The Personalized Healthcare Ecosystem of the Future: Welcome to the Year 2030

Against your better judgment, you've just checked your contact lens-enabled news feed. You're annoyed, because President Meghan McCain has just used the Trump Doctrine to "fire" Medicare's lead administrator over the botched roll-out of the Agency's block-chain claims payment system.  The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh. 

 

It's the year 2030, and personalized "eDxTx" (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of "Medicare for All" (a.k.a "TrumpCare") has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit.  Geico's ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.

Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor's team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long.  The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer. 

As you sit down and use the heads up display in your lens to ponder the short-list of candidates to replace the fired administrator (a well-placed leak suggests it reportedly includes Elizabeth Holmes), the patch modulates your drug dosing to account for the change in body position.

You're hungry and looking forward to your specially tailored evening meal that is being drone-delivered to your patio in.... your contact lens again... 28 minutes. 

This is one of the five days out of the week that you adhere to a configured meal of calories, carbs, proteins, fats, nutraceuticals, probiotics and prebiotics that's adjusted to meet your taste preferences. It will also achieve an optimal body fat percentage, and reduce your risk of cancer and a host of other chronic conditions. The other two days use competitive gamification that is linked to your online preferences to reward you with a real burger for meeting your nutrition goals.  Not for everyone, but your behavioral reward profile suggested that that would help motivate you to stick to the diet. Who knew?

You ponder getting a burger tonight, but fight the temptation by triggering a mindfulness app through your lens.  The lights in your living space also dim and a riff made up of an pleasing artificial jazz-indie chord progression offers a well-placed distraction.

Diet and risk reduction are not the only an ingredients you use to achieve your goal of living 105 years, but also participating in next month's Goggle Spartan Race.  Come to think of it, time to tailor a set of 3D printed sneakers. You look forward to you and your personal life-drone (your spouse suggests it's more evidence of your narcissism; you've named it "Donald" to confirm her suspicions and annoy her) competing in a mix of virtual and real obstacles in a course of that includes real rope climbing and a virtual 3-D avatar obstacle course. The drone and wearables will network, monitor and heads-up display your neuro and cardiovascular dashboard for optimal performance. It will also use the same technology that they used in hospitals to anticipate any medical emergencies that could happen to you.

Naturally, your drone will use artificial intelligence to image, edit and securely post the race video for friends and family to view.

That's what you did last year, when the video also showed you twisting your ankle.  You had to go to a treatment center and be evaluated the old fashioned way, where a doctor treated you.  Some things never change, but avoiding those opaque bills and paying your deductible using virtual currency was so convenient.

As your pour yourself your recommended 1.2 ounces of bourbon (personalized by the distillery with a proprietary combination of esters and lactones to create your preferred finish), you reflect on how healthcare has changed since the days of in-home monitoring and physician teleconferencing. It worked well while it lasted, but was soon eclipsed by the cloud-based technology that combined physician intelligence ("physint") with Watson (artificial intelligence) that "scaled" in an era of fully automated care. 

Sort of like the driverless car that will take you to next month's race.

Speaking of old fashioned cars, that eDxTx medical alert last year reminded you of that old fashioned "check engine" light.  It seems a biochemical marker profile was consistent with the presence of an early stage tumor.  Based on your past medical data, the calculated Bayesian risk that the tumor was real approached 1%.  Watchful waiting using Medicare's IPAB guideline recommendations was raised as an option by your doctor, but you decided to undergo the additional testing to rule it out.  Naturally, your insurance covered most of that cost.

You finish your bourbon after you get an alert that the pizza has arrived.  You silently wish President McCain good luck. Some things never change.

Image from Wikipedia

Complaining? How's that Working for You...

We all complain from time to time and that's called life, but what about when it interferes with our fitness?  What good does it do to constantly complain, be unhappy and bring on a full "Debbie or Dave Downer" attitude without being willing to change the situation?  It's like a leaky faucet we watch drip all over the place, complain about it but refuse to fix the darn thing.  Too many people are complaining and not doing, and seriously, how's that working for you?

