Clinical info available YEARS before CDC guidelines and apparently IGNORED by them .. because they had an agenda ?

Posted on January 14, 2019 by Pharmaciststeve

Need for High Opioid Dose Linked to CYP450

https://www.medscape.com/viewarticle/771480

September 25, 2012 (Phoenix, Arizona) — Patients with chronic pain who require high doses of opioids to achieve pain relief show exceptionally high rates of defects of the cytochrome P450 (CYP450) enzyme system compared with the general population.

The CYP450 enzyme system is known to play an important role in the metabolism of opioids, and recent advances in genetic testing allow for the easy detection of defects to the enzymes.

“We’ve known for years that among patients with the exact same pain conditions one may need 500 mg of morphine a day while the other may need only 50 mg, but we’ve always wondered why,” lead author Forest Tennant, MD, told Medscape Medical News.

“It turns out that among high-dose patients, about 85% have these defects in 1 or more of their CYP450 enzymes.” In the general population, only about 20% to 30% of people have CYP450 defects, he said.

His findings were presented here at the American Academy of Pain Management (AAPM) 23rd Annual Clinical Meeting.

Emerging Frontier

To evaluate patterns among his own patients with intractable pain, Dr. Tennant tested 66 patients attending his clinic in West Covina, California, who required more than 150 mg equivalence of morphine a day for pain relief.

The patients were tested specifically for the CYP2D6, CYP2C9, and CYP2C19 enzymes. The results showed that 55 (83.3%) of the 66 patients had 1 or more CYP450 defects, 21 (31.8%) had 2 defects, and 6 (9.1%) had 3 defects.

According to chronic pain management expert Gary M. Reisfield, MD, genetic research is poised to reveal expansive new insights into the mechanisms of why some patients respond to medications whereas others don’t.

“Pharmacogenomics represents the emerging frontier for understanding interindividual variability in opioid efficacy and toxicity, and in guiding safe and effective opioid pharmacotherapy,” said Dr. Reisfield, an assistant professor and chief of Pain Management Services in the University of Florida College of Medicine’s Divisions of Addiction Medicine and Forensic Psychiatry and Department of Psychiatry in Gainesville, Florida.

“With regard to opioid response, the mu-opioid receptor, the ATP [adenosine triphosphate]-binding cassette subfamily B, and other genes are believed to play significant roles,” he explained.

With CYP450, a “superfamily” of enzymes responsible for the metabolism of most opioids, various polymorphisms and variables in activity can have clinical significance.

The enzymes, for instance, have been implicated as playing a role in the overactive metabolism of codeine. In a recent case, the US Food and Drug Administration (FDA) in fact issued a warning about the risks associated with codeine after 3 children died and a fourth child nearly died after having been administered codeine following tonsillectomy and adenoidectomy.

“Once in the body, codeine is converted to morphine in the liver by an enzyme called cytochrome P450 isoenzyme 2D6 (CYP2D6) (and) some people metabolize codeine much faster and more completely than others,” the FDA wrote in a statement.

“These people, known as ultra-rapid metabolizers, are likely to have higher-than-normal levels of morphine in their blood after taking codeine. These high levels can lead to overdose and death,” the agency said. “The three children who died after taking codeine exhibited evidence of being ultra-rapid metabolizers.”

Conversely, some people are “poor” metabolizers of codeine, meaning that they have few, one, or no copies of the gene or CYP2D6, Dr. Reisfield added.

“Such individuals are incapable of metabolizing codeine morphine, and thus incapable of deriving analgesia from administration of the medication.  Both genetic defects would be detected through CYP2D6 genotyping.”

Drug Seeker or Higher Requirement?

That being said, Dr. Reisfield suggested that the new study’s findings, although intriguing, leave many unanswered questions.

“The study adds to a nascent literature on pharmacogenomics in opioid therapy,” Dr. Reisfield said. “Dr. Tennant demonstrates an association between CYP ‘defects’ and requirements for high opioid dosages. He has not, however, established a causal association.”

The study’s limitations include that “the most frequent defects were in CYP2C19, which plays an inconsequential role in methadone metabolism, but plays no role in the metabolism of other opioids,” Dr. Reisfield said.

Meanwhile, CYP3A4, an important enzyme for the metabolism of most opioids, was not genotyped in the study, Dr. Reisfield said.

In addition, the specific opioids used were not identified, which is important because some opioids, including hydromorphone, oxymorphone, and morphine, are not metabolized by CYPs, he added.

It’s not known whether subjects were receiving other medications that could have affected CYP metabolic activity.

Dr. Tennant acknowledged that the study would have benefited from more information from a control group of patients with chronic pain who did not require the high doses.

No one should be called a drug-seeker these days until you’ve done the CYP450 testing.

“It is unknown just how prevalent severe intractable pain patients with CYP 450 defects who require high dose opioid therapy may be compared to the general, chronic pain population, but it is probably a small percentage,” he wrote.

“This study makes it clear, however, that some severe chronic pain patients have major CYP defects that affect opioid metabolism and dosage.”

At the very least, the findings suggest that CYP450 testing can represent an important starting point for evaluation when high doses of opioids are required, Dr. Tennant asserted.

