I oppose over-testing and over-treatment, so I really had to think hard five years ago when I turned 45 and my doctor offered PSA screening for prostate caner. The US Preventive Services Task Force (USPSTF) had just come out against PSA screening, concluding that the harms outweighed the benefits.
I know that PSA is a very imperfect indicator. I definitely want to avoid the stress and possible discomfort of having a biopsy. I’m worried about false positive and false negative biopsy results. And I don’t relish the significant potential for incontinence, impotence, or bowel problems from treatment.
But at this stage of my life I am willing to accept a significant risk of morbidity in exchange for a small reduction in mortality risk, which is my impression of what my choice to have the PSA test means. In 10 or 20 years I probably won’t feel that way. And I hope there will be better detection, follow-up and treatment options by then.
I’m also confident in my ability to make informed choices with my physicians along the way. The PSA test itself was done as part of routine blood work and there was no additional risk from that. My doctor and I agreed that if the PSA is elevated we’ll discuss what to do next. At that stage I’ll also have the chance to do more research and get more opinions if necessary. I’m not automatically going to get into a cascade of follow-up and treatment.
Now the USPSTF appears to be coming around to my way of thinking. In particular, they note that more men are choosing “active surveillance,” i.e., keeping a close watch rather than jumping straight to aggressive treatment.
The choice about whether to undergo PSA testing and what to do once results are in is a great opportunity for shared decision making. And this is what should be encourage.
When we think of insurance, it’s usually for things that are rare and expensive. You never want to use your car insurance, fire insurance, or disability insurance and you don’t use file a claim for routine things like changing the oil, buying a fire extinguisher or missing a day of work with a sore back. Insurance works best when it spreads big risks over a large pool of people.
But healthcare is different, and health insurance covers even small, routine things like primary care physician visits. Direct primary care practices change the model because they are paid directly by the patient, not the insurance company. That keeps costs down and increases the alignment between doctor and patient.
I like the idea, and in fact I interviewed an early practitioner of primary care back in 2009, before the Affordable Care Act!
Recently, I spoke with Dr. Jeffrey Gold, of Gold Direct Care in Marblehead, MA. He filled me in on how his practice works and why he’s a proponent of the direct model.
(0:10) What do you mean by “direct” primary care?
(0:47) How does that feel different from a typical primary care office? Is it the same thing as a concierge practice?
(4:58) You don’t accept insurance. Does that affect your overhead and enable you to be more cost effective?
(7:08) What happens when a patient goes out of your orbit to see a specialist or be hospitalized? Do you still have to deal with insurance companies then?
(9:38) Are there particular kinds of patients that are a really good fit for a direct care model?
(11:22) What would be the impact on the overall healthcare system if every patient were a direct care patient?
(14:10) Does the Affordable Care Act help or hinder what you are doing? What changes would you like to see in the healthcare law?
Wayne Lipton runs Concierge Choice Physicians, which converts traditional physician offices to “hybrid”concierge practices that provide new options for patients and increase physician income. While we typically hear about concierge practices in primary care, the model is expanding to other specialties.
In this podcast interview, Wayne and I discuss the hybrid concierge model for cardiology:
(0:11) What is a typical cardiologist’s practice like these days and how has it changed?
(1:01) How have the practice changes worked out for physicians and patients?
(1:48) Do patients with cardiac issues use their cardiologist as primary care physicians or do they still maintain primary care relationships?
(3:06) Within primary care we’ve seen a shift toward concierge models. Why haven’t we seen that in the specialties?
(4:22) What is a hybrid model like? Does a physicians have to remember when they are acting as a concierge versus the traditional hamster wheel model?
(6:15) Are a lot of the cardiology concierge patients also concierge primary care patients?
(8:26) How does a concierge cardiology practice differ from a concierge primary care practices? How do the economics compare?
(11:08) What do health plans think of concierge medicine? What is the impact on new models of reimbursement?
(13:37) Would a practice that added on a hybrid model be more or less attractive to an ACO? Would the practices want to participate?
(15:50) How broad is the opportunity to add this model in cardiology? Are other specialties also ripe?
TytoCare hopes to take telehealth to the next level by providing a solution that allows clinicians to conduct remote examinations. Patients (or caregivers) will use a TytoCare device to conduct an exam that can be interpreted by a physician over a cloud-based platform with video conferencing.
