tv Politico Discussion on Opioid Abuse Diabetes CSPAN November 6, 2018 12:58pm-3:05pm EST
senate, and governors' races from around the country and we'll get your reaction to the election taking your phone calls live during washington journal. contraction span, your primary source for campaign 2018. >> tonight on c-span3, american history tv in prime-time looks at naval warfare in world war i. naval war college professor stanley carpenter describes the fleets of the allies and the central powers, their artillery and battle strategies employed at sea. american history tv is tonight at 8:00 eastern, here on c-span3. >> food and drug administration commissioner scott gottlieb recently spoke in washington about his agency's efforts to combat the nation's opioid epidemic. it was part of a forum hosted by politico that also touched on treating diabetes.
>> good morning. as they've just told you, i'm joanne kinnon, the executive droe editor at politico. using tech and innovation to combat opioid abuse and diabetes. and thank you for those of you who were on the live stream today, too. we're glad you can join us. it's a really timely conversation. we have two huge public health crisis in this country. unrelated, but we'll find some common themes today. diabetes and the opioid crisis. we'll explore the role that technology and digital tools can play in preventing and treating diabetes and curbing the opioid epidemic. more than one third of americans have diabetes or pre-diabetes and an estimated 115 people are dying every day because of opioid abuse. that's a lot. today, we're focused on new
approaches that the public and private sectors have to explore to address both of these problems. our conversation will take place in three parts. first, i will be joined i be fda commissioner scott gottlieb for a keynote interview to discuss the opioid crisis in the united states, from the perspective of the federal government and the fda. you all know what an activist fda commissioner he's been and we just had an interesting conversation, which we will open up to you. next, i will be joined by a panel of health and tech experts, including clinicians, to discuss what's working and what is still needed as we address the opioid crisis. then my friend and colleague, arthur alum, who's our e-health editor will be joined by a panel to discuss the role digital technology can play in improving the treatment of diabetes. as you follow our discussion on stage, follow the conversation on social media using the hashtag politico health, one word. you can also use opioids or
diabetes, but we're politico health. and before we begin, i would like to thank our sponsor, anthem, for their support in making this program possible. and here to say a few words on behalf of our sponsor is chief clinical officer at anthem. dr. freedhoff, welcome. [ applause ] >> well, good morning, everyone. and on behalf of anthem, i want to welcome you to our discussion on the tale of two crisis. i'm dr. steven freedhoff, and i'm chief clinical officer at anthem. we'll be talking this morning about how we can use innovation and technology as additional levers to combat two of the most complex challenges today in health care. the growing diabetes epidemic and the devastating expansion and consequences of opioid use disorder. while addiction and diabetes are quite different, surprisingly, they have several important characteristics in common. the two crisis have forced us to
become much more creative in thinking about how society can address these two health care epidemics. the crisis are multi-factorial in original and the solutions, therefore, will be multi-complex, requiring a fundamental shift in how we support individuals affected by these two different conditions. we must learn to see people in much more holistic terms than they have before, including where they live and work, and not simply as needing treatment with medications in a doctor's office. the time people spend interacting with their physician or other providers is absolutely important, but it represents the tiniest fraction of a person's lived experience throughout their lives. given the human toll, the economic cost, and the speed with which these two epidemics have been progressing, the implications are simply too great to ignore. and as crises often do, the sense of emergency has sparked a remarkable amount of innovation. and we have the opportunity today and in the future to
leverage new technologies to tackle these problems, as yet another lever in our approach. i'm very honored to be here today with some very, very important experts, who can look at these two epidemics through very different lenses and share their perspectives with you. and give us an update on some of the innovations that are increasingly becoming available. despite the magnitude of these epidemics, one of my reasons for being here is to share optimism. i'm dmurnencouraged, because we seen an unprecedented share of medicine. all oaf these innovative approaches and fresh thinking have begun to produce some early and measurable results. as a health benefits company that serves more than one in eight americans, we at anthem have not just an opportunity, but a responsibility to create a better health care future. our reach and our relationships allow us to bring together a