“No one should be called a drug-seeker these days until you’ve done the CYP450 testing to see if that patient simply needs an awful lot more medication than someone else.”

Dr. Tennant and Dr. Reisfield have disclosed no relevant financial relationships.

American Academy of Pain Management (AAPM) 23rd Annual Clinical Meeting. Abstract 5. Presented September 21, 2012.

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Ohio: Gov John R. Kasich .. keeps claiming that Ohio has a opiate OD problem..little did he know ?

Posted on January 14, 2019 by Pharmaciststeve

Mount Carmel doctor, nurse and pharmacist accused of administering lethal doses of fentanyl

https://www.10tv.com/article/mount-carmel-doctor-nurse-and-pharmacist-accused-administering-lethal-doses-fentanyl

COLUMBUS – A Mount Carmel West doctor, nurse and pharmacist have been accused of ordering and providing lethal doses of fentanyl to an Ohio woman and as many as 26 other patients, according to a civil lawsuit filed Monday and statements made by the hospital.

The physician, Dr. William Husel, has been fired, according to a hospital statement, and 20 other hospital staff have been removed from providing further patient care while the hospital investigates.

Reached by phone Monday, Husel declined to comment 10 Investigates. An email and voice message were left for his attorney.

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According to a copy of the complaint, Mount Carmel hospital administration reached out to former patient Janet Kavanaugh’s family on Monday, January 14, 2019 and alleged that the “actions described in the lawsuit are not an isolated incident, but rather, a repeated course of conduct by the Defendants with respect to at least 26 other patients at Mount Carmel.”

Mount Carmel released a statement to 10 Investigates that read in part:

“During the five years he worked here, this doctor ordered significantly excessive and potentially fatal doses of pain medication for at least 27 patients who were near death. These patients’ families had requested that all life-saving measures be stopped, yet the amount of medicine the doctor ordered was more than what was needed to provide comfort. On behalf of Mount Carmel and Trinity Health, our parent organization, we apologize for this tragedy, and we’re truly sorry for the additional grief this may cause these families…”

The statement went on to say: “We’re working hard to learn all we can about these cases, and we removed 20 hospital staff from providing further patient care while we gather more facts. This includes a number of nurses who administered the medication and a number of staff pharmacists who were also involved in the related patient care.

Mount Carmel provides compassionate care that takes into account the decisions of patients and their families. We believe in helping patients who are near death die peacefully and naturally.

The actions instigated by this doctor were unacceptable and inconsistent with the values and practices of Mount Carmel, regardless of the reasons the actions were taken. We take responsibility for the fact that the processes in place were not sufficient to prevent these actions from happening. We’re doing everything to understand how this happened and what we need to do to ensure it never happens again. We’re joined in this effort by leaders of Trinity Health and we’ve asked outside experts to assist us.”

Two other people named in the lawsuit, nurse Tyler Rudman and pharmacist Talon Schroyer, also declined to comment when reached by phone Monday evening. They also declined to say if they’re still working for the hospital.

The lawsuit, filed Monday in Franklin County Common Pleas Court, alleges that Dr. William Husel ordered 1,000 micrograms of fentanyl be administered to an Ohio woman, Janet Kavanaugh, through her IV.

“Defendant Husel’s order of a grossly excessive and inappropriate dosage of Fentanyl was reviewed and approved by Mount Carmel’s pharmacist – Defendant Schroyer – and the medication was made available to Defendant Rudman, Janet’s nurse,” the lawsuit states. “Defendant Schroyer knew that the ordered dosage of Fentanyl was grossly inappropriate, served no therapeutic purpose or function, and would only serve to hasten the termination of Janet Kavanaugh’s life.”

The lawsuit goes on to allege that Rudman administered the lethal dose of Fentanyl to Kavanaugh on December 11, 2017 and that she died within minutes of receiving the injection.

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If you want Congress to listen to you… this is how it is done

Posted on January 14, 2019 by Pharmaciststeve

Dems Are Partying With Lobbyists In Puerto Rico While Government Employees Are Losing Their Homes

https://townhall.com/tipsheet/bethbaumann/2019/01/12/dems-are-partying-with-lobbyists-in-puerto-rico-while-government-employees-are-lo-n2538964

Spotted: Sen. Bob Menendez on the beach at a resort in Puerto Rico on Day 22 of the partial government shutdown. Reports say dozens of Dems are in PR for the CHC BOLD PAC winter retreat — including meetings on Maria cleanup, and a party with PR’s “Hamilton” cast.

We’re currently in the midst of the longest government shutdown in American history. President Donald Trump said he would stay in the White House all weekend, in hopes that Democrats would be willing to negotiate a budget that included funding for his highly-anticipated border wall. That definitely won’t happen now that it’s known that at least 30 Democrats are partying in Puerto Rico with hundreds of lobbyists. It’s all part of the Congressional Hispanic Caucus BOLD PAC winter retreat, The Washington Examiner reported.

Apparently Democrats decided to hold the retreat in Puerto Rico to help draw attention to the destruction Hurricane Maria caused back in 2017. They brought 250lbs of donated medical supplies. But the trip is lavish. BOLD PAC chartered a 737 for members, their families, and chiefs of staff to attend for the weekend. 

No one knows exactly which members are in attendance. Speaker Pelosi was rumored to be in attendance but one of her staffers said she was unable to make the trip. 

