Creating the Future of Health Care
By Anne Delotto Baier '78
Major forces are shaping the future of U.S. health care beyond political debates about insurance coverage. Driven by a need to reduce unprecedented costs, our nation's health care system is evolving from one of paying physicians and hospitals for the volume of services delivered to one focused on the quality of care provided and the maintenance of good health. As part of this transition, massive new databases, electronic health records and powerful computers are helping researchers learn more about disease causes and outcomes, as well as assess the effectiveness and costs of various treatments. Advances in science and digital technology are changing how physicians, nurses, pharmacists and other clinicians deliver services, as well as how patients engage in their own care.
Shifting from volume to value
When speaking to community and professional audiences, USF Health's Dr. Charles J. Lockwood often points out that, despite the vast sums the United States now spends on health care – one-sixth of our economy according to the latest Commonwealth Fund report – the health status of its population is worse than virtually all high-income countries. This includes such measures as infant deaths from prematurity, obesity rates and life expectancy.
"We pay a lot more for a lot less," says Lockwood, senior vice president for USF Health and dean of the Morsani College of Medicine. (The Commonwealth Fund report, "Mirror, mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care" offers an in-depth cost-to-benefit comparison across 11 comparable nations.)
Traditionally, physicians or other clinicians have been paid for the amount of services they deliver. This fee-for service model, driven by quantity of care (volume) rather than the quality and cost of care (value), can promote unnecessary or duplicated treatment. It's a system primarily oriented toward disease treatment and cure, rather than preventive care that keeps patients out of the doctor's office. "Right now, the big spend is not on maintaining health, but restoring health," says Dr. Edmund Funai, chief operating officer of USF Health and senior vice president for USF.
"If you get shot in the chest or hit by a car, we do a great job of saving your life," says Jay Wolfson, associate vice president for health law, policy and safety at USF Health. "But the overall outcomes have not been so good for those with, or at risk for, hypertension, diabetes, or other chronic conditions." But, the mounting financial pressure of costs is unsustainable, and change is coming.
Growth in health care expenditures has driven up our federal debt burden, taken a bigger bite out of employees' paychecks, and strained families and communities, says Dr. Lockwood. It has led to demand for change from consumers, business leaders, and insurers for "value-based care" – that is, improving the quality of health care delivered and reducing its costs.
In 2015, the U.S. Department of Health and Human Services announced explicit goals and a timeline to move the Medicare program, and health care system at large, toward paying providers based on the quality rather than the quantity of care. Many states, including Florida, have followed suit in this drive for value-based care.
USF Health leaders are working with the university's hospital and community partners on new approaches that deliver the highest quality, patient-centered care possible while controlling costs. For example, last year USF Health's multispecialty group practice – the largest in West Florida – joined Florida Medical Clinic, Florida Orthopaedic Institute, the Pediatric Health Care Alliance and Women's Care Florida to form a clinically integrated network called the Tampa Bay Health Alliance (TBHA). This network of providers collectively totals more than 1,300 health care professionals caring for more than 750,000 patients across the Tampa Bay region.
The five medical groups practice independently but, as with all CINs, the TBHA providers collaborate to coordinate care – all for the common benefit of the network's larger patient population. They share patient data and treatment protocols to offer cost-effective care that works best, says Daniel Vukmer, TBHA chief executive officer and senior associate vice president at USF Health. "Providers are learning they need to work together, as opposed to compete, to provide value to patients – and quite frankly, to stay in business" Vukmer says. "Health care is evolving from a cottage industry to a much larger scale," Lockwood says. "We're working with our TBHA partners to achieve economies of scale in information technology, patient navigation and other areas that will lead to safer care, higher patient satisfaction, better outcomes and lower costs."
The promise of "big data"
USF Health College of Public Health Dean Donna Petersen would like to think that a focus on the social determinants of health – such as education, access to healthy foods and exercise, safe neighborhoods, and social engagement – will play a greater role in the value-based health care equation.
"It's amazing to me that public health's prevention argument hasn't yet been so successful," Petersen says. "It's difficult to earn a good wage and be a contributing member of society without good health, and in the big picture that means more than the absence of disease. We spend most of our health care dollars on care at the end of life. What would society look like if we spent more on the front end?"
All stakeholders must tackle the challenges of complex societal ills to rein in health care spending and achieve better health and well-being for individuals and communities, Dr. Lockwood says. "Eighty percent of health outcomes are outside the control of those providing medical treatment. As a society, we have some tough decisions to make about personal accountability and improving the health of our populations."