variety of stakeholders to address complex conditions like this. it enables us to improve lives, empower communities, and simplify health care, which is really at the heart of everything that we do. all of us here today are familiar with the statistics. there are stark reminders in our neighborhood and in the news every single day. according to the cdc, between 2000 and 2014, we saw a 200% increase in the rate of overseas deaths involving opioids. the daily headlines, though, remind us that that 200% increase over those four years was simply just in the beginning. and beyond the human consequences, the economic consequences are estimated at over $78 billion a year and they are growing very, very quickly. as for diabetes, the latest data show that it is the seventh leading cause of death in the united states. the annual cost of care exceeds over $300 billion. but these numbers don't even
capture the human toll. for that, to get a true glimpse, we see it when someone we love loses their sight, their ability to walk or their freedom, once they become committed to dialysis, all as a result of diabetes. as a family physician, i know how important it is to provide people with access to doctors and treatments, but that's just part of the picture. despite our very historically medicalized model, health youms are determined not only by the care that people receive. that actually represents a very, very small proportion, but drives health yooutcomes. primarily, it's driven by their genetics, the life choices they make, and ultimately, often by the zip code that they live in. for many years, when i was teaching residents and medical students, we would talk about the integration of physical and behavioral health and how critical it was to take an integrated approach. unfortunately, despite that, even society and many physicians
continue to see them very separately. but this is not the reality and it's certainly not the way that patients see themselves. once we begin to see the patient as a whole person and truly think about all the various factors that affect their health, wellness, and ultimate outcomes, we'll be much more successful about prevention, early intervention, and preventing barriers to living. i know this may not sound like the conventional thinking of at health benefits company, but this is how we are thinking about complex conditions at anthem. we truly believe that industry stakeholders have a responsibility to address the opioid epidemic and we are taking an integrated approach. from a preventative standpoint, one of our major focus areas has been around decreasing the number of new start prescriptions filled at pharmacies for opioids. a few years ago, we set a company-wide goal of reducing that number by 30%. and among many of the different approaches we took, we began to limit new start, short-acting opioid coverage to seven days for all of our members in our
affiliated health plans, including medicare members who were starting new prescriptions. i'm happy to say we reached that target two years ahead of schedule and are now seeing a # ho 40% reduction in the number of opioid prescriptions filled. this keeps medicine out of people's medicine cabinets that could potentially be diverted or abused. and it makes it more difficult for people who are at risk for dependency to inadvertently keep using these medications longer than the prescriber even intended. in terms of physicians, ideally, we want to be able to give them additional tools to assist with judicious prescribing. for example, by utilizing analytics, we're able to notify providers when a patient may be at risk. this helps the provider make an informed decision about whether to even start the patient on an opioid medication and how to better manage them once their utilizing opioid medication. we've also provided training to
physicians in sbert as well as medication-assisted treatment and advise them on how to be additionally reimbursed for providing these services to patients. earlier, i mentioned the need for a more holistic approach to care. today, we have a more nuanced understanding, which has led to better treatment protocols. two years at anthem, we looked at our pharmacy and medical claims and we realized that less than 20% of consumers taking medication assistive therapy to treat their opioid use disorder were actually receivesing behavioral health counseling. and that is much, much too low of a number. we now have emptfforts underway double the t amount of medications that they're receiving. this is an example that's already led to innovation. to fill gaps in access to counseling, we've expanded our
telehealth capabilities to provide consumers in remote areas or other access difficulties with remote access to qualified therapists, via telehealth. on the diabetes front, we've taken the same integrated and holistic approach to prevention and treatment and it enables us to develop more innovative interventions for people at risk of or struggling with diabetes. for example, for people with diabetes, to manage their condition requires an incredible amount of time and attention, even when they're not in the doctor's office. e recognizing this need, we provide more day-to-day support when and where it's needed. this includes individual health coaches and varies tools that help individuals and provide guidance on things like nutrition and meal choices. we're providing a greater degree of behavioral health support for depression and other conditions related to diabetes. as many of you probably know, when individuals have an underlying co-morbidity of a behavioral health diagnose, it
