In 2021, the AMA, in collaboration with Manatt Health, released case studies featuring organizations that are measuring the value of their virtual care programs as part of the Return on Health Framework. Two years later, we're checking in on the progress. On this episode, guest Dr Richard Milani, Ochsner Health, shares how their Hypertension Digital Medicine Program has improved patient outcomes, reduced avoidable emergency department utilization, and improved primary care capacity.
To explore this case study: https://bit.ly/44DVsUR
To discuss on the Physician Innovation Network: https://bit.ly/3XqQSqF
To explore the Return on Health Framework: https://bit.ly/433P4oF
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Stacy Lloyd: Welcome back to the STEPS Forward® podcast. My name is Stacy Lloyd and I'm the director of digital health here at the AMA. I'm back with another episode focused on the AMA's Return on Health Framework, which helps health systems and practices measure the value of virtual care programs within their organizations. As I mentioned in our last few episodes, to bring the framework to life, we collaborated with various health systems and organizations to gather case studies on their virtual care programs to better understand how they're measuring value in their environment. So after a couple of years, we're checking in on the progress. One of those systems we partnered with was Ochsner Health, and we are joined today by Dr Richard Milani, chief transformation officer for Ochsner Health, and the director of innovation at Ochsner and innovation accelerator within the health system. And he was gracious enough to share a case study with us on their Hypertension Digital Medicine Program. Dr Milani, welcome, and thanks for joining.
Richard Milani, MD: Yeah, it's great to be back, Stacy. Thanks for having me.
Lloyd: So could you set the stage for our audience? Tell us a little bit about Ochsner Health, your existing digital medicine program and innovation efforts overall, and then specifically touch on the program for hypertension that we featured in the report.
Dr Milani: Sure. Ochsner is a non-for-profit health system, it's headquartered in New Orleans, but we encompass several states now. We see about, roughly, between a million, million and a half unique patients a year. We have about 40 hospitals and several hundred outpatient facilities, including urgent care and regular routine ambulatory care. We rolled out what we called our first digital medicine program, which was hypertension in 2015, so we've been at this for a while now, this is not something we just started in the pandemic. And today we have roughly about 20,000 patients in our hypertension program alone, but we have other programs as well, so programs in diabetes that are modeled the same way, in COPD, and in dyslipidemia. That's where we are today.
Lloyd: Awesome. We will definitely dig into some of those, but first to get an update on the hypertension program, we highlighted that one in 2021 in the report, and the program in general was really working to improve clinical outcomes for patients with uncontrolled hypertension, reduce avoidable ER and inpatient visits by improving that control, and then also helping to improve primary care capacity as well. So how has this played out since the program launched, and has that been successful? Has the program evolved over the last few years? Touch on a couple of those things for us.
Dr Milani: Yeah, absolutely. So the good news is that we have very high evaluations by our patients, let's just start there. So our net promoter scores consistently run around d87, and we, actually we could talk about this, developed a trial in a large Medicaid-only population with several thousand in that population, and if we talk about net promoter scores there, it's actually 91, which is really extraordinary. We have seen better control. So let's just start with the simple measurement of control. We see generally two to threefold better control rates in our program than standard of care. We can get into all the reasons why. And that's been very consistent since its onset. We've had outside payers actually measure med adherence and they reported back to us and published the findings. We were the only program that they've ever actually evaluated that demonstrated improvement in medication adherence over time, whereas most chronic disease patients will see a reduction in med adherence over time.
So we have very high levels of satisfaction, improved med adherence, better control rates, and then we actually brought in a third party actuarial to look at benefits from a cost perspective, a financial perspective. And what we're seeing generally around—at least in our Medicare age population, or 65 plus—around a $350 per member per month in savings in that population. And again, that's due to, as you'd expect, if you have better control over a long enough period of time you'll see the benefits of treating hypertension. So those include all kinds of things, including stroke reduction, heart attacks, et cetera. So really from a 360 perspective, it's hitting on all cylinders. In terms of physicians, we have now 100% of our primary care docs enrolling patients into the program. They have a very high level of satisfaction with it because, again, it's easier for them to be able to have patients automatically enrolled, we take over managing the hypertension, and making sure that their patients are well controlled and stay that way.
