In their day-to-day life of researching today's health care issues and speaking with members, Advisory Board experts come across many interesting health care-related tidbits. They share five of their favorites—along with their implications for society, the health care system, and even your hospital.
1. We could prevent 30-50% of cancer cases
Deirdre Saulet, Practice Manager, Oncology Roundtable
I recently revisited this fact during a conversation with a handful of cancer program leaders and was struck by it once again. In health care, we tend to categorize cancer as an "unavoidable" condition. Most of my time—and an overwhelming majority of cancer research funding—is spent trying to make people's experience with cancer better, whether through improved efficiency, personalized treatment, symptom management, or cross-continuum navigation. It's a worthy mission, and one I'm extremely grateful to work on. But is that the best place to focus? Wouldn't prevention—or at least early detection—be the most effective way to improve the cancer patient experience?
The NCI's 2018 budget included more than $4 billion for basic research into the mechanism and causes of cancer, and just $339 million (5.7% of the total) on cancer prevention and control. Meanwhile, obesity rates are climbing—which can increase one's risk of developing 12 different types of cancers; our lung screening rate hovers around 2%, and only half of adolescents have received their recommended HPV vaccines (an omission which gets far less attention than measles).
We're still far away from a system focused on prevention. To change that, we would need to mount an all-out public health offensive that would successfully change people's behaviors, ensure compliance with vaccinations, and convince industries to prioritize the health of their communities over their wallets. But since it's harder for us to move the needle on these types of initiatives, we've instead focused on finding a "cure" ever since Nixon's War on Cancer in 1971.
None of this should downplay the tremendous progress we've made in early detection and personalized treatment over the past two decades. Just ask Jimmy Carter. But it's also time to seriously think as a country how we can prevent hundreds of thousands of Americans from ever having to receive this devastating diagnosis in the first place.
2. Offering rideshare services to patients does not improve the primary care appointment attendance rate
Tomi Ogundimu, Practice Manager, Population Health Advisor
Health systems are increasingly investing in interventions to address social determinants—and transportation is often at the top of the list. The Altarum Institute estimates 3.6 million Americans miss or delay medical appointments each year due to a lack of transportation, and many more rely on medical transport with long-wait times and high rates of driver no-shows. Therefore, many provider organizations (and health plans) have begun to partner with popular rideshare companies like Uber and Lyft, aiming to get patients to their appointments more easily (and at lower cost than traditional NEMT services).
I understand why. The opportunity to reduce costly no-show rates is vast. Missed health care appointments cost the U.S. health care system $150 billion per year, and the average clinic can have no-show rates as high as 30%. However, these partnerships hinge on a basic question: Does simply providing patients with no- or low-cost rides to appointments actually close the gap?
The reality is that there has been very little research done on the effectiveness of arranging non-emergency transportation services from patients. Earlier this year, my team systemically reviewed the peer-reviewed literature on transportation as part of our Care Delivery Innovation Reference Guide. We found that when studies do exist, they show inconsistent rates of success. Some individual case studies report benefits in improved no-show rates and reduced costs. However, other studies and randomized control trials found no significant differences in either no-show rates or ED use. Indeed, a 2018 JAMA study on the impact of rideshare for Medicaid patients found low uptake and significant drop-off rates. In the randomized control trial, 56.3% of patients were not interested in rideshare services and, even among the 32.4% of patients that scheduled rides, only 19.8% ultimately used the service.
Providing transportation is not a silver bullet to solve the challenge of no-show rates, even among lower income, vulnerable populations. We need a more targeted approach. Transportation is often only one of many underlying factors that lead to missed primary care utilization (and subsequent avoidable ED use). Rather, it's your patient outreach strategy that really matters. Organizations with successful programs typically integrate transportation services into existing care management responsibilities, as staff-patient relationships are what help surface information about when and how to offer transportation services (or address other social determinants that preclude access).
3. Deaths from heart disease are suddenly rising—but only among one part of the population
Megan Tooley, Practice Manager, Cardiovascular Roundtable
I've spent the past ten years working with cardiovascular leaders, and have seen how much time and how many resources they've devoted to trying to improve care for cardiovascular patients. So far, their efforts seem to be paying off—we've been seeing steady year-over-year declines in deaths from heart disease nationwide.
However, I recently read several articles that stopped me in my tracks. The headlines proclaimed that deaths from heart disease actually increased over the past few years. I knew I needed to explore the data further.
Upon reading the complete CDC report, it became clear that the increase has only taken place in a specific sub-group: adults ages 45-64. In fact, while this age group saw a 22% decrease in mortality from heart disease from 1999-2011, their mortality rate reversed recently, increasing 4% from 2011-2017. Surprisingly, across this same time period, mortality rates continued to decline among adults older than 65, and decline then level off among the younger 20-44 population.