is far more difficult for them to effectively manage other conditions. again with diabetes, lack of access to nutritious food has a major effect on individuals with this chronic condition. without the right food, it's very, very difficult to manage the condition, as treatment of diabetes is a very integral part of that includes dietary management. for that reason, we're piling programs around the country with things like vouchers, that people can redeem for fresh foods and vegetables. we also provide cooking classes and nutrition education for individuals at risk. so everything i've been describing goes far beyond the medical model. however, the causes of these conditions similarly go far beyond a traditional medical model. and i firmly believe that we can only be successful in combatting diabetes and opioid abuse epidemics if we can continue to take a holistic approach like this. finally, in closing, i want to emphasize how much i appreciate this opportunity to be here with
all of you today. it's kpigd fexciting for me to your ideas on how we can tackle two of the most pressing health care epidemics facing the united states today. we talk a lot about a brighter health care future and working together is really the only way that we can get there. so, thank you very much for your time and attention this morning. [ applause ] >> please welcome back politico's joanne kennon and the united states food and drug administration commissioner, scott gottlieb. [ applause ] >> so thank you, dr. freedhoff, and thank you to anthem, and thank you to dr. gottlieb who invited himself here. we love that. i've asked for another pharma reporter to keep up with him, although i don't know that i'll get it. let's just dive in. i told him before we came on that when i first started, when
i was told i had to do an event on tech and opioid and innovation, my first response was, what does that have to do with it? and when i began reading and thinking who we were going to invite or who might invite themselves, i came up with a list of like 20 things. one of them is just the starting point for at least part of this epidemic is prescribing and tell us about what you're doing with e-prescribing and where you're going with that. >> thanks for having me. i reached out to me, because we did want to talk about this subject. >> and i'm making fun, but we're thrilled to have you! we usually have to beg. >> we got new authorities from congress. we have been saying for about 18 months now, the rate of new diction addiction is a function of prescribing. many people became medically addicted to opioids.
in many cases, they were legitimate prescriptions being written for medical purposes and people became conditioned to opioids and a certain percentage became addicted. so one of the ways to address this is to cut down on exposure in the medical setting. i think that the crisis is shifting and it's becoming a crisis more of illicit drugs. then the question becomes, how can we rationalize prescribing, cut down on doses that get dispensed and cut down on the strength of the doses dispensed. we think if we can shift to more electronic prescribing of opioids, have integration with hr as a mdmp integration with hrs, so you know when people are getting prescribed opioids from other physicians in other states, it will allow doctors to have better visibility into what people are being dispensed, allow health plans to have better visibility. and we have made a number of pushes historically at fda to
try to implement mandatory education for prescribers, the last time in 2009. and it was ultimately stymied for a variety of reasons i can get into. but i think if we have better technology and a fully electronic prescribing system, it's going to make the implementation of e -- of mandatory education much easier. and as you know, in the new legislation that recently passed, there'ses a mandate that prescribing under medicare part "d" for opioids needs to be done electronically. and i think by 2021. and that's going to drive a lot of implementation across the market. i think once part "d" has that mandate in place, a lot of other systems will have to go towards fully electronic prescribing. >> what are the barriers of getting doctors to switch to electronic? >> cost. i mean, you have to have the systems in place and i think there's also barriers with physicians who just aren't accustomed to prescribing that way. in certain states, you have electronic prescribing. other states are starting to put mandates in place for electronic describing. and in certain practices, all of
the prescribing is electronic. but it's not ubiquitous. you have a lot of older practices, smaller practices that still don't have there tools to do it. but i think that we're -- you know, we're getting to a point right now where there's a critical mass of providers that do. the providers that don't do it will have to opt out or just make the conversion. but that's been the historical barriers, is just having the tools and sort of the wherewithal of being able to do it. >> when the opioids came on the market instead of the flood of the market, the default really became a 30-day prescription. and it became a 30-day prescription, it was sort of well intentioned that went long. that it was going to be easy -- doctors didn't want to have the patient come in to pick up five different paper prescriptions if they needed a renewal. they didn't want to deal with the telephone tag. the patients wanted all generics. they were more expensive if you had to get five days at a time with five different co-pays. it just sort of quickly evolved and the insurance industry thought they were doing