Organizers must have realized how horrible the optics are: Here are Democrats, who claim to be the champion of the worker, partying in Puerto Rico while 800,000 federal employees are worrying about how they’re going to pay their bills and keep a roof over their heads.

Bold PAC Chair Rep. Tony Cardenas released the following statement about the shutdown and their “important weekend” in Puerto Rico:

House Democrats voted to open the government multiple times; sadly, Senate Republicans and President Trump are continuing to put partisan politics ahead of our country, forcing the government to remain shut down. As our Bold PAC members make their way to Puerto Rico for this important weekend — the largest contingency of House Democrats to visit Puerto Rico where they’ll be hearing from Commonwealth and local elected officials about the ongoing recovery efforts — we will be closely monitoring the situation in Washington. If there is any progress by Senate Republicans or the White House to reopen the federal government, then we will act accordingly.

This gathering was planned months before Trump decided to shut down the federal government for his unnecessary and costly border wall. The purpose of hosting Bold PAC’s retreat in Puerto Rico is to see and hear from the more than 3.5 million American citizens who have been working tirelessly to rebuild their lives on the Island after Hurricane Maria. This remains a national priority, and it is necessary for us to be there and honor our fellow American children, seniors, veterans, men and women.

So now it’s President Trump’s faults that Democrats flee? Come on now. They could have easily canceled the trip if they truly cared about working people.

Because nothing says “I represent the American people” like sitting on a warm sandy beach while people are fighting to put food on their tables, clothes on their backs and roofs over their heads because politicians can’t agree on anything.

Great job representing your constituents, Democrats. Job well done.

It is simple, charter a large plane to take 30 members of the House, their spouses and their chief of staff. Mix in a HUNDRED OR SO lobbyists all funded by a half dozen or so large companies. Take them all to a warm Caribbean Island and put them up in a luxury beach hotel for the weekend.. 

Those poor members of Congress, this 115th Congressional session started way back on Jan 3rd, 2019… no wonder they needed a “warm weather vacation”

If any of you are stilling wondering why all of your emails, faxes, letters, phone calls, signing petitions and other attempts in contacting members to share your concerns about something/anything… this should demonstrate just why your efforts may seem to have fallen on deft ears…

Apparently there is no published list of which 30 members of Congress are on this “vacation” except for Sen. Bob Menendez got his picture taken on the beach. Of course, Senator Menendez  has been under investigation for corruption for the past 5 yrs and was just dismissed a year ago. https://www.theguardian.com/us-news/2018/feb/01/bob-menendez-federal-prosecutors-dismiss-corruption-charges

 

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quote of the day: each of the 169,936 PREVENTABLE deaths recorded in 2017 were PREVENTABLE

Posted on January 14, 2019 by Pharmaciststeve

Report: Americans Are Now More Likely To Die Of An Opioid Overdose Than On The Road

https://www.npr.org/2019/01/14/684695273/report-americans-are-now-more-likely-to-die-of-an-opioid-overdose-than-on-the-ro

For the first time in U.S. history, a leading cause of deaths — vehicle crashes — has been surpassed in likelihood by opioid overdoses, according to a new report on preventable deaths from the National Safety Council.

Americans now have a 1 in 96 chance of dying from an opioid overdose, according to the council’s analysis of 2017 data on accidental death. The probability of dying in a motor vehicle crash is 1 in 103.

“The nation’s opioid crisis is fueling the Council’s grim probabilities, and that crisis is worsening with an influx of illicit fentanyl,” the council said in a statement released Monday.

Fentanyl is now the drug most often responsible for drug overdose deaths, the Centers for Disease Control and Prevention reported in December. And that may only be a partial view of the problem: Opioid-related overdoses also have been undercounted by as much as 35 percent, according to a study published last year in the journal Addiction.

The council has recommended tackling the epidemic by increasing pain management training for opioid prescribers, making the potentially lifesaving drug naloxone more widely available and expanding access to addiction treatment.

While the leading causes of death in the U.S. are heart disease (1 in 6 chance) and cancer (1 in 7), the rising overdose numbers are part of a distressing trend the nonprofit has tracked: The lifetime odds of an American dying from a preventable, unintentional injury have gone up over the past 15 years.

“It is impacting our workforce, it is impacting our fathers and mothers who are still raising their children,” said Ken Kolosh, manager of statistics at the National Safety Council. Kolosh said that those accidental deaths usually affect people in the “core of their life,” with greater financial and emotional ramifications than deaths of those in their later years.

The Two-Way

Pedestrian Fatalities Remain At 25-Year High For Second Year In A Row

Vehicle crashes remain a leading danger as well. Kolosh said half of people who died in crashes they analyzed were not wearing seatbelts. Meanwhile, the frequency of pedestrian deaths has increased, led by a jump in fatalities in urban areas.

Pedestrian deaths have been at a 25-year high, according to the Governors Highway Safety Association. A 2017 study found that an average of 13 people a day were killed by cars between 2005 and 2014, and that people of color and the elderly are disproportionately at risk.

“Historically, roadways have been designed to make it as efficient as possible for the vehicle,” Kolosh said, noting that bicyclists and pedestrians have been shortchanged. “We now have to do a far better job of building our infrastructure to accommodate all road users.”