The study didn't try to hypothesize what caused these trends. However, this data actually reflect the sentiments I've heard from our members about their changing patient population. I've spoken with CV leaders who have been in their roles for 20+ years and have seen a clear transformation in the patients entering their hospital. The CV patient archetype of yesterday was older, often a smoker, and male. Today, as smoking rates have declined and more patients are developing obesity and diabetes at a younger age, the patient archetype is younger, more comorbid, and more chronic. They're also more likely to be female; as the report also highlights, mortality has increased at a 7% rate in women and only 3% among men.
So what does this mean for health care providers? For one, care protocols may not currently be set up to identify and manage cardiovascular disease (CVD) in this patient group. Rather, they may overemphasize screening for older individuals while missing those as risk of a cardiac event, or missing out on symptoms specific to women with CVD (as I've reflected on previously, women are underserved by current CV care protocols and clinical research). Additionally, these patients are going to require greater coordination, not just across the continuum but also across specialists managing increasingly common comorbidities like diabetes and obesity.
This change will also have a financial impact. For the system as a whole, the American Heart Association forecasts a 135% increase in medical costs associated with CV disease by 2035, and a 55% increase in indirect costs due to lost productivity. This report shows that much of this burden may be felt among those age 45-64—pre-Medicare age. This means we may see more CV patients covered by private payers or uninsured, a different dynamic for CV programs traditionally tied to CMS payment mechanisms. As heart disease increases in middle-aged, working adults, I wouldn't be surprised if CV programs see more private sector activity aimed at reducing the cost of cardiovascular care delivery, or even steering to higher-value specialty providers (like Walmart is doing).
4. For most of world history, economic growth averaged 0% per year
Thomas Seay, Executive Editor, Daily Briefing
Here's a fact that floored me recently: From the dawn of agriculture until 1820, world per capita economic growth averaged almost exactly 0% per year. That's the jumping-off point of The Birth of Plenty, the neurologist William Bernstein's magisterial and effortlessly readable overview of the history and root causes of economic growth.
If you're like me, your first reaction to this claim might be to say, "Really? How does anyone know what economic growth looked like in, say, 431 B.C.?" And as Bernstein acknowledges, we don't know—but that's mostly beside the point.
After all, we know our long-ago ancestors lived hand-to-mouth: the economic equivalent, roughly, of the $400 a year required to live at a subsistence level in a less-developed country today. If that's true, then as Bernstein argues, "[W]orld per capita GDP growth since the birth of Christ could not possibly have been as high as, say, 0.5%; if it were, per capita GDP would have grown from $400 in current dollars to over $8.6 million by the year 2000!"
Is it a stretch to consider the absence of premodern economic growth to be a "health care fact"? Perhaps. But if our economy hadn't started rumbling forward in the 19th century at a rate of 2% or so per year, today's $3.5 trillion U.S. health care sector would be inconceivable. Even purchasing a single MRI machine, if such a thing had existed, would have bankrupted a premodern city.
The obvious question, then, is: What changed? Why, after millennia of stagnation, did the global economy suddenly start booming? That's the mystery that Bernstein spends the rest of his book unraveling.
Plenty of his research feels resonant to today's health policy debates. It's tough, for instance, to read his chapters on the importance of intellectual property protections or well-functioning capital markets without pondering their implications for modern questions about drug patent protections or health care financing. But Bernstein is no free-market purist: He also argues that economic growth can survive significantly higher taxes than exist in today's America, while high levels of inequality can be corrosive to economic stability. In other words, there's plenty of food for thought here regardless of your political leanings.
(A bonus fun fact, also courtesy of Bernstein: In medieval towns, "homicides were twice as common as accidental deaths," and "[o]nly 1% of murderers were brought to justice." I think I'll stick with the modern age, thank you very much.)
5. 44% of leaders at large health systems believe AI will become a transformative, essential part of our health system
Craig Pirner, Managing Director, Talent Development
Recently, I joined a group of health system executives for a presentation about the application of artificial intelligence (AI) in health care delivery. From a technical perspective, the presentation was interesting, if a little mind-boggling! From a leadership perspective, it was fascinating. Most leaders believe that AI can—and will—change the health system significantly. In my colleague's survey of 125 health care leaders, many, especially those at large health systems, believe that AI could bring transformative value to their health system. Another large percentage think AI has great potential, but just don't know what role it will play.
But my conversation with the health leaders also illuminated how challenging leaders think it will be to guide their organization through AI adoption. The conversation really started to take-off when the executives began to think about the leadership challenges associated with technology as disruptive as AI—particularly those of an adaptive, rather than technical, nature. What is the health system leader's role in ensuring that AI technology is applied inclusively? How will they navigate the losses that those whose professional identities are disrupted by AI may feel? There are not easy answers to those questions, but it was fulfilling to see a group of executives begin to grapple with them and see a role for themselves in managing the significant adaptation that AI may require.