something to make a 30-day -- thought they were safe, right. make it 30 days. and we all know that became part of the disaster. how do you shift that? you have these guidelines. some states have mandates, some health plans have mandates, but how do you really push that 30-day to what is it, 3, 5, whatever you -- >> so we're developing -- we're working to develop evidence-based guidelines on what the appropriate dispensing should be. we have a meeting with the national academy of medicine. i think that meeting is november 13th to start the process of developing evidence-based guidelines. and in the legislation, there is a direction of congress for us to do that. evidence-based guidelines are very different than consensus guidelines, like which d d.c. develops. what evidence-based guidelines are, it's based on retrospective evidence. so when we look at laparoscopic
appendectomy, based on what the actual ouelletization was. if we can develop those evidence-based guidelines, with we can incorporate it into drug labeling. and it can eventually be used as way, if you have a fully electronic system to regulate what's being dispensed by provider systems, by insurers. now, what we want to do, what we're going to make very early implementation of is unitive dose packaging. so think of like blister packs. we think that there should be some packs on the market, a one-day pack or a two-day back. 90% of all prescribing is the immediate release formulations like vicodin and percocet. a lot of times doctors will dwa default to a two-week supply or 30-day supply, like wisdom tooth. no one should be getting 30 days for a wisdom tooth extraction. so that's something we'll do very quickly in terms of the new
shorts. you can marry it up to mandatory education and electronic prescribing, because you can envision a world where if doctors want to, they can prescribe the one or two or let's say you have a five-day pack on the market for orthopedic procedures, that require longer use duration of use. any doctor is allowed to prescribe those. but if you want to go to a 30-day prescription, you have to go through mandatory education. there's another gate if you want to provide a longer term prescription. some providers will go through the mandatory education. if you do cardiac surgery, you might have toll write longer durations. but for most physicians, they won't. >> explain the cabbage -- >> cabbage, cardiac bypass surgery. most physicians will say, i only need to provide one or two three days. but if you have that kind of a
system, you know, the technology helps facilitate the implementation of that, because you can make, first of all, the education can be online. you can do the check on whether the physician qualified for the longer duration. so that's the kind of system we're envisions in the future. >> dr. freedhoff mentioned that anthem is doing this. and one of the things i came across in talking to people and researching ises there all of this information in the ehrs, the electronic health records. and we have not been great at figuring out how to really learn -- instead of just writing stuff down or typing stuff in, how to extract knowledge. so how are we beginning to be able to use data and analytics and new tech tools to look at patients and see where their red flags are earlier. >> yeah, so we've talked to some intermediaries including one medical society, and that's developing what you can call a risk score for patients.
risk of developing an opioid use disorder from a prescription, based on information that's in the ehr. so there are tools like that being developed. there aren't necessarily things we would regulate. these are things that would fall within the practice of medicine. but there are opportunities for that once you have, you know, prescribing online, on an electronic prescribing that's integrated with an ehr. because there are risk factors that help identify patients who are at higher risk of developing a potential use disorder from an opioid prescription. and as physicians, sometimes we're not very good at being mindful of that and that information isn't readily available at this sort of point of care, when you're seeing a patient. i used to practice as a hospice and in the er, and you know, we took the history of some of the patients, but it was hard to extract the past history that might have been revealed some indications that they would be at higher risk of developing an addiction from that prescription. >> so through the ehr, as it's
going to evolve, it will be hooked right into the electronic prescribing, right? >> right. and the pdmp is also becoming integrated with the ehrs, as well. so these systems that allow you to look in a multi-state way to see if patients are getting precipitations out of state are becoming more interoperable with the ehrs. >> so the fda can't. the pdmps are state regulated. there's nothing in the new federal agency that makes these checks mandatory for doctors, is there? >> there's nothing that makes them mandatory. that would be a probably a state medical board issue. there is legislation that requires interoperability, i believe. and we've been working closely with congress. >> because right now you have the pdmp over here and your ehr over here and you have to click in and -- you had to click in and click out of two systems and they're beginning to merge in some states, in some systems better than others. so that will give you -- that