Kolosh said he hopes the council’s analysis will allay unfounded fears, and remind people of more common dangers.

“As human beings, we’re terrible at assessing our own risk,” Kolosh said. “We typically focus on the unusual or scary events … and assume that those are the riskiest.”

He said data show the opposite is true.

Health

U.S. Life Expectancy Drops Amid ‘Disturbing’ Rise In Overdoses And Suicides

For example, an American’s likelihood of dying in a “cataclysmic storm” is just 1 in 31,394.

Dying as an airplane passenger? 1 in 188,364.

In a train wreck? 1 in 243,765.

Falling? 1 in 114.

Kolosh said the probability of dying in a fall has increased (it was 1 in 119 last year), driven by more recorded falls among older adults as the U.S. population ages. Experts say the best way to prevent that risk is exercise. It’s a reminder, Kolosh said, that each of the 169,936 preventable deaths recorded in 2017 were preventable.

“Your odds of dying are 1 in 1,” Kolosh quipped. “But that doesn’t mean we can’t do something. If, as a society, we put the appropriate rules and regulations in place we can prevent all accidental deaths in the future.”

My math may be wrong… but we have about 320 million people in this country and if we have 1 in 119 chances of dying from a fall… would that mean that you divide 320 million by 119 ?  That comes out to 5.8 million will die from a fall..

Use the 1 in 96 chance of dying of a opiate overdose … comes out to 3.3 million dying from a opiate overdose.. where the last I saw the CDC reported some 70,000 deaths from ALL DRUG OVERDOSES…

Maybe they are using the “new math” and I am still using the “old math ” ?

Using these numbers and the reports out yesterday that the USA’s birth rate is at a THIRTY YEAR LOW… between the two… the population of USA could be totally EXTINCT in a few generations ?

Filed under: General Problems | 7 Comments »

The “bad” happens when patients are forcibly tapered off their medications, leaving them with no way to adequately address their pain

Posted on January 13, 2019 by Pharmaciststeve

Oregon’s illegal drug users rewarded as chronic pain patients suffer

https://www.statesmanjournal.com/story/opinion/2019/01/11/oregons-illegal-drug-users-rewarded-chronic-pain-patients-suffer/2548946002/

As a general practitioner, I have seen the “good,” the “bad,” and the “ugly” of the “opioid epidemic.”

The “good” happens when patients are stabilized on their analgesics and able to return to work or volunteer and regain a better quality of life. 

Clinically proven questionnaires are available and I use them in my practice to pre-screen and continually rescreen all patients, which helps significantly with identifying and addressing any areas of concern. 

I review Oregon Prescription Drug Monitoring Program (PDMP) data every morning on every patient that I will see that day.  Unfortunately state law doesn’t require that level of review, so many providers fail to use this benefit, but at times it’s an inaccurate resource. There are time considerations in utilizing the PDMP, and some providers say they don’t have time, but when they can assign a staff member to do it, there’s no  excuse for not using this valuable tool.

The issue: Two Views: Is Oregon abandoning those living with chronic pain?

A different perspective: Chronic-pain patients suffer as agencies try to regulate addiction

The “bad” happens when patients are forcibly tapered off their medications, leaving them with no way to adequately address their pain.  Only recently have some insurers started providing more physical therapy, chiropractic, and other treatments, but unfortunately with limitations to the number of visits or total overall costs, they fall short of even a complimentary treatment. 

I have seen providers misread drug tests and dismiss patients with rapid or no tapers.  They fail to do confirmation testing to ensure the office test is accurate.  They look for any excuse to fire the patient. Many of these patients will become unable to work, become less functional at home, and personal relationships become strained.  Some patients end up divorced or contemplate suicide when their pain is uncontrolled.

The “ugly” happens when federal and state agencies blame the opioid epidemic on providers and patients. 

They are easy targets because the provider has an office and the patient uses a pharmacy. They have tried unsuccessfully for decades to arrest the street dealers and buyers who hide in the shadows. 

The government’s own data shows that the vast majority of “opioid” deaths occur as a combination of illicit drugs that were never prescribed to the deceased. But patients who have been using their drugs properly are attacked and degraded. 

Patients are dismissed from their providers for doing nothing wrong, all because the provider fears the government will take away their license if they continue prescribing pain medications. 

The illegal drug users get rewarded with lighter sentences, safe injection places to use their illegal drugs, and disability or unemployment benefits because they’re too busy doing drugs to do anything else. 

They are not dismissed or tapered, and continue getting their Methadone or Suboxone medications from treatment centers even when they fail their drug tests. 

Many of today’s opioid opponents were once prescribers themselves making a living off patients’ pain. Then public opinion shifted. So those prescribers changed their tune. They went where the government’s money flows.

That’s how sharks congregate.

Dr. Darryl George is with Affordable Integrative Medicine in Roseburg, Oregon. Reach him at office@doctor-george.net.