The company took a step forward recently by obtaining FDA clearance for its digital stethoscope. The approach looks pretty cool, but clearly it will be a challenge to get the devices out to patients ahead of need and to do so cost effectively.
CEO & Co-Founder Dedi Gilad answered my questions via email:
1.What was the inspiration for Tyto?
I founded TytoCare along with Ofer Tzadik, another lifelong leader in Healthcare IT, in 2012. The story is similar to that experienced by most families when at a young age, my daughter suffered from a series of earaches requiring constant medical treatment. With two working parents, it became increasingly difficult to travel in and out of the local physician’s office on a regular basis. The experience was not easy for my daughter either, waiting for hours in the crowded doctor’s office in considerable pain and discomfort.
After consulting with my pediatrician, I recognized the strong need for change in the way primary care is delivered today. I collaborated with Ofer Tzadik to design a new medical experience, one that would not only mutually benefit both the doctor and the patient, but also serve to strengthen this vital relationship. The result of this endeavor is TytoCare, a company prepared to lower the load and cost of U.S. healthcare services, improve accessibility to healthcare services even from the comfort of home, and reshape day-to-day healthcare as we know it.
2.Why a dedicated device instead of using a tool everyone already has, i.e., a smartphone?
TytoCare’s examination tools and complete telehealth platform work with a smartphone or tablet and include a stethoscope, otoscope, tongue depressor, camera, and thermometer. While a smartphone can only offer video and audio technology, Tyto enables the patient to conduct actual exams of the heart, lungs, heart rate, temperature, throat, skin and ears. This cannot be done with video alone and more importantly, it requires an interface and technological infrastructure that simply wouldn’t be cost effective in a smartphone.
3.How will distribution to end users work? It seems like logistics will be difficult. For example, do you expect everyone to have a device in place before they need it?
To begin, distribution will start with health institutions though a full consumer product is coming in 2017. We expect that consumers will see the value in being able to perform live, remote medical examinations at home, in place of rushing back and forth to the doctor’s office.
4.What is the cost of the home and pro solutions?
TytoPro will cost $999.00 plus a monthly fee based on usage, and TytoHome will cost $299.00.
5.More broadly, what are the overall economics of the solution? Is there a financial return on investment? How do you think about calculating that? Is it more appropriate for certain segments of patients or providers?
Certainly, and our work with leading financial institutions has reinforced the financial ROI.
The incredible benefit of the product is that its applications are endless because it simultaneously empowers doctors and clinicians while unlocking the full benefits of telehealth for patients. TytoHome can be beneficial in many different scenarios – for geographically isolated patients and those who lack easy access to medical facilities; those who are turning to urgent care because they cannot get an appointment in time at their regular establishment; patients with chronic illnesses or other conditions that require monitoring and frequent, tiresome trips to the doctor or hospital; school or traveling nurses; and of course, parents at home with kids.
6.What is the lifecycle for this solution? Do you expect to upgrade the devices over time? Can that be done through software or will it require hardware to be replaced?
We will likely add additional examination capabilities over time, but the majority of upgrades can be made through software updates.
7.What else should readers know?
TytoCare is a complete end-to-end telehealth platform that provides a telehealth experience comparable to in-person visits. It truly fills the missing link in telehealth between the in-office professional and the at-home patient by delivering comprehensive exam results – of the ear, nose, throat, heart, lung, stomach, skin – as part of a complete telehealth visit. The exam data can be delivered to a clinician via “live telehealth exams” or through the “exam and forward” function – sending the exam results on to be examined by the clinician later.
TytoCare can be used anytime, anywhere and by anyone. Patented guidance technology directs and enables anyone to collect the right data so a clinician can make the proper diagnosis. The advanced digital exam tools use clinic-grade technology to capture high resolution images and sounds, allowing for more kinds of remote diagnoses and increased accuracy.
The secure cloud-based platform enables integration with existing HER systems and provides analytics for decision support with health alerts. TytoCare offers HIPAA compliance, and the modular product design also supports open APIs so other examination devices can be integrated within TytoCare.
Health Business Group is a sponsor of the upcoming anniversary party for Massachusetts Health Quality Partners (MHQP). I asked MHQP’s President, Barbra Rabson to reflect on the first couple decades.
MHQP is about to celebrate its 21st anniversary. What are you celebrating?