will turn the -- that's one of the ways that the pdmp -- and we're trying to figure out how to marry public health -- >> there's some states that require. ohio requires physicians to do it. i think that's becoming more ubiquitous. and there are the -- >> because it doesn't do a whole lot of good if nobody checks. >> right. and when i started in this job not too long ago, 19 months ago, the pdmps were no t -- there were very pdmps that were interoperability. now the national board of pharmacies that has created a system where there's much more integration between different state pdmps. so it's changed a lot. >> so, "a," it will be easier for doctors. it will be one click or an easier obstructiinteraction bet two. it will be ease, it will be more useful. because as you go into your hr, you'll have these connections to the guidelines as they develop, that it will overright, right? it might not override, but if
you have the one day procedure, the one that you need one day of opioid after, the actual ehr and electronic providing will be -- if you try to do 30 days, it will start yelling at you. >> right. if you have evidence-based guidelines, you can integrate the guidelines into the ehr. you can do it with consensus guidelines. i think with evidence-based guidelines, with we'll have more certainty. and i think the health system will feel more comfortable, especially if we can build those guidelines. the pdmp is a tool to evaluate whether the patient is getting multiple prescriptions. those are patients who probably, in some cases, are looking around for drug. we still have to be very mindful of that first prescription in the treatment naive patient. and the fact that a certain percentage of patients who started on opioids will develop long-term use and dependency and a certain percentage of those will meet the qualified use disorder. it's not just about a number of the precipitations the that i have written and tills zpen s
dispensed. and it's also the morphine equivalent, the potency. if people started on higher dose opioids a to the outset, they're more likely to develop a long-term dependency and more likely to develop the risk of addiction to the opioids. so when you're prescribing, it's not just about making sure that the patient is clearly indicated and you've dispensed ten pills when ten pills will do and not 30 pills, but also -- >> lower dose. >> the dose. right, a vicodin isn't the same as percocet, which isn't the same as rocxyroxycodone. if you prescribe two percocet pills every day versus one, you reach what is considered a safe daily limit very quickly. doctors need to be mindful of that. we'll be talking much more going forward, the agency, the fda will, also about the dose that's being dispensed and thinking of morphine equivalence. that's another thing that technology enables. most providers don't really know.
they don't do the conversions in their head. if you look at the drug label, we try to be very careful to provide conversions. but it's conflict complicated a providers don't know a about the potency of each drug. >> and i want to talk about the apps. there's a number of online programs, some of which go through the fda for certification and some of which are just out there. so there are sort of -- some of them are sort of self-help program. use this program and you'll get off opioids. so talk a little bit about what you regulate, how a consumer can tell if they go google something, that will actually be of use to themselves or a loved one, and their role in terms of support. you know, the medication is going to be the gold standard for most people, but what else
do people need? and where does the online component, you're not regulating telemedicine, that's css. but i guess one of the questions i have is, how much is a tool and how much is a toy? and how much might even be a dangerous toy and where does the fda come in in trying to -- it's a wheat and chaff. >> we've approved some digital health tools as supportive tools for patients who have opioid use disorder and are going through treatment. mat's effective, but it's effective in the context of psychosocial support. and a tool that can help patient patien patients, provide support to patients going through a treatment could be effective. >> and ei think anything making a claim that a digital health tool as sort of a stand-alone device -- >> i did see some online. >> yeah, that's definitely not fda approved. and that's something we would probably take action against if we saw it. and we have taken action against
products that have been making unapproved claims, particularly dietary supplements and other products claiming they can be used for opioid use disorder. but there are some tools that can be helpful in the context of a comprehensive approach to treatment, that couples drug therapy with psychosocial support. >> and that may be particular useful in rural areas that it's not enough providers who can provide these supports. people who are just stigmatic, still don't want to go into a clinic and would rather do something at home. so they have a role. should it stay? if i were to click on something, should it say fda approved? you know what the internet is lake. >> i'm not sure i would trust it even fit said. >> how do people find out? >> typically these would be fda cleared. you can find out by going to our website. we have a landing page for the medical device center that has a collection of the medical devices that have been approved for help and treatment of opioid use disorder and it would probably be an fda-cleared