And then in terms of capacity, this has been very difficult to measure. The one thing we can say is that I don't think there's any spot in the United States where we have an overabundance of primary care doctors. I'm saying that obviously with tongue in cheek because we'd have a deficiency. In terms of numbers of primary care doctors, we know that they represent the backbone of the health care systems and we certainly can't hire enough of them and they're not being produced enough either, so we've got a real problem there. If we're offloading, this is one of the few things that actually offloads work, we're not adding work to them, we're making it easier to do their jobs, and so by virtue of offloading a lot of work that involves chronic disease care, we're opening up slots for new patients to be seen, and so we know that we can improve capacity in that regard.
So it's been a real plus for them. I know that actually our leaders in primary care at Ochsner actually use this as a recruiting tool when trying to hire new doctors because they're saying, “Hey, wouldn't you rather be here where this kind of stuff is done, on your behalf behind the scenes, that improves your work life and allows you to potentially have less pajama time having to get in front of the medical record?”
Lloyd: So you really touched on all of the value streams, which I believe really was something that I think Ochsner was really strong in terms of our original case study, and touching in that clinician experience, patient experience, outcomes, access to care, financial impact, and even health equity, being able to offer your program across different patient populations even regardless of ability to pay for these programs. So this seems like a very established program. You just gave us an update on the continued success really, and it seems like it's only getting better.
I love the financial piece of this, not because it's the most important, and I'm going to get to some of this question later, but it's still something we continue to hear from even an advocacy perspective in terms of making some of these programs stick and getting coverage for these types of services. Is that offering this going to cost more money? Is it going to increase utilization and create over utilization? But I think what you said was so powerful is when we control it, it actually reduces costs because you're not having those acute events that are more high-dollar later on. But what I also think is so important to recognize and I think gets a little bit lost is some of that outcomes change requires time, and we need to make these services available and be able to track it over a significant amount of time to see that benefit. It's not just this quick fix when we're talking about, especially, chronic disease. So I really like that you and Ochsner have committed to doing that and tracking that and making it available long-term so we can start to see that impact and have that on paper. So here's where I would love to get into a little bit of how has all of this success really led to newer programs, and how are those going?
Dr Milani: That's really exciting, the opportunity to develop new things. And I'll give you another type of program. We build these from a medical perspective, but obviously if somebody wants to bring up the financial component, it's nice to be able to talk about it. So we developed a program over the past couple years that we've completed the pilot and we've got results that are very exciting, and it's in this 65-plus population again, but if you actually look at the cost data across the United States, so if we're just talking about total cost of care in any age group, if you look at 65 plus, the leading cost of care, at least in the US that's been recently published, is actually dementia. The second leading cost of care across the United States for that age group is cardiovascular. And the third leading cost may surprise folks, but it's in falls, and it's a huge problem.
It's about 28% of adults in that age group will fall each and every year. Not all falls of course result in injury, but we do know that 99% of hip fractures are due to falls, we know that the leading cause of head trauma in that age group are due to falls, and the leading admission to a hospital for any form of trauma in that age group is due to falls. It's also one of the leading causes of loss of independence. So if you want to end up in a nursing home, so to speak, start falling a lot. Just as a way of reference, there really is not a fall specialty if you think about that. There's little bits that are in different areas, but we do know that 60% or more of falls are due to more than one reason. So if you just go after one thing, you're unlikely to be able to address it.
So we decided to be able to try and put together a completely virtual digital program in falls, and it's really a couple of fundamental components. The first has to do with an alert system, which is what most people want. You've seen those little lanyards that people will have sometimes, “Help, I can't get up.” And basically it's a button that allows you to get to dispatch that can send an ambulance if you're alone and you're stuck. And so we did this in partnership with Apple, and because an Apple Watch does have that same characteristics, the difference being of course is that there are several differences. One, there's a lot of stigma associated to these lanyards, and when you actually interview folks, and there's actually been studies that have published on this where obviously there's real stigma associated with the watch. And we also know that the watch has very, very good GPS location finding, which some of the lanyard companies, not all of them, but have some issues.
So we did that in combination with a multi-modality prevention program. The goal is, could we make a serious impact in terms of hospitalizations due to falls? So we want to track falls, but you couldn't track every fall possibly, but you can certainly track emergency room visits and hospitalizations due to falls. So the program went through all the components that impact falls. We actually did this all virtually. We can get into the details of it, but the good news is that at the end of the pilot, we had several hundred people in our pilot, we demonstrated a 60% reduction in hospitalizations due to fall. So that's within six months. And that held up at the end of a year as well.