Complaints only go so far and then the radio gets turned off.  Who wants to continually listen to a self-bashing session when the outcome is always the same. Getting fit and maintaining a healthy body starts by stopping the complaints and getting to work on fixing the problem.  The extra fat on the gut or butt isn't going to disappear on it's own no matter how much complaining comes out of your mouth.   What will help is putting the negative energy (complaints) into positive action.

Start by ditching the complaints, accepting who you are right now and apply strategies to make you feel better about yourself.  Get serious about your fitness by keeping a food and exercise journal.  Use it to chart your feelings as well and if you have a complaint, write it in the journal and move on.  Stop dwelling on the "wah wah" and steer your attention toward eating healthier.  Instead of sitting on the couch downing beers after work, go for a walk for example.  You will be amazed how small changes will eventually provide big results.

Stop complaining about not having the time.  Really?  We are all busy and there is someone busier than you working out or prepping healthy food right now. What's in your pantry?  Is it filled with processed boxed foods and sugar cereal? What's going on in the refrigerator?  Is it filled with salami, beer and cheez whiz?  You get my point and I'm stressing to please clean-up the food because a large percentage of your fitness success is determined by what you put in your face consistently.  When is the last time you exercised?  Time to dust the fitness shoes off and get moving.  You will burn some extra calories and feel great for accomplishing a great workout.  Exercise is also linked to stress relief and increased self-esteem.  Be willing to do what it takes, stop complaining and you know that old saying "sh*t or get off the pot" well it truly applies here.  Straight talk but all in fitness love.  Be well and Stay Healthy!

Head on over and read my new articles "When BCAAs Help the Most" and "Are Energy Drinks a Safe Pre-Workout Choice?".  Take some time to look around my page and find articles specific to what you like.  It is important to feel motivated and informed!

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Darla Leal, Fit-over-50
Stay Healthy Fitness

       

Stop Enabling Yourself

What comes to mind when you think of enabling someone ... healthy or unhealthy?  The recent definition refers to providing help that perpetuates a problem rather than fixes it.  You know, the reasons and excuses we make to justify a person's behavior or actions even sacrificing our own health and well-being in doing so.  It can develop into such dysfunction where we actually believe we are helping a situation.   "The reality, though, is that enabling not only doesn't help, but it actively causes harm and makes the situation worse."  When an enabler steps in to help an addict for example, they take away their motivation and desire to get help or change. According to Psychology Today, "enablers help addicts dig themselves deeper into trouble."  

What does this have to do with fitness?  Well, it happens to pertain quite a bit to health and fitness.  Are you making excuses and justifications not to start a fitness program?  Not the right time?  My spouse is keeping me fat?  My friends sabotage me?   Lying to family and friends about a "fake" fitness program? What unhealthy beliefs do you create preventing you from getting fit and why are you enabling that?  This is my point and yes, I strongly disagree with enabling behavior.  It is time to stop enabling yourself.  Being a healthy and fit person will take breaking the cycle of enabling.

When you stop enabling unhealthy behavior, you will see an improvement in your mental game, motivation to exercise and eating right.  Continuing down a path of excuses will only make things worse and illness will eventually come knocking at your door.  We have only one body and playing around thinking our behavior will not come back to bite us in the backside is well, negligent.  Life is too short to entertain enabling behavior further and it is time to make a shift toward healthy decisions.  We can no longer hide behind our justifications that keep us digging a deeper unhealthy hole.  I know this is an in-your-face blog, but it is also what I call tough fitness love.  So, are you ready to stop enabling yourself and get serious about your health and fitness?

Don't miss out on my sport nutrition and fitness articles!  Newly published this week are "Eat Dark Chocolate to Improve Your Workouts" and "Why You Should Eat White Potatoes."   Take some time to peruse the site because it is chalk full of helpful fitness and nutrition info!

Read My Sport Nutrition and Fitness Articles!

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Be Well and Stay Healthy! Darla Leal

What I Eat

People often ask me what I eat.  I've been reluctant to share, because it feels egocentric and I'm a private person by nature.  I also don't want people to view my diet as a universal prescription for others.  But in the end, as someone who shares my opinions about nutrition, it's only fair that I answer the question.  So here we go.