A recent National Academy of Medicine report synthesizing expertise of the nation's leading health scholars and policymakers cites the need to harness and curate massive data sets to reveal and track subtle population patterns affecting health. This "big data" can include patient information captured by electronic health records, insurance claims, pharmacy records, public health agencies, clinical research networks, or others involved in the health care process.
"Using big data, we can learn more about disease causes and outcomes, advance precision medicine by creating more precise drug targets, and better predict and prevent disease occurrence or onset," write the authors of Vital Directions for Health and Health Care.
The Veterans Health Administration (VHA) captures information for U.S. veterans across time and likely holds one of the largest compilations of population and clinical health data from all 50 states. Over the last decade VA big data text mining expert Stephen Luther (PhD '97, College of Education) has led nearly $6 million worth of federally funded health informatics and outcomes research involving pain care quality, fall-related injuries and mild traumatic brain injury. Luther, assistant director of the VA's Tampa-based Center of Innovation on Disability and Rehabilitation Research and a USF College of Public Health adjunct associate professor, frequently collaborates with faculty investigators from USF Health and the USF Muma College of Business.
For a five-year retrospective study targeting more than 12,300 veterans with spinal cord injury who received care in the VA health system, Luther and colleagues tapped into electronic health record information to measure the risk of pressure ulcers in this patient population. Ultimately, the researchers plan to create an assessment tool to more accurately predict the probability of developing pressure ulcers, which can lead to costly hospitalizations and life-threatening complications.
"If a short automated checklist in the electronic health record could identify those veterans at highest risk, clinicians can make sure they get the maximum resources to prevent pressure ulcers" like a specialty wheelchair cushion or more frequent turning in bed, says Luther.
"As rich big data, like that currently available in the VHA, gets more broadly integrated into the health care system, we'll be able to ask and answer important questions as never before to improve health care and patient safety."
Etienne Pracht, USF associate professor of health policy and management, agrees big data can be a powerful tool to help guide cost-effective medical decisions, but cautions that it should be used "responsibly" with input from physicians and other clinicians immersed in the practicalities of caring for patients.
For the foreseeable future, Pracht says, "a doctor still has the comparative advantage in diagnosing and figuring out what might happen next for an individual patient, because we are not all robots with standardized parts."
From hospital to community to home
Most health care executives agree that hospitals of the future will be reserved for the sickest patients requiring the most intensive treatment; in fact, as health care costs increase, the transition from inpatient to more (and less costly) community- and home-based care is already under way. Enabled by digital technology and prodded by growing consumer desire for greater access, convenience and personalized service, more hospital systems are expected to transition to patient-centered, connected networks of physician group practices, retail clinics, post-acute care centers, and other community facilities. As hospitals extend care beyond their walls, telehealth to remotely consult with, monitor and even treat patients in their own homes may become more attractive.
"Virtually every company that runs a wire into your home is interested in health care because it's a huge part of the economy, and it offers alternative ways to provide and monitor care that don't necessarily involve doctors' offices or hospitals," says Funai, adding that telehealth at its best can help engage the average patient in their own care. "You can monitor somebody's vital signs and other indicators of well-being, their adherence to taking medications. You can communicate in real-time through video." Funai foresees that the technology revolution in the home that now allows someone to adjust air conditioning temperatures or turn off lights in their house from across the country may eventually be embraced by the health care industry.
"I can imagine the day when, by and large, you have your annual physical exam in your own bedroom, remotely. I can envision the day when patients who have even major surgery end up going home within 24 hours or so, as long as they don't need intensive care," he says. USF College of Engineering associate professors Carla VandeWeerd and Ali Yalcin worked with graduate students to design "Homesense," a wireless data management and analytics system using small inexpensive sensors (no cameras or wearable devices involved) unobtrusively installed throughout a house to monitor select activities. With feedback from study participants in 10 homes, the researchers continue to refine the prototype and plan to expand the sensor system to 30 to 50 homes over the next year.
The sensors measure pressure, motion, contact, temperature and light intensity. They detect when a door to the house has been opened as someone enters or exits, whether a toilet has been flushed, how long a person spends in bed or a recliner, when someone showers or bathes, even if a drawer where prescription medications are stored has been opened. Confidential data are analyzed and uploaded to a website, which participants can access with a secure log-in.
The technology "learns" patterns of behavior and captures deviations in activities of daily living, such as more sedentary behavior that may signal a change in mobility and increased risk for falls, or more frequent nighttime trips to the bathroom that may indicate an early bladder infection. "The system detects those things right away and can notify caregivers or a case manager who can get you to a doctor's office before a simple urinary tract infection ends up as a kidney infection requiring hospitalization," VandeWeerd says. "The idea is to intervene as early as possible to help people stay active and live healthier in their own communities, for as long as possible."