So that's another example of putting together a virtual program at home. They're not coming in, there's no face-to-face visits here that could be done anytime, anywhere where there's really a thorough evaluation and a very comprehensive approach that generated very high satisfaction, again, very similar to what we've seen in other digital programs, and huge impacts in terms of quality of life obviously, and of course cost of care as well. So there are programs that can be done in the digital world that can actually generate a pretty short term ROI.
Lloyd: That's great. Having all of the success in tracking the impact of these programs specifically for digital and virtual care space programs, it has been super crucial today for various reasons to payment policy expansion of coverage, so I'm interested in what you've seen in terms of forward progress, either locally within your system, talking to the payers and working with the payers within the network that Ochsner serves—have you been able to gain some traction and additional coverage for these benefits and programs because of being able to say, “Here's the success, here's the impact that this is really making.”?
Dr Milani: I wish I could give you great news on this front. The answer is not as much success as we would like. Now, the good news for us, and of course this applies to other health systems and maybe not to other health systems, is that maybe around a third of our patients we're fully at risk for. So there's not a lot of work to have to do to be able to demonstrate in our own population this is actually not only benefiting the people that we serve, which is our primary mission as a non-for-profit, but also generating real savings in terms of dollars spent, so that's actually less dollars spent is profit that we can turn into other programs. So when we've gone to traditional payers, the weakness that I've seen consistently—and this is a generality—it doesn't apply to a specific payer in any one market, but typically most commercial insurance companies will want to see an ROI within a year.
As you've already pointed out, some things can be done with an ROI in a year, and some may take two years, or three even. But generally, chronic disease care does require a little bit of time to generate the benefit of better control. So moreover, even if you publish your findings, which we publish all of our findings, by the way, they'll want to reproduce it all over again once again and again and again. So you're having to, I use this phrase all the time, reprove that gravity exists in multiple times. Even though we've established that gravity is this and this is what something weighs, they'll come back and say, “Well, maybe not in our patients.” So that's a little bit of a tough play. I will say that the interest level in other health systems that are taking risk is extraordinarily high to implement these kind of programs, but generally we don't see that same sort of excitement typically, or there's a lot more rigor to have to go through when trying to negotiate with payers.
Lloyd: I think the evidence question is continually coming up across different stakeholders, even some health systems or physicians that we talk to that aren't using these tools in practice and aren't prepared to or wanting to integrate those in because of this evidence. And it's like, “At what point is it enough evidence? We're creating it, we're publishing it, we're doing the work.” Hopefully we'll figure that out sooner rather than later and get some movement going there.
So the AMA also recently released the Future of Health Report that looks at the digital health disconnect, which we described as the gap between the potential of digitally enabled care and today's reality of both in-person and virtual care working in parallel instead of creating that somewhat seamless experience that delivers the right care, at the right time with the right modality. So I think it sounds like your programs are doing this really well already, but looking at your current and future programs involving digitally enabled care, how would you rate or talk about Ochsner's creating that seamless experience? Where do you think you fall on that? And then also, secondary question would be what challenges still exist and where are the biggest opportunities for improvement there?
Dr Milani: First of all, a great point, great question. And I'm not sure that we've perfected anything, we're certainly on that journey, and I think as each year goes by we're further along the journey. If we were to start off by saying what would be the idealized, if we were just looking up at the clouds and imagining what that future could be, it'd really be identifying problems at the moment they occur as opposed to waiting to find out days later or to make an appointment and do all the things necessary before a person could interact with the health system. The ideal scenario would be once that person finds out, we may know it roughly at the same time and we can start figuring out the right timing and the right place and the right venue for managing that individual.
And I think what's going to happen to all of us is this, and that is what we're seeing more and more, is that the ability of technology to be able to pick up problems. We can go back to the Apple Watch, as an example, it's not just Apple, but as a great example it can identify that you fell, let's say, it can identify that you're now in atrial fibrillation. Those are a couple of common examples that people grasp. Your iPhone can identify gait abnormalities that put you at risk for, say, a fall. But we also know that there's new technology coming around the corner that I could identify that your blood sugar's elevated or that you have high blood pressure, you didn't even know it. Imagine a world where you have on just a device that's telling you the time or doing whatever other functions that you need in your day-to-day life when it pops up and tells you, “Stacy, over the past two months, your blood pressure's been high.”