We are celebrating the courage and vision it took 21 years ago to found MHQP, and the amazing two decades of progress we’ve made since our inception. Our 21st anniversary is symbolic of our coming of age and reaching a level of maturity. MHQP has become an important part of the Massachusetts healthcare landscape over the decades thanks to the commitment and hard work of our diverse stakeholders – including patients, physicians, hospitals and payers. More than 40 sponsors and over 300 people are gathering on November 2 to celebrate MHQP’s unwavering commitment to reliable healthcare measurement and transparency and our pioneering work in the Commonwealth and the nation to systematically capture the patient voice and integrate it into care improvements.
At our anniversary celebration we will be honoring the vision of MHQP’s Founding Circle –Blue Cross Blue Shield of MA, Fallon Health Plan, MA Business Roundtable, MA Hospital Association (MHA), MA Medical Society (MMS), Harvard Pilgrim Health Care (HPHC), Tufts Health Plan and the State (Governor Charlie Baker was a founding member of MHQP when he was Secretary of Administration and Finance).
We will also be awarding MHQP’s first award in honor of the late Richard Nesson, MD, a founding visionary of MHQP when he was the Chair of the MHA Board in 1995 when MHQP was established. We are delighted that Susan Edgman-Levitan, the executive director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital and the founding president of the Picker Institute will be the first recipient of MHQP’s H. Richard Nesson Award.
How has the environment changed in MA over the past 21 years? What role has MHQP played in that?
The healthcare environment is drastically different than it was when MHQP was founded in 1995. When MHQP first started collecting and reporting comparative statewide performance information, we were the only game in town. For example, MHQP’s first in the nation statewide patient experience survey of acute care hospitals and public release came a full decade before CMS developed the hospital H-CAHPs survey! Likewise, when MHQP began collecting and reporting statewide clinical and patient experiences measures for ambulatory care, MHQP’s data was the only reliable source for quality benchmarks for our provider organizations. Before MHQP’s comparative quality reports, Massachusetts provider organizations only knew their own performance scores, they had no comparative benchmarks or best practices to drive performance improvements. Physician leaders (Barbara Spivak, Tom Lee and others) have told us MHQP’s performance reports were invaluable to them because our reports became the writing on the wall that they needed to make significant investments in their organization in the form of electronic health records and quality improvement infrastructure to advance their performance to the level they aspired to.
Another big change is that our reimbursement systems now provide millions of dollars of incentives for provider organizations to improve performance. When MHQP first started the term ‘pay-for-performance’ had not yet been coined. MHQP has always [encouraged] improvements through public reporting of reliable and trusted comparative performance information – relying on physicians’ intrinsic motivation to perform as well as they can. Now that provider compensation depends heavily on measurement we need to work harder to make sure we have accurate and fair measurements of quality care.
Finally, back in 1998 when MHQP first started reporting on patient experiences of care, patient experience was not considered a core measure of quality. MHQP’s statewide collection and reporting of patient experience helped draw national attention to the importance of listening to patients, and in 2001 the IOM introduced the concept of patient centered care as a key element of quality care in the Crossing the Quality Chasm Report.
Kindred organizations to MHQP have arisen around the country over the last couple decades. How do you relate to them?
MHQP was one of the first regional health improvement collaboratives (RHICs) to be founded in the country. Gordon Mosser (founding CEO of ICSI in Minnesota) and I organized the first meeting of regional collaboratives in 2004. As a founding member and past Board chair of NRHI (the Network for Regional Healthcare Improvement), it has been very gratifying to see so many new RHICs being established. There are now more than 40 across the country. I have been told by many of the younger RHICs that MHQP was a role model for them when they were first starting out, and I take great pride in that.
What does the future hold?
Great question, and one I have been reflecting on as we have been looking back on our first 21 years. One of the biggest challenges (and one of our greatest failures as a health care system) has been that we have not done a good job engaging our patients as a resource to help us improve outcomes. In many cases we have actively refused to seek input from patients, and when given feedback we have ignored it. We are now trying to make a 180 degree shift on this, to better engage patients in the co-production of solutions, and it is not easy because it requires a shift in mindset. I believe that MHQP’s two decades of experience capturing the patient voice and integrating that voice into care improvements positions us extremely well to support our practices and healthcare systems as they embark on this journey.