In my food choices, I try to strike a balance between nutrition, cost, time efficiency, animal welfare, pleasure, and environmental impact.  I'm the chef of my household of two, and I cook two meals a day, almost every day, typically from single ingredients.  I prefer organic, but I don't insist on it.

Eggs from my hens

My diet changes seasonally because I grow much of my own food.  This started out with vegetables, but recently has expanded to staple foods such as potatoes, flour corn, and winter squash.  I also have a small flock of laying hens that turn table scraps, bugs, grass, and chicken feed into delicious eggs.

The primary guiding principle of my diet is to eat somewhere between a "Paleolithic"-style diet and a traditional agricultural/horticultural diet.  I think of it as a broad ancestral diet.  Because it's partially inspired by agricultural/horticultural diets, starch is the main calorie source.

My meals are organized around three food groups: a protein, a starch, and vegetables/fruit.  If any of those three are missing, the meal doesn't feel complete.  I'll start with those categories and move on from there.

Read more »

Is the "Obesity Paradox" an Illusion?

Over the last two decades, multiple independent research groups have come to the surprising conclusion that people with obesity (or, more commonly, overweight) might actually be healthier than lean people in certain ways.  This finding is called the "obesity paradox".  Yet recent research using more rigorous methods is suggesting that the paradox is an illusion-- and excess body fat may be even more harmful to health than we thought.

Introduction.  What is the obesity paradox, and why does it matter?

Read more »

The Latest Health Wonk Review

Here we go again.  While money can't buy love, Steve Anderson over at Medicare Resources looks at money and healthcare reform, and a whole lot more!

Enjoy!

A Quick Fix is Like Using Duct Tape for Fitness

Duct tape is awesome, but it's not meant to last.  In a pinch, the strong stuff can fix things temporarily but doesn't quite do the trick long term.  If you want something repaired right, it takes the right tools and materials, agreed? Quick fixes are the same as placing duct tape all over your fitness.  Speaking personally, I don't want a short-cut but a permanent solution to staying fit.

Unfortunately duct tape fitness is the most popular route for most people and as the sticky starts wearing off, it reveals what still remains ... an unhealthy body. The tape removal is painful and frustrating, but somehow the roll gets pulled back out and the ducting process begins again.  Temporary happiness but what a yo-yo ride.

It's time to toss out the tape and get real with what it takes to fix things right. Our healthy lifestyle tool box should contain things like dumbbells and jump ropes along with lean proteins, good carbs, and healthy fats.  Other great add-ins are motivational sayings, music, and awesome fitness clothes.  Probably one of the best tools pulled out of the box is a fitness accountability journal.

There are no short-cuts to where we want and need to go.  Duct tape has no business in our fitness and lifetime journey of  being healthy.  We should not be covered in a sticky mess revealing yuck on the inside when the tape is pulled back.  Our society needs to stop embracing the quick fix as any type of healthy remedy because that is crap.  What needs to happen is building a strong toolbox we can carry for a lifetime and daily use of the contents.  Be well and Stay Healthy!

My articles on the about.com network will help you build the toolbox you need for a fit body and healthy life.  Start with these great reads!

10 Foods You Should Eat Every Day
Read the Article!

Want Less Fat and More Muscle, Eat Protein for Breakfast
Read the Article

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Darla Leal, fit-over-50

Bro-pulation Health

The Population Health Blog wishes a health insurer would be as clever as the marketeers behind the Geico "Flextacular" commercial while extolling the virtues of its population health program.  For example, wellness with less bro'tatoe chips and bro'nuts and more bro'colli, bro'bacco cessation, and bro'ing to the gym for some exercise.

Persons with diabetes could strive for a lower Bro1c, hypertensives could seek a lower bro' pressure while persons with heart failure can 'bro to the doctor if their weight goes up by more than four kil'brograms in a 24 bro-ur period. 

Make that bro-pulation health.

Speaking of 'bro's, like many readers the PHB was also astonished by bad-boy "Pharma 'Bro's" smirking insolence during the Feb. 4 Congressional hearing on how Turing Pharmaceuticals turned a generic into a $750 pill.  That being said, the adult witnesses at the hearing later pointed out that the initial retail price - once the supply chain does its work - has little correlation with the final negotiated rate.  For Medicaid patients, that turned out to be "a penny a pill." 