I think it's important to understand that only 22% of Americans, adult Americans, get screened every year, which means that 78% don't. And if you don't go through screening, you may have diabetes or high blood pressure or cholesterol problems or whatever else that we screen people for and not know it. And then, of course, your first symptom of that or problem may be much further down the road. What if we could be partnering with you in a good way so that when you get notified maybe there's an issue, we get notified too, and then we interact right there. Some of that could be done virtually, some of that could be done digitally, some of that might have to be in person, but the point is we can create a relationship and a profile that would ideally figure out the best way to manage that in the moment. And I think that's where we're heading.
We have a program now in elderly folks that live alone where we can track passively, you're not seeing anything, there's no audio, visual going on, activities of daily living. And what we're finding is we start seeing aberrations there that's a leading indicator to days to maybe even weeks later that they may have a problem that leads to a hospitalization or a clinic visit. So what if, once that is identified, we can then maybe call out to them and say, “Hey, I'm a nurse or I'm a this, how you doing?” And perhaps we could intervene sooner, that makes everybody better.
If you're looking at it from the finance perspective, obviously I've avoided a more serious hospitalization. If I'm looking at it from a clinical perspective, I've treated something or dealt with something early in the course versus late, and now it's easier to treat, we've won together. And from the patient perspective, hey, I didn't end up in the hospital or I'm still independent, or whatever it is that we were wanting to achieve in terms of quality of life. So I think that's where all this is going towards. And what we want to create in terms of a system is how can we meet you at any moment in time, depending on the condition, with the best interventions, whether they be in person or virtually?
Lloyd: What do you see as our biggest challenges to getting there? Do you envision a world where most patients are receptive to that? I'm interested in what you've seen from the patient perspective and how they react to that, like, “Hey, we noticed this is happening,” and maybe they weren't even aware of it, but also from the clinician perspective, and it's really a different way of thinking about how we deliver care, and I think there is still some struggling to get everyone on board with that way of care delivery.
Dr Milani: Yeah, that's a good question. I think there's two points I'd make. One is let's forget the health systems, let's forget doctors, the technology's already happening independent of us, whether we like it or not. I'm not Apple, I'm not Google, I'm not Amazon, I'm not any of these companies, and they're making these things and people are purchasing them. So my point is that it's already popping up and telling people, “You have a problem here.” So now let's just use the AFib example. You're Stacy, you're living in A, B, C city anywhere in the United States, and it pops up and says, “This looks like AFib, the average time to see a cardiologist across the United States is 22 days.” That's where we are today. And moreover, there's going to be time before that you're going to probably contact maybe a primary care and then they're going to refer you and off you go, and that's it.
I also will give you another story, and I'm sticking on the AFib thing because we just started with it, but the majority of stroke presentations in AFib, the patient, the majority they were unaware they had AFib prior. So it wasn't like you had a symptom, you even knew a problem, and all of a sudden your first thing is you wake up one day and you can't move. The other point you bring up as well, do people want this? And the answer is I don't know, but they're buying the technology and it's giving them feedback already, so why shouldn't health systems pop up and say, “Hey, if you're interested, we can be here for you. If you're not, that's okay. This is a free country. You do what you want.”
But if we're going to be receptive, I would think that the systems that are ready to do that are going to certainly be those that are going to win over those that are not, because I would think that there'd be a huge number of people that would say, “Yeah, I don't want to wait 22 days. I didn't know I had this problem. I'd like to deal with it right now if I could.” And we'll do it on your schedule as opposed to all kinds of shenanigans to get on my schedule kind of thing. So I think that's how things are going to evolve. And like I said, it won't be a requirement for anybody, but it'll certainly be an opportunity, an option for people, and I think people will take it.
Lloyd: I think that's a really interesting and good way to look at consumers and patients and people who are already buying these things: How can clinicians, health systems take advantage of what they already have to better manage them from afar or know what's going on with their health? Because I think some of the argument too historically has been when you go to a primary care physician, you go in for your annual visit and then you don't see them again for a year at best. So I think having those extra touchpoints and leveraging what is already being used with the patient or in the home is a really good way to look at it to keep people healthy. So any final thoughts on the future of health and where we're going?
Dr Milani: I think it's the points that I brought up that I think the future of health care is going to be more in-the-moment, we're heading more and more closer to that, and I think that's good news for people that want to stay independent and stay healthy. So I'm excited about our future.
Lloyd: Well, thank you, Dr Milani, for being with us today. Congratulations on continuing all of the success of the program that we featured in our Return on Health Report and the other ones that have continued to be successful for Ochsner and the health system and its patients and population, so great to talk to you today. That will wrap us up, and we'll see you next time on the STEPS Forward® podcast.
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