device. it would say cleared. and mostly what you're talking about are digital telt tools. i'm not sure any of them have. >> and what are the tools we don't have? some of the tools are probably in rudimentary form. what else do you and cms and samsung and everyone else, it's a really complicated epidemic. there's the heroin component, the black market component, the overprescribing component, there's now the fentanyl. what tool do you sort of see vaguely out there that we're going to be able to pull in soon? >> i think the challenge for me in the near term is just the integration between the different tools. i think we have good technology and it's not ubiquitous and it's not as tightly integrated. this has been something we've been working on over the last year. the vision i laid out, where you
can marry evidence-based guidelines with blister packs and then couple it with mandatory education to create a cutoff for physicians who can and can't describe. if we can implement that kind of a system, i think we can sharply cut down on overall exposure and help rationalize prescribing and creating some hurdles to prescribing, but i think reasonable hurdles that wouldn't be overly burdensome to providers because you're using technology to help facilitate it. now, i will tell you that in the 18 months we've been working on this, we're a lot further along than i thought we'd be on that now. the legislation, i think, was very important. that's going to give it an important nudge to the entire market. we're not quite there yet, but that's why the first thing we're going to do are the blister packs off the legislation and mandate -- >> can they raise cost or -- >> it will. it will. yes, they're pretty cheap. >> mostly generic. >> the ir drugs are generic and they're very cheap. and that's part of the problem, that potentially some safer
formulations are not generic and more expensive, so there's a lot of default prescribing, because they are so cheap. it will increase costs, because there is a packaging cost to it. >> but not like -- >> no. the problem is, if you go from like 5 cents a pill to 10 cents a pill, you guys are going to report a 100% increase. but it's a small amount of money in the scheme of things. so it will raise costs. but i think it's manageable for the system. >> and last question, because we're about out of time. there's a lot of research being done, nih and elsewhere for a safe painkiller. because you take away painkiller, you're not taking away pain. are we going to be skeptical enough when somebody comes along and says, this one's safe, start pribing? >> i think we are skeptical, frankly. the problem in this space, there's been no free lunch. every drug that's ever been aproved for the long-term management of pain has had
liabilities associated with it. whether it's certain side effects, even things as simple as nsaids and tylenol. even now, we see a common abuse ofganpe ofganpe ofganpentniods with opioids. there's a lot of early innovations that looks like they could be the same as opioids, without the same levels of addictive quality. >> how many years out? >> i think we're more than a couple of years out of something that looks really good. the things that look very promising, it's still earlier stages of developing. >> so we are out of time. i'm delighted that you came. >> thanks for having me. >> it was really great to have you. >> so with that, we'll -- while we change panels here, i want to remind everyone here in the audience to use the conversation on twitter and to tweet your questions. [ applause ]
using the hashtag, political health, and i will use the ipad if i can make my innovative technology to work to draw up some of those questions and i would like to introduce our panel for the next half, the next segment. samantha arsenal is the director of national treatment at quality initiatives at shatterproof. dr. eric weintraub is an associate professor at the department of psychology at the university maryland school of medicine. and as we will find out, he is a teleprescriber or a teletreater. dr. liz get goodman is the executive vice president of government affairs and innovation in america's health insurance plans or hip. so thank you all and let's jump in. so one of the things that, you know, as i said, when i started thinking about it, other than telemedicine, pdmps, i didn't
quite get the -- initially i was having trouble thinking, what is the tech. and you, actually, we have three really different areas here of expertise. and so i want to talk a little bit about what you're doing with tech innovation and then where do we go with it? sam, you work at shatterproof, which is a treatment advocacy organization, a treatment organization. and one of the things that we at politico have talking about and you clearly have been thinking about is, we have a need for treatment, we have a grow iing money going into treatment and how do you know what's good? so let's talk a little bit about one thing each and we'll come back and have a bigger discussion. so a little bit about the ra ratings you're trying to develop. >> so when you think about addiction treatment, people have this idea of what addiction treatment looks like. and a lot of the times, it's not actually what the evidence shows is the best way to treat