Lana Carter, 76, one of the first to test the USF-created system, agrees. After hip replacement surgery this spring, she permitted access to her Homesense website by two daughters living in Nevada and California so they could keep an eye on her daily activity from across the country. "I want to live my life and age in place; I hope my daughters never have to take care of me," says Carter, who pursues a busy life schedule of dancing, yoga, and Pilates. "They know my daily routine and habits, so if something (like a change in activity) bothers them they can call someone to check on me."
Engaging patients with mobile health technology
Mobile health technology is an emerging industry expected to grow as big data analytics improve and integrate with smartphones, tablet computers and wearable devices that track vital signs and chronic disease symptoms in real-time. More physicians, nurses and other practitioners will learn to use this mobile technology to communicate with patients and begin applying data to impact outcomes.
Several USF nurse scientists are working on mobile health applications that help patients who struggle with self-management of cardiovascular disease. Among these scientists is Theresa Beckie, professor in the USF Health College of Nursing and the Morsani College of Medicine's Department of Cardiovascular Sciences, whose research includes individualized approaches to cardiac rehabilitation for women.
Beckie collaborated with associate professors Kaushik Dutta of the Muma College of Business and Sriram Chellappan of the College of Engineering to create a behavior-changing mobile app called Herbeat. The app is intended to help women with coronary heart disease who suffer a heart attack, or who undergo open heart surgery or stent placement, improve their exercise performance, maintain a healthy diet and manage stress levels on their own after they leave the hospital. Combining mobile technology (a wristwatch activity tracker and sensors wirelessly connected to a smartphone) with communication and coaching by a health provider, Herbeat incorporates techniques known to change health behaviors and reinforce better choices. Last year, Beckie received a National Science Foundation Innovation Corps (I-Corps) award, which supported the USF researchers' initial interdisciplinary work to develop Herbeat into a commercially viable product. With Dutta as her mentor, she also acquired a USF Foundation grant to start a company to assist with commercialization.
Transitioning to team-based care
The future of health also includes greater use of interprofessional services. USF is helping build the health workforce of the 21st century by teaching students to work together as interdisciplinary, coordinated teams that put the patient at the center of care. Medical students volunteer alongside pharmacy, physical therapy, public health and social work students as they provide free care to a local underserved community at the USF Health BRIDGE Clinic. Cross-disciplinary teams of USF Health students train together in the Experiential Learning and Simulation program at the Center for Advanced Medical Learning and Simulation in downtown Tampa. Doctoral-level physical therapy students share first-year anatomy, physiology and other basic science courses with medical students. With faculty supervision, pharmacy and medical students jointly see patients, consult on diagnoses and develop plans of care together.
The interprofessional approach has been incorporated into the university's faculty practice group, which combines the strengths of practitioners across health care disciplines, including physicians, nurses, pharmacists, public health professionals, physical therapists and physician assistants. "Health care today is a team profession. No single person or specialization can address all the complexities of a patient's needs," says USF Health College of Nursing Dean Victoria Rich.
USF Health College of Pharmacy Dean Kevin Sneed is nationally recognized for leading the way in team-based practice. "We're more invested in identifying which medications can achieve an optimal health outcome than just dispensing the medication, in helping to measure and monitor that outcome, and then communicating with physicians, nurse practitioners, physician assistants and other team members to optimize and maintain the health of that individual patient," Sneed says. "The only reason we're able to do this at such a high level at USF is the interprofessional collaboration among our health colleges."
Complex disease involves many complicating factors, including the patient's environment and behavior. "And, you're not going to fix that as a doctor unless you build a big team around you," Funai says. "One of the things we have going for us at USF is that we train the entire team. Even beyond health care professionals at the bedside, we can add the perspectives of others in social work, engineering, and government."
From trial and error to precision medicine
Charles Mahan, looking trim and fit at age 76, has not escaped a family history of heart disease. So he was eager to find out whether any of the 15 medications he takes for various cardiovascular conditions may be influenced by his genetic makeup. Mahan, a professor emeritus and former dean of the USF College of Public Health, was recently referred to the clinical pharmacogenetic testing service at USF Health Pharmacy Plus, a state-of-the-art pharmacy within the Morsani Center for Advanced Healthcare. After a simple saliva cheek swab was sent to the laboratory for analysis, he met with College of Pharmacy Assistant Professor Theresa Vo, who leads the Pharmacogenetics Clinic. She explained the results of the 20-gene test panel, including whether his DNA might play a role in the effects of his current medications, or how it might affect future treatments.
