taught her how to read labels and make healthy choices.
Brenda also took direction from the health coach and began using a pedometer and started a daily walking program with friends. She checked in with her health coach every week and received new ideas and encouragement. She attended cooking classes and started exercising. Now Brenda is a non-smoker. She’s losing weight, and feels stronger and more fit than ever!
Charlie’s a 57-year-old in Wood River man experiencing a stroke. He was at work when he noticed that his hand was weak and he couldn’t pick up his coffee cup. A colleague noticed that his speech was slurred.
His colleague called 911 and Charlie was taken to St. Luke’s Wood River Emergency Room. The ER team had already been notified and was ready for Charlie’s arrival. He was whisked into a room where a quick assessment was performed.
A nurse hit the “e-ICU” button on the wall. A camera came on and a stroke neurologist in Boise appeared on the monitor. The stroke neurologist could watch the ER physician conducting the neurologic exam.
The medical team quickly moved Charlie to radiology for a scan. The images were visible to the neurologist in Boise and a diagnosis of stroke was made.
It was determined that Charlie was an excellent candidate for clot-busting drugs and the medication was administered. And whereas before Air St. Luke’s would have been dispatched to pick up Charlie and fly him to Boise, the remote monitoring meant that Charlie was able to remain at Wood River, saving thousands of dollars of cost and keeping things close to home for Charlie’s family.
Charlie recovered well from his stroke and was able to be discharged home with a treatment plan that included physical therapy, speech therapy, occupational therapy, and a nurse care coordinator to ensure that his care was coordinated and his progress tracked and to adjust his treatment plan as he improved. Once he returned to work, Charlie’s nurse practitioner monitored his weight, blood pressure, and fitness to ensure that he would be at minimal risk for another stroke.
Charlie’s health plan through SelectHealth means he can pay a monthly premium with all of his care paid for, without additional charges for his hospital stay, scans, blood tests, therapy, and follow-up visits. He receives regular messages from St. Luke’s about vaccinations and screening tests that he needs to make sure that his health remains strong following his stroke. A daily medication alarm reminds him to take his aspirin and other medications.
Denise is a 63-year-old widow in Nampa with heart failure, diabetes, and kidney dysfunction. She has a primary care physician who has been treating her diabetes, a cardiologist for the heart failure she developed two years ago, and a nephrologist (kidney specialist) because her kidneys are failing.
She has a long history of diabetes. In the past, Denise’s diabetes was not well controlled. She did not feel that she understood her diet or medications and at times, skipped her medications. Several times, Denise was discharged from the hospital only to be readmitted within a week or two when her diabetes got out of control or she developed some other complication. She racked up huge medical expenses due to the hospitalizations and the many physicians involved in her care, some of whom she didn’t even remember.
Now that she has a St. Luke’s team of physicians, each has access to all of her medical records, and they are kept up-to-date with her current medications and recent lab tests. All of her physicians are on the myStLuke’s electronic health record, so they all have access to the same information in a timely way.
Denise’s daughter lives in Denver. She worries about her mom, but is able to log into myChart and see all of her mother’s test results. She also can email her mother’s doctors with any questions.
Denise now participates in a care coordination program through St. Luke’s Humphreys Diabetes Center. Denise enjoys the classes about how to live with diabetes, the importance of her diet, and medications. She has a glucometer that measures her blood sugars and transmits the results electronically to her physician’s office. If her blood sugar is out of whack, she receives a phone call with instructions from her doctor or physician’s assistant. She hasn’t had to return to the hospital for her diabetes, and her daughter is very relieved.
Every other month, Denise visits the heart failure clinic, where a heart failure specialist and a team of professionals helps make sure that her medications are adjusted properly. The myStLukes electronic health record provides all of her caregivers with alerts about possible medication interactions and other information.
In between visits to the heart failure clinic, a nurse coordinator visits Denise at home to ensure that her questions are answered, her living situation is safe, she is taking her medications as prescribed, and she is keeping her appointments. Denise checks her weight and the nurse coordinator monitors her readings as they are transmitted electronically from Denise’s bathroom scale. She gets calls from the nurse to see how she is feeling and instructions from the heart failure clinic regarding any medication adjustment.