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She was stuck – unable to change doctors without a referral from her current pain doctor, who refused

Posted on January 13, 2019 by Pharmaciststeve

Chronic-pain patients suffer as agencies try to regulate addiction

https://www.statesmanjournal.com/story/opinion/2019/01/11/chronic-pain-patients-suffer-agencies-try-regulate-addiction/2548890002/

Could the fact that a prescriber CHANGES or DELETES a pt’s diagnosis and replaced it with a diagnosis does not fit the pt’s health condition be considered MALPRACTICE particularly if the “new therapy” causes the pt’s quality of life to deteriorate ?  And the prescriber basically “holds the pt hostage” for refusal to refer the pt out ?

The pt’s insurance should have a network of approved prescribers and they should be able to intercede on the pt’s behalf in find a new prescriber and should the pt file a complaint with the state’s Medical License Board for both malpractice, pt abuse and unprofessional conduct ?

Opioid. For many, the word elicits images of addiction, but that’s only one side of the story.

This is our side, the one that’s no longer socially acceptable, that shatters bias and stigma. It’s the side of the story that I live — that of the chronic pain patient (CPP), not the addict.

The vast majority of people who use prescription opioids never become addicted; they use their medication as prescribed. It facilitates their lives, and if it’s discontinued they will lose quality of life.

The issue: Two Views: Is Oregon abandoning those living with chronic pain?

A different perspective: Oregon’s illegal drug users rewarded as chronic pain patients suffer

My mom worked at the United States Post Office, a job she loved. After a work injury and failed surgeries, she was left in pain, permanently disabled, and unable to function.

She tried every alternative, but nothing helped. Finally, she started opioid medication and began living again — raising her grandchildren, maintaining her home and life. Then her primary doctor retired. She was referred to a well-known Salem pain doctor who, despite 13 years of MRIs, other tests and records, insisted she either accept a diagnosis of Substance Use Disorder (SUD) and receive Suboxone or be tapered completely off medication, and receive nothing for pain. She did everything right, didn’t fail one drug urinalysis (UA), took medication as prescribed, but it didn’t matter.

She was stuck – unable to change doctors without a referral from her current pain doctor, who refused. She wasn’t an addict, didn’t have SUD, but was desperate to maintain her life.

Suboxone was ineffective for her pain — it isn’t even approved for pain. Without effective medication, my mom stopped living. She agonized in bed all day, every day. She’s not alone.

Today, a father is confined to his bed with untreated pain because his doctor was forced to taper him off analgesics. A parent looks down at the deceased body of their child who chose to die rather than face another day in horrible pain.

These stories are not unique or hypothetical — many are suffering. 

Legislation, proposals and rules threaten this fate for every CPP. While opioids are not the answer for everyone, for some they’re a life saver.

Merging CPP with addict is a misconception not supported by data. It’s a tactic to blur the lines. It starts with a heart-wrenching story of addiction and ends with punishing CPPs.

Recently, there was a press release for the Prescription Drug Monitoring Program which began with a tragic account of addiction. The solution was to further restrict CPPs, instead of curbing addiction. This is a common tactic.

CPPs are shamed, suffer discrimination and stigma. We are guilty until proven innocent, and forced into highly regulated pain contracts, random UAs, and even with compliance, many are forced off their medication.

You’ve heard one person every three days dies of an opioid overdose in Oregon (not necessarily CPP). In those three days, over 15 times more people die of alcohol-related deaths.

Four years ago, a drunk driver permanently broke my body so now I’m a CPP, and yet he is free to drink as much as he chooses while I am in danger of losing my quality of life.

All in the name of fighting addiction.

Wendy Sinclair, who lives in Adair Village, is co-founder of the Oregon Pain Action Group and Oregon Legislative Coordinator for The Alliance for the Treatment of Intractable Pain. Reach her at wendyrsinclair@gmail.com.

 

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It is a RIGGED GAME !

Posted on January 13, 2019 by Pharmaciststeve

Filed under: General Problems | 2 Comments »

Liking vs Sharing on FACEBOOK

Posted on January 12, 2019 by Pharmaciststeve

Some of us have regularly discussed why many in the chronic pain community do not seem to be connected in general.

I have been paying attention to the number of “likes” verses the number of “shares”

There in may lie the problem… according to what I have read when someone “likes” on a post or comment in FB.. apparently all it does is place one of various “icons” on the post

Whereas, when someone “shares” a post… it is copied out to all of their FB friends.. which might almost bring them up to speed on what is happening or not happening in or to the chronic pain community and in turn they may share if with all their friends.

Maybe more “sharing” of FB posts might get more in the chronic pain community on the same page and more “bodies” into “the fight”

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sick of suffering website

Posted on January 12, 2019 by Pharmaciststeve

Four lawsuits have been filed so far. I have joined 2 so far and will be joining the other 2 this week.

Please join all of them if you can. Especially if you or someone you love is in pain and being tortured because of opioid hysteria and lies that the CDC publicly admitted to telling via padding the OD statistics.

If you live in a state not yet listed and want to file please contact Robert D. Jr. Rose and let him know.

Please share like crazy!

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A glimpse into the future of healthcare in America ?