The PHB suspects that the staff advising the House Committee on Oversight and Investigations knew this, but went along with their bosses' interest in publicly humiliating Mr. Shkreli.  While his bad behavior may be symptomatic of a deeper personal contempt for the rules, what this also demonstrates is that the U.S. is one of a handful of countries where we are able to publicly laugh at those in power and walk freely out of the room.  Good for us.  

An Update on the Evidence of the Impact of the Patient Centered Medical Home on Cost and Quality: Of Soup and Weather Vanes

In its work with a variety of payer and provider customers, the Population Health Blog has advised that primary care medical home planning is more "soup" than "soufflé," and that outcomes are more a matter of direction than preciseness.  Naturally, the MBA-types that populate and advise the C-suites and Boards of our health institutions never liked hearing that, preferring instead to impose their notions of cookbook orderliness on what they disdain as inefficient.

Bunk.

Anyone who has had an underinsured patient in crisis in their clinic at 4 in the afternoon knows what the PHB is talking about.

Which is why the trained professionals who actually take care of primary care patients will find a lot to agree with in the Patient-Centered Primary Care Collaborative's report on the Patient Centered Medical Home's Impact on Cost and Quality. 

This is a summary of the 30 recent peer-reviewed, state, industry or federal publications examining medical homes' impact on cost, utilization or quality.  There are pages of tables that conveniently describe the initiatives, the payment methodology, their impact on cost/utilization (mostly good), and the impact on other outcomes (mostly good).  To the PCPCC's credit, the review is free of the trade association-style framing that can obscure neutral assessments of the data; it even includes an entire section dedicated to study limitations.  Good for them.

Two PHB Insights

   

Soup: While often portrayed as a caveat, one of the major insights of the report is that the PCMH is best thought of as a "model" of care defined by a set of "attributes" that include patient-centeredness, comprehensiveness, coordination of care, accessibility and quality/safety.  Do right by adapting those principles into a clinic and, to paraphrase Justice Stewart, you'll know it when you see it.  Turning to the "soup" analogy, if it's liquid, there's stock, the ingredients are softened and the flavors have been extracted into a broth, you've got something that will satisfy. 

Let a thousand medical home clinics bloom.

Direction: Another major point of the review is that outcomes vary considerably, and not just in terms of dollar impacts, but on various measures of utilization and outcomes.  The insight here is that the "directionality" of this model of care is "pointing" toward lower overall costs with better clinical outcomes.  Unfortunately for administrators and insurers everywhere, the answer to "how much" is that "it depends." 

Fortunately for patients, the wind is blowing in the right direction

There are some other interesting take-aways. 

As "alternative payment models" (reminding the PHB to also use acronym "APMs" whenever possible) expand, the funding for PCMHs is likely to grow. The Medicare Access and CHIP Reauthorization Act (another acronym "MACRA") has fans in the PCMH community. 

$4.90 per patient per month is an average payment for medical home services, with dollar add-ons possible from various measures of performance, shared savings, care coordination, pre-payment and risk adjustment (see above on how "it depends"). 

Multi-payer collaboration convening commercial and government payers is more likely to have an impact on PCMH outcomes than single payer programs. Based on experience, this reminds the PHB of a similarity between the PHB spouse and Medicare: compromise is always possible so long as you do it her way.

Next Steps

The PHB couldn't have said it better.  Advocates for the PCMH need to continue to share their design and outcomes in the public square so that everyone can better understand its strengths as well as weaknesses and to make this soup even better.  As the report concludes

"Investment (ROI) or “total cost of care” research is needed that assesses the costs associated with PCMH transformation (or “upstream” spending) that results in “downstream” savings, through reduced ER visits or hospitalizations. This would demonstrate the extent to which spending on primary care results in long term ROI to the overall health system."

"As in past years, there was a dearth of studies that evaluated cost or utilization measures together with patient experience or provider satisfaction and health outcomes, essential elements of the Triple Aim. As we evaluate cost outcomes associated with the model, we must increasingly evaluate the model as a whole to ensure that cost savings and better patient care go hand in hand."

Soup and vane images are from Wikipedia