addiction. so there's a lot of misconceptions that addiction must be treated in a 28-day residential rehab program. that's absolutely true for some individuals, depending on their level of disease severity and what level of care that they need, but not for everyone. and there's also a lot of different viewpoints on how addiction is treated at an outpatient setting or in all settings, really. and one of the best practices in treating opioid use disorders, specifically, is medication-assisted treatment. yet, only 40% of the addiction treatment facilities in the united states offer even one of the medications used to treat opioid use disorder. when you look at all three, that number drops to 3%. and some of them are just offering those medication s for withdrawal management. so when you have people looking for addiction treatment, they're in a time of crisis, what do they do? they don't usually go to their primary care physician and ask for help because of all the shame and stigma. they usually turn to google or maybe they heard that their
neighbor's son had an addiction and they say, oh, you sent him to a rehab program in florida? okay, we're going to try that. but they don't use the same channels as other medical treatments. and there's no standard of how treatment is delivered. and so what we've set out to do is to create a system that creates a start and measures addiction treatment programs with delivering those best practices. so using reliable and valid measures gathered through claims data and provider surveys, very similar to the way that leapfrog approaches hospitals. and also including the consumer experience of care to be able to say, this treatment program delivers this quality of care. and be able to have that in a way that consumers can search it, to find care. as well as to provide to payers and employers and other groups to align market forces with the better quality to drive the entire system to adopt those best practices.
>> so trying to become a "good housekeeping" seal of -- the treatment that -- a way to sort of know to get through this jungle. >> if you think about sunscreen, people know that you want to find a sun screen that has a certain spf and it has uva and uvb protection and it's waterproof and all of these things. when you think that addiction treatment, you don't know what to look for. >> you don't know how to tell if that sunscreen has those things. it's not on the label. and now a lot of treatment programs are saying they're doing things and their websites look great or they have very fancy commercials of people sitting on the beach in malibu and it looks very relaxing. but it's not actually going to be medical treatment for a chronic disease.
let's go straight to ahip and come back to telemedicine. one of the problems we heard from dr. gottlieb is, we've overprescribed. we are producing that overprescribing, but we are totally not there yet. so part of it, insurers have a certain amount of leverage and even in this case maybe some moral authority to try to bring things down. so talk about how that's being tracked, how data is being used and any comment on how quickly people will adopt the blister packs and the e-prescribing. >> so i think the e-prescribing, i'm not sure i have an opinion on how quickly people will adopt it. you know, many prescribers have adopted it. >> it's the kind of thing, once you do it, you wonder why you didn't do it last year? >> yes, absolutely. so i think that some of that, it's wonderful that it is now
within the opioid package, required. but i think that it's also one of those things that is part of the -- as the system requires it, as the pharmacies won't accept it otherwise the system will evolve. ahip has been working for some time on the safe initiative. so many of our members have set prescribing goals to reduce the numbers of opioids prescribed. and many of them have a achieved them. one of the biggest things is the stop tool and that is a tool that can be used to measure prescribers against one another, with respect to their compliance with the cdc guidelines. so the stop initiative is around supporting adoption of the cdc guidelines. >> so if we're both orthopedists and i'm prescribing 30 days of the strongest stuff i can prescribe and she's doing two days of a little baby dose, what
happens to me? do i get publicly shamed? do i get a note? what's the insurer versus the health system? how do i become a good, healthy, responsible provider? >> sure. so most of our members, i wouldn't say all. i don't know for certain all of our members. but certainly those participating in the stock coalition are limiting the amount of opioids prescribed. >> so to be clear, we're not talking about cutting off chronic patients. we're talking about an opioid naive or someone who hasn't had them in years. not the patient. that's a whole other very long, conflicted discussion. but you walk in with a broken foot, do you need an opioid? and if you do, how little do you need? >> correct. so they are putting in edits that limit the number of pills, to your example, that an individual patient could receive on a first prescription.