Posted on January 12, 2019 by Pharmaciststeve

The No. 1 takeaway from the 2019 JP Morgan Healthcare Conference: It’s the platform, stupid

Written by Dan Michelson, CEO, Strata Decision Technology | January 11, 2019 |
This is very interesting “crystal ball view” into the way that healthcare is provided and received.  Some of my readers have some difficulty to understanding the larger picture outlined here.  The biggest casualty of all of this consolidation could be a lot of the for profit insurance industry and the PBM industry. Strangely what is being discuss seems to parallel those processes behind the concept of Affordable Care Act (Obamacare) which was described in that structure as ACO’s (Accountable Care Organizations) which basically hypothesized that the ACO’s would be a collective organization that would provide “total care” to a fixed number of pts for a certain $$$/pt/month and be at financial risk.  I also find it interesting that it is mentioned in this article that this all started about 10 years ago…. which just happens to be about the same time that the Obama administration came to power. Whether pts benefit or suffer from this type of organization is yet to be seen and may not have a final picture/conclusion for a decade or more into the future.

If you want to understand the shifting sands of healthcare, you’ll find no better place than the nonprofit provider track during the infamous JP Morgan Healthcare Conference that took place this week in San Francisco.

Over 40,000 players were in town from every corner of the healthcare ecosystem. However, if you want to hear the heartbeat of what’s happening at ground level, you needed to literally squeeze into the standing room only nonprofit provider track where the CEOs and CFOs of 25 of the most prominent hospitals and healthcare delivery systems in the country shared their perspectives in rapid-fire 25 minute presentations.

This year those presenters represented over $300 billion, or close to 10 percent of the annual healthcare spend in U.S. healthcare. These organizations play a truly unique role in this country as they are integrated into the very fabric of the communities that they serve and are often the single largest employer in their respective regions. In other words, if you work in or care about healthcare, understanding their perspective is a must.

Every year I take a shot at condensing all of these presentations into a set of takeaways so healthcare providers who aren’t in the room can share something with their teams to help inform their strategy. So what do you need to know? Glad you asked, here you go.

Shift Happens — Moving from Being a Healthcare Provider to Creating a Platform for Health and Healthcare in Your Community

Trying to synthesize 25 presentations into a single punch line is pretty stressful. I listened to every presentation, debriefed with other healthcare providers in the audience afterwards and then spent the next 48 hours trying to process what I heard. I was stumped.

But then, finally, it hit me. To take a new spin on an old phrase, “It’s the platform, stupid.” To be clear, even though I’ve been in healthcare for close to 30 years, “stupid” in that sentence is absolutely referring to me.

So the No. 1 takeaway from the 2019 JP Healthcare Conference is this — for healthcare providers, there is a major shift taking place. They are moving from a traditional strategy of buying and building hospitals and simply providing care into a new and more dynamic strategy that focuses on leveraging the platform they have in place to create more value and growth via new and often more profitable streams of revenue. Simply stated, the healthcare delivery systems of today will increasingly leverage the platform and resources that they have in place to become a hub for both health and healthcare in the future. There is a level of urgency to move quickly. Many feel that if they don’t expand the role that they play in both health and healthcare in their community, someone else will step in.

Folks in tech would think of this as the difference between a “product” strategy (old school) and a “platform” strategy (new school). Think of this as the difference from cell phones (Blackberry) to smartphones (iPhone and Android devices). One was a product, the other was a platform. Common platforms that we’re all familiar with such as Facebook, Amazon, Google, Apple and even Starbucks have always 1) started with a very small niche, 2) built an audience, 3) built trust and 4) then added other offerings on top of that platform. By now there is no need for a “spoiler alert.” We all know that this strategy works and these companies have created a breathtaking amount of value. The comforting news for hospitals and healthcare delivery systems is that many have already completed the first three steps and have many of the building blocks they need to leverage a “platform” as a business strategy. The presentations at the JP Morgan Healthcare Conference made it clear that most are now actually taking that fourth step to separate themselves from the pack.

There is enormous upside to those who understand this pivot and take advantage of this change in the market. Dennis Dahlen, CFO of Mayo Clinic, shared his perspective on this: “Thinking differently in the future is essential. In many ways, at Mayo, we are already operating as a platform today, but we have to continue to leverage this approach to uncover additional ways that we can be a hub for both health and healthcare in our community.” Mayo’s platform includes leveraging research, big data, expert clinic insights and artificial intelligence to create new value for Mayo’s clinical practice as well as new opportunities for Mayo’s partners.

To be clear, the mental shift here is massive. It’s the difference of being on defense (where most healthcare providers are) to be being on offense (which is where they know they need to be). Executive teams have focused their time, energy and resources on driving and supporting inpatient admissions via a traditional bricks and mortar presence coupled with the acquisition of physician practices. The difficulty of thinking through what it means to truly be “asset light” and taking a different approach shouldn’t be underestimated. The good news is that the recent financial results of many health systems have improved, providing a little breathing room for investments to enable this shift in strategy. Those who don’t may fall way behind. 

A New Way of Thinking — What it Means to be a Hub

Being a hub is essentially bringing together people with common interests to spark innovation and facilitate work getting done more efficiently. Examples include Silicon Valley as a “tech hub,” Los Angeles as an “entertainment hub,” New York as a “financial hub,” Washington, D.C. as a “hub for politics” and how essentially every college town is or can become a “research hub.”