Overall, the results indicated that his medication regimen was working, and not prone to severe adverse side effects, based on his genetics – with one exception. "The report said one blood thinner I'm on is genetically a weak drug for me, and there are several alternatives that may work better," says Mahan, who planned to discuss the option with his doctor. While pharmacogenetics, also called pharmacogenomics, is a promising tool for identifying differences in DNA that may alter how an individual's body reacts to a particular drug, experts point out that targeting "the right treatment, at the right dose, for the right person, at the right time" is still largely a research enterprise. Cancer is one area where clinicians, particularly those in academic centers, use DNA analysis of tumors to target the most individually effective chemotherapy treatments.
Sneed expects that pharmacogenetics will break into mainstream medical practice as heath care professionals gain greater access to big data, computational power and genetic sequencing, and as the cost of testing drops with evolving technology. "Precision medicine will get us away from trial and error and hone in on what works best for you as an individual," Sneed says. Customizing drug or other therapies based on an individual's genome is just one aspect of precision or personalized medicine. It also aims to predict who is at risk for developing a particular disease as well as disease characteristics and prognosis.
Dr. Stephen Liggett, associate vice president for research at USF Health, refers to precision medicine as "a work in progress." Realizing the emerging field's full potential will require a better understanding of how environmental variables – including diet, exercise, the gastrointestinal microbiome (gut bacteria) and toxin exposure – interact with genetic variations to affect disease and its treatment, says Liggett, a National Institutes of Health-funded principal investigator who holds 16 patents on genetic tests for precision medicine in heart and lung disease. "We now can obtain millions to billions of pieces of data from a person's genome, but how much objective information do we have on that individual's lifetime environmental influences? Very little, it turns out."
Nanoparticles offer great potential for safer, more precise treatment of cancer, cardiovascular disease and other inflammatory disorders because of their capacity to effectively deliver drugs or other therapeutic agents directly to specific cells types with fewer side effects, says USF Health Heart Institute Founding Director Dr. Samuel Wickline. These tiny carrier systems – 10 to 50 times smaller than a red blood cell – can deliver a sizeable dosage to targeted tissues while avoiding potentially toxic accumulations of the drug in circulating blood. Wickline, a physician-scientist with a strong track record of entrepreneurial research and impressive NIH grant funding, works with USF biomedical engineer Hua Pan to design nanoparticles for a variety of diagnostic imaging and therapeutic applications.
One of the Heart Institute's driving themes will be translating findings that prove promising in the laboratory into products commercialized for clinical use. Wickline's laboratory has a jumpstart on biomedical research aiming to advance two promising nanotechnologies to early-stage clinical trials within two years. One targets pancreatic and colorectal cancers and the other aims to improve port access for dialysis patients.
Wickline and Hua also work with cardiologist Dr. Michael Fradley, director of the Cardio-Oncology Program at USF Health and Moffitt Cancer Center, along with other collaborators at Moffitt. They are investigating genetic signals that may help predict which patients receiving new drugs that boost the body's immune response against certain cancers are likely to develop cardiovascular complications. The research could lead to new nanotherapeutic agents selectively delivered to curtail heart muscle inflammation resulting from cancer therapy.
Striving for a healthier future
So what will the future of health care look like? Most USF experts interviewed were hesitant to predict, but some areas of agreement on trends emerged:
- Big data will get bigger and, hopefully, more integrally connected to electronic health
record systems so that providers and patients can make decisions leading to better
health at lower cost.
- Health technology will become smarter and more mobile, and increasingly diagnosis
and treatment will happen outside hospitals and clinics. Our ability to legislate,
regulate, and pay for new models of care delivery and to address ethical concerns
about data security and patient privacy needs to catch up with technological advances.
- As science advances understanding about individual genomes and improves upon nanodrugs and devices, clinicians will become more precise at predicting and controlling health at the micro-level, possibly even before disease takes root.
Finally, while it may seem straightforward, value is difficult to define and measure in a way that health consumers, providers, insurers, businesses and other stakeholders all agree upon. Greater overall consensus about what health outcomes matter most will be vital to achieving high quality care at reduced costs.
"As a society, we need to align the desired outcomes of our care with our ways of paying for the care people need," USF Health's Funai says. "There's a grand experiment going on regarding how best to manage the health of the population, and also save money." The solutions, Funai adds, may be decades away. "We all have a stake in working together to achieve a future of healthier citizens."