Future Now
The IFTF Blog
Interview Summary - Dr. David Sobel, Kaiser, April 3, 2009
HC2020 Interview Summary: Dr. David Sobel, Director of
Patient Education, Kaiser Permanente
Interviewer: Richard Adler * Date: April 3, 2009
1. His/her work (+ key issues)
For the past 30 years, has been working at Kaiser on preventive
medicine and health promotion "Trying to prevent medicine for 30
years."
As a primary care physician, he was interested in why people, even
those with health coverage, DON'T come in to get care. A lot of
it was "embedded in a culture of despair and dependency, and on
a lack of information. Realized that much of health status
is dependent on a range of psycho-social factors.
He has focused on supporting self-care, patient education,
psycho-social interventions.
When efforts are undertaken to reorganize health care, focus
is almost always on just the tip of the iceberg. But the
great bulk of health care is always provided by people
themselves. Their decisions about adhering to prescribed
regimens, when to seek care, is largely determined by
psycho-social factors in their lives.
We refer to providers and consumers as a dichotomy - but it
is really a false dichotomy. We have largely failed to
empower/support people to be better providers of their own health.
Examples of resources that help empower people: Healthwise,
health-oriented social networks, chronic disease self-management
program.
To improve health care, don't start with the providers,
but with people: what are their concerns, what are their
true needs in order to effectively self-manage their health?
If incentives are correctly aligned, there can be a shared
interest among all providers in supporting patients' well being.
Example: instead of having to refer patients to specialists for
future consultations, Kaiser's PCPs can call a specialist for
a brief phone consultation while a patient is with him/her. PCPs
can also request a consultation with a specialist by phone or
email. Also, when patients come for appointments, they get a
print-out tailored to their current situtation, including
recommendations for preventive measures. Doctor has
a decision support system to guide interactions.
Kaiser already has secure messaging between patients and
physicians. In the future, Kaiser will have better ways of collecting health
information from patients, so that doctors will be able to
review the information during appointments.
TRENDS/CHALLENGES
2. How optimistic about future of health/healthcare in 2020?
There is great potential for using technology to empower
people and to free physicians to spend more time with
patients. We tend to underestimate people's willingness
and ability to adopt new technologies. For example, a
lot of people use ATMs today who were not the early
adopters.
Older, frailer patients who may not be comfortable with
technology have children who are tech-savvy. And the
Boomers who will be getting care in 2020 are tech-savvy,
while the next generation is even more so.
One challenge: although technology can be used to collect
huge amounts of data, we need to make sure that providers
don't have to sift through all of it to find what's rele-
vant. Need intelligent systems that automatically triage
the data, support self-care and get the most relevant
information to providers. The system should be able to
help determine when patients need to be seen -- and when to
send an ambulance.
Reason for pessimism: there is "a huge amount of magical
thinking" about the benefits (cost savings) from more
extensive preventive care." If people get good preventive
care, they will live longer and eventually develop more
expensive problems: e.g., someone who survives a heart
attack may live long enough to need a hip replacement.
In some cases, the best way to save money is to STOP treat-
ment. E.g., a lot of people are being treated for
hypertension with little change in outcomes. At best,
if preventive care is effective, there will still be a
long lag time before there is a payoff.
3-4. Biggest trends or challenges & responses
1) We still underestimate the behavioral and psycho-social
dimensions of health. People who come in to see a PCP are
often in distress -- they real issue may not be physical,
but problems caused by a lost job, trouble with kids, etc.
The health care system is not well-equipped to take on big
social issues (just as the schools have been asked to do),
but the system needs to be better at providing "behavioral
interventions" -- e.g., teaching coping skills in dealing
with social problems.
In many cases, it is difficult for a physician in his office
to detect what is going on in people's lives, but a short
visit to their homes could yield important insights. Example
of a company that provides nurses for case management for
most costly patients - when a nurse made a home visit, she
discovered that issues had to do with living conditions and
with sleep problems. These are not high-tech solutions.
2) Clay Christiansen's Innovators Prescription - argues for
a greater focus on self-care. Much of what Sobel does as
an MD could be done by a nurse practitioner; much of what
is done by nurses could be done by patients themselves --
if they were empowered and equipped to do so.
3) Development of SHARED SYSTEMS that support collaboration
between physicians and patients. Intelligent systems that
will detect and deal with both UNDERTREATMENT and OVERTREAT-
MENT.
More information can also improve quality of care. Study
of diabetics found that a significant percentage were not
taking prescribed medications. But there was also a
failure of physicians to adjust dosages when symptoms were
getting worse. Better checklists, better protocols will
help ensure more uniform responses.
4) End of life care is responsible for a large portion of
health care spending. It is a stubborn problem, but small
changes can yield big results. Proper self-care includes
patients being able to decide when to forgo care.
FUTURE SCENARIOS
7. Most preferable scenario
- We will have achieved something close to universal coverage.
- There will be incentives in place to maximize "win-win-win"
solutions for payers, providers and patients.
- More care will be provided by integrated group practices
(like Kaiser), with care largely pre-paid, with a system
that shares information between patients and providers.
- Resources for psycho-social support will be integrated
with the health care system. [Today, mental health services
are largely separated from other health care services. Kaiser
now integrates "behavioral health specialists" -- psychologists
and social workers -- with primary and specialty care providers.
This helps physicians by alleviating them of burden of having
to deal with mental health issues.
- Patient compliance will improve as a result of having more
information about why they should take their meds, more support
for problems that interfere with compliance.
8. Most plausible scenario
- We have some form of universal coverage, but with a lot of
limitations, penalties and rationing of care.
- Systems that provide better outcomes will increase, but
fragmentation of care will still be the rule.
- We will have made little progress is "psycho-social care,"
which is still discounted as an important factor in health.
9. Most negative scenario
- The health care system will suffer because of widespread
economic collapse: we don't have the resources to sustain
even the current level of care.
- The number of uninsured will increase.
- The health care system is beset by a series of crises:
- mass infections/epidemics (e.g., influenza)
- terrorist or bio/nuclear attacks
- climate change leads to larger environmental crises,
such as more outbreaks of food contamination
For a system that is already struggling, there is not much
excess capacity to respond to these crises, which could
overwhelm the system.
10. Wrap-up
Kaiser has a real commitment to innovation. The reason that
it is not cited as often in case studies as places like
Virginia Mason, Geisinger or Intermountain Health is that
is is "orders of magnitude larger" than these places, so
is harder to follow and report on what it is doing. Kaiser
Northern California is #2 on 23 HEDIS quality measures.
In in an annual award for best hospital IT, Kaiser hospitals
won 12 of 15 awards in California.
Interview suggestion: Dr. Robert Pearl, CEO, Permanente
Medical Group, Northern California