Denise is also attending cardiac rehabilitation at St. Luke’s Meridian. An exercise physiologist has worked with Denise to design an exercise program that is helping her feel stronger while not overly stressing her heart. The program has even helped better control her diabetes.
While Denise’s daughter was in town visiting, the palliative care nurse and doctor visited to see if there was anything they could do to help in controlling any shortness of breath or other symptoms. They discussed whether Denise would want dialysis if her kidneys stopped functioning. They also talked about what Denise would want if her condition deteriorated, she ended up in the hospital, and faced the possibility of CPR or a breathing machine. Decisions agreed to meant that Denise’s daughter would not have to make the decision if Denise was unable to or her daughter could not be reached. Denise and her daughter were grateful and relieved to be having this discussion.
And in the meantime, Denise feels better and stronger than she ever has. She has SelectHealth insurance and pays only a monthly premium. She no longer receives hospital bills and doctor bills. St. Luke’s takes accountability for engaging her in her own care, educating her, and monitoring her progress, and responsibility for managing the costs of her care. As a result, Denise does not have to pay more for each test or procedure.
What is the point of these stories? They’re the best way I can think of to describe what St. Luke’s is trying to do to ensure population health and accountable care. We see that when it comes to health care, people fall into one of four broad categories: healthy people, who merely need education to remain that way, preventative services to help keep them healthy, and health screenings to identify if there are any risk factors that need to be addressed; people who feel well and may not be getting medical attention, but who are at high risk of developing serious health problems and becoming patients; acutely ill people, who need high-quality, state-of-the-art care to reduce the potential for complications and return them home and to work as soon as possible; and people who are chronically ill, often with multiple illnesses that require care coordination and management of care transitions.
St. Luke’s is making significant investments and preparations to be able to be accountable for the care patients receive, for the outcomes of that care, and for the cost of that care, and risk-based contracting is a critical part of the puzzle. This is the idea that I illustrated above, where patients would just pay a monthly premium and then not incur additional hospital and physician bills.
That is the “risk” that SelectHealth and St. Luke’s are preparing to be able to take. And while the national discussion today is on prices, and I certainly agree that healthcare prices are too high, under risk-based contracting, prices become irrelevant. There is no charge for each individual service provided, as there is today.
I know it’s been hard for some to believe, but St. Luke’s efforts to be proactive, to keep people from becoming patients, and to coordinate the care for patients will drive down healthcare costs more than cutting prices ever will. It is estimated that at least 30 percent of healthcare spending is low-value or no-value. Merely by cutting out that waste, St. Luke’s will significantly impact healthcare costs and reduce insurance premiums. After all, the price of a service you don’t need or doesn’t benefit you is too high, even if it is relatively inexpensive!
So will the future I’ve described be here in 20 years? Ten years? After all, other leading health systems like Kaiser Permanente and Intermountain Healthcare have been working on this for three to five decades.
St. Luke’s Health System is not even eight years old. We are adopting all the best lessons, learned from all of the leading health systems, and working hard to have all of this in place in 2016. The people of Idaho cannot wait decades to have this kind of care available.
We recently faced a tough antitrust suit, and even though the judge stated in his opinion that we have to “shift away from our fragmented delivery system and toward a more integrated system where primary care physicians supervise the work of a team of specialists, all committed to a common goal of improving the patient’s health,” he indicated that the antitrust laws would not allow it.
He went on to say, “St. Luke’s saw this major shift coming some time ago. And they are to be complimented on their foresight and vision.”
In referring to our affiliation with Saltzer Medical Group, the judge also stated, “The Acquisition was intended by St. Luke’s and Saltzer primarily to improve patient outcomes. The Court is convinced that it would have that effect if left intact, and St. Luke’s is to be applauded for its efforts to improve the delivery of health care in the Treasure Valley.”
The judge determined that we could achieve all of our intended goals with Saltzer without employing Saltzer physicians. Next week, I’ll look at what we're trying to do and how our affiliation with Saltzer was intended to advance population health.
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.