Given that hospitals and health systems are the largest employers in their community, they are already set up to become a hub. In the past, they leveraged that position to simply care for the sick. Increasingly in the future, these organizations will be health and healthcare hubs for innovation and building new companies, for bringing the community together to tackle issues like hunger and homelessness, for education and training, for research and development partnerships, for coordinated, compassionate and longitudinal care delivery for treatment, for support groups for specific chronic conditions, for digital and virtual care, and for thoughtful and effective support for mental and behavioral health. Changes in the care delivery market over the last 10 years have put the right building blocks in place to make this happen.

Hiding in Plain Sight — The Single Biggest Change in Healthcare We May Ever See Has Already Happened

Taking advantage of becoming a hub and leveraging the strategic concept of being a platform requires new thinking, new structures and new skill sets. The great news for healthcare providers is they have already made the toughest move of all in order to set this in motion.

Over the last decade, there has been a massive level of consolidation with hundreds of hospitals and thousands of physician practices being acquired every year. While more mergers and acquisitions will still happen, this stunning and fundamental restructuring of healthcare delivery has taken place and there is no turning back. This is likely the single biggest shift relative to how healthcare is structured in this country that will take place during our lifetime, and it barely gets mentioned. The strategy many were chasing was primarily being driven by a “heads in beds” pay-off that was both based on offense (“an easier way to grow”) and defense (“we better buy them before someone else does”). That said, as this consolidation happened most healthcare delivery systems were really just an amalgamation of stand-alone hospitals set up as a holding company that provided no real leverage other than more top-line revenue.

During the JP Morgan Healthcare Conference, it was clear that most have made the shift from a holding company into a single operating entity. Chicago-based Northwestern Medicine shared a very refined playbook for quickly bringing acquisitions onto their “platform,” and the results are pretty stunning as they have transformed from a $1 billion academic medical center into a $5 billion regional healthcare hub in a handful of years.

And over the last few years, these organizations have gotten super serious about making the toughest decisions right away. The mega-merger of Advocate Health and Aurora Health, the largest healthcare delivery systems in Illinois and Wisconsin respectively, was accompanied by a gutsy decision to fast-track the implementation of Epic at Advocate to get the leverage of a single EHR platform across the system. While many focus on the cost of the transition and the shortcomings of some of the applications, what gets missed is the enormous long-term leverage this provides regarding communication, integration, continuity of care and, of course, access to data and the potential to improve clinical and financial performance. This creates a “platform-like” experience for both employees and customers. 

So, the twist in the story is that the pay-off for consolidation will likely be very different and perhaps much better than many had originally intended. They have the building blocks in place to be a health and healthcare platform for their community. But now they need to figure out how to truly take advantage of it.

Your Action Plan — 6 Ideas from 25 Healthcare Delivery Systems on How to Leverage Your “Platform”

During their presentations the 25 non-profit provider organizations opened up their playbooks on how others can leverage their platforms and the idea of becoming the hub for health and healthcare in their respective communities. Here is what they shared.

1. Create the Digital Front Door — or Someone Else Will

The big shift in play right now is the moving away from traditional reliance on transactional face-to-face interactions with individual providers. Building relationships and trust is something that has been a core competency and core strategic asset for hospitals in the past. In the future, this simply won’t be possible without leveraging digital platforms as we do in every other aspect of our lives today. As Stephen Klasko, MD, CEO of Philadelphia-based Jefferson Health, shared, the real strategy will be to deliver “health and healthcare with no address.”

Many provider organizations are moving aggressively to create digital front doors. Kaiser Permanente delivered 77 million virtual visits last year. Intermountain introduced a virtual hospital that provides over 40 services and has delivered over 500,000 interactions. Nearly every health system leverages MyChart or a similar personal health record platform. There is an enormous amount of risk for hospitals and health systems that don’t take action here, as traditional healthcare providers will be competing with more mainstream and polished consumer brands for the relationships and trust of the folks in their community.

As the team from Spectrum Health shared, “87 percent of Americans measure all brands against a select few — think Amazon, Netflix and Starbucks.” Google, Apple and Facebook as well as Walgreens or CVS are all going after this “digital handshake,” and are big threats to healthcare providers. There is no question that some of these organizations will be “frenemies,” where they are both competing and collaborating. Healthcare organizations will need to approach any partnerships mindful of that risk.

2. Drive Affordability and Reduce Cost — or Risk Being the Problem

As the burden of the cost of care increasingly shifts to the patient’s wallet, healthcare providers will need to play in driving affordability. Coupled with the recent federal requirement to post prices online, there is a great deal of visibility around the price of care, even if the numbers are way off the mark. Understanding and reducing the total cost of care is now viewed as a requirement. As legacy cost accounting applications relied on charges as a proxy for cost and were limited to the acute care setting, most provider organizations have or are now in the process of deploying advanced cost accounting applications with time-driven and activity-based costing capabilities including a number that presented during the conference, such as Advocate Aurora Health, Bon Secours Mercy, Boston Children’s Hospital, Hospital for Special Surgery, Intermountain Healthcare, Northwestern Medicine, Novant Health, Spectrum Health and Wellforce.

This was one of the hottest topics during the conference, and there was significant buzz regarding having a single source of truth for the cost of care across the continuum. Vinny Tammaro, CFO of Yale New Haven Health, commented, “We need to align with the evolution of consumerism and help drive affordability in healthcare. How we leverage data is mission critical to making this concept a reality. Bringing clinical and financial data together provides us with a source of truth to help both reduce the cost of care as well as reallocate our finite resources to high impact initiatives in our community.” Organizations like Intermountain Healthcare, which implemented a 2.7 percent price reduction in exchange pricing, are taking the next step in translating cost reduction into lower prices for consumers. And now healthcare systems are starting to work together to create additional leverage via Civica Rx, which now includes 750 hospitals joining forces to help lower the cost of generic drugs.

3. Tackle Social Determinants of Health — or You Won’t Be the Hub for Health in Your Community

It is always less expensive to prevent a problem than it is to fix it. The good news is that the economic incentives for hospitals and healthcare delivery systems to both think and act that way are beginning to line up. They are certainly there already for providers that are also health plans such Intermountain, Kaiser Permanente, Providence St. Joseph Health, Spectrum Health and UPMC. They are also in place for providers that have aggressively taken on population-based risk contracts such as Advocate Aurora Health. With that said, it feels like every health system is starting to lean in here — and they should.

Being the central community hub for these issues makes a ton of sense. The way that Kaiser framed it is that while they have 12 million members, there are 68 million people in the communities they serve. Taking that broader lens both allows them to make a bigger impact but also broaden their market. Many organizations, such as Henry Ford Health System, are taking on hunger via fresh food pharmacies. Geisinger shared how a 2.0 reduction in Hemoglobin A1c reduction leads to a $24,000 cost reduction per participant in their fresh food “farmacy.” So while hospitals are perfectly positioned, have the resources and know it’s the right thing to do, they are now also beginning to understand the business model tied to targeting the social determinants of health. There is also strong strategic rationale associated with taking on a broader role of driving health versus only providing healthcare.

4. Create Partnerships for Healthcare Innovation — or Lose the Upside

Spectrum Health has a $100 million venture fund. Providence St. Joseph’s Health announced a second $150 million venture capital and growth equity fund. Mayo Clinic Ventures has returned over $700 million to their organization. Jefferson Health has a 120-person innovation team focused on digital innovation and the consumer experience, partnering with companies to build solutions. These are all variations on a theme as virtually every organization that presented is leveraging their resources to make a bigger impact and drive additional upside from their platform. “We have close to 900 agreements with over 500 partners,” stated Sanda Fenwick, CEO of Boston Children’s Hospital. “Our strategy is to be a hub for research, innovation and education in order to help evolve how care is delivered. This can only be done by collaborating with others.”

5. Become the Hub for Targeted Services and Chronic Conditions — or They Will Go Elsewhere

Perhaps the best example here is the work of Hospital for Special Surgery, the largest orthopedics shop in the world. It is has become a destination for good reason — fewer complications, fewer infections, a higher discharge rate to home and fewer readmissions. The most compelling data point is that when patients come to HSS for a second opinion, one-third of the time they receive a non-surgical recommendation. The same type of shopping is increasingly going to happen for chronic conditions.

Healthcare delivery systems that take a more holistic yet targeted approach have significant potential. They will need to think more deeply about the end-to-end experience and become immersed within the community outside of the four walls of the hospital. Other players in the community, such as CVS Health and Walgreens, would say they have a platform — and they would be right. The platform that healthcare providers have built and are building will absolutely be competing against other care delivery platforms.  

6. Leverage Applied Analytics — or You’ll Lose Your Way

In order to enable everything listed above, the lifeline for every health and healthcare hub will be actionable data. Applied analytics is a boring term that is actually gaining traction and starting to dislodge buzzwords like big data, machine learning and artificial intelligence relative to its importance to healthcare providers.

Similar to how analytics are being used in a practical way in baseball to determine where to throw a pitch to a batter or position players in the field, healthcare providers are pushing for practical data sets presented in a simple, actionable framework. That may seem obvious, but it is simply not present in many healthcare organizations that have been focused on building data warehouse empires without doors to let anyone in. Many organizations, such as Advocate Aurora Health, Bon Secours Mercy and Spectrum Health, have deployed more dynamic business decision support solutions to access better insight into performance and care variation. This allows them to assess opportunities to reallocate resources to invest in more productive ways to leverage their platform.   

While leveraging a platform as a business strategy is new to healthcare providers, the good news is that building blocks are already in place. It’s time to leverage that platform to drive better outcomes and more affordable care in the community. And now is the time to get started.

Dan Michelson is the CEO of Chicago-based Strata Decision Technology. Mr. Michelson has authored recaps of JP Morgan Healthcare conferences for the past several years for Becker’s. Read his account of the 2018 event here and the 2017 event here.

Presenting non-profit provider organizations during the 2019 JP Morgan Healthcare Conference included the following: AdventHealth, Advocate Aurora Health, Ascension, Baylor Scott & White Health, Bon Secours Mercy Health, Boston Children’s Hospital, CommonSpirit Health, Geisinger, Hartford HealthCare, Henry Ford Health System, Hospital for Special Surgery, Intermountain Healthcare, Jefferson Health, Kaiser Permanente, Mayo Clinic, Memorial Sloan Kettering, Northwell Health, Northwestern Medicine, Novant Health, Oregon Health & Science University, Providence St. Joseph Health, Spectrum Health System, SSM Health, University of California Health, UPMC and Wellforce.

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