they're also using all of the big data that was described earlier, to track prescribing patterns and to look at -- to manage networks in a way to identify when you talked about. it is not public shaming. we don't engage in public shaming, but we absolutely can help our members identify doctors who work in a way that is consistent with our view of what our safe and appropriate prescribing practices >> the idea of mandatory physician education, i mean, one thing that's always struck me is right now, if you're a doctor, you can prescribe the opioids. but if you're a doctor, you can't prescribe the drugs we're going to talk about in a minute. you need a license in training and limits. you can prescribe opioids to everybody who walks in your office. the good doctors don't, but we all know that some doctors have. and it's easy to do. and there's nothing really stopping you.
or hadn't been anything stopping you. and yet we're in a situation where you need special licensing and training to do the treatment drugs. so basically, this won't be -- we're moving to -- it won't be a licensing in quite the same way as suboxone, but, an education -- sort of a containment through the electronic record and the regulations and the health plans and what your ehr is going to tell you. >> it's also critical that health insurers use their utilization management tools, right? so the reality is, i know that people don't like prior authorization, but to your point, about anybody prescribing as much as they want, and they have been, the value of utilization management tools, the value of prior authorization, the value of concurrent review is that you are watching how the membership is using those drugs. and intervening when you see what looks like it might be an
aberrant practice. the other thing that's critically important is that the new legislation stays consistent with state law to give medicaid managed care plans, not all plans, we would like it to be all plans, access to prescription drug monitoring programs. it is very hard, if you have people who are moving between plans, or moving between doctors, to identify that in absence of the availability of that data. >> even with the ehr now, as they move toward integration of the electronic medical record and electronic health record, we still haven't solved all it will interoperability issues with the ehrs. so as a physician, i might not really have a complete picture of everything that this patient is -- all their conditions, all their drugs, all their providers still may not be what i see when i click joe smith. >> absolutely.
and there are often -- and i'll let the doctor speak to this, but there are often drugs that are prescribed that make the issue even worse, right? that somebody has a co-occurring disorder of some kind. some people have a co-occurring disorder of assignment kind, and that that physician is looking at that patient's medical record, from their interaction with that practice. and only that practice. physical they're in a more integrated delivery system, which is part of the value of moving to value-based purchasing, where you're looking at bundles or an aco, that it is more than that practice. but you're going to see only the patient's experience with that one doctor. >> but also, it's not going to largely include the integration
of those systems. >> and that was part of the bill that was just passed. >> now for the first time. >> but the information sharing, that didn't get into the bill. >> that's right. they may be incentivized. that's a small win. they're just completely separate, but they're still not going to be able to share the information. >> i think many of us forget how rural maryland is, right? we go over to plbaltimore and back. it's a rural state. there are not a lot of providers when you get out to places like cumberland and hagerstown. so you have stepped into the void. why don't you just talk about why we found out about you? >> sure, okay. well, i've been working baltimore city for many years, treating patients and individual s with opioid use disorder.
the suburban and rural owners have been disproportionately impacted. approximately three years ago, we had colleagues that were actually here today that work in hagerstown, and they lost their provider. as you were saying, to deliver medication-assisted treatment. >> which is what you have to be lined and trained to do. >> there's three medicines. one is methadone, which has to be delivered in highly regulated clinics. over 90% are in urban areas. bupunorphrene, you have to have a special license. and when people are in withdrawal, they're not going to stay and receive counseling. medications aren't a cureall for everything, but they're a cornerstone of the treatment of opioid use disorder.
they were approached about trying to help them out. they were like, we can't drive out here. it's an hour and a half and we had a pretty robust telehealth department division in our apartment, so we talked to them. we were not tech guys, either. so we were clinicians. >> but you have kids. >> i think there's two kind of people that go into telehealth. i was talking about this before. those that are interested in technology and others that kind of stumble into it. >> you were a stumbler? >> we were a stumbler. but we figured out how to deliver care. we set up a video conferencing system and there were some complexitiesed complexities to doing it and we started treating patients. i think at this point -- and we've expanded. now we're in five different sites at different parts of the state. people keep coming to us because they can't find providers. in this past week on the eastern shore of maryland, one of the
providers had some significant problems. he had 90 patients and one of the health officers for one of the counties approached us and said, can you help us out, because we don't have anybody to take his place. we actually just published a paper that our work is doing video conferences is just as effective as face to face based on our numbers. people are being retained in treatment and stopping drug use, just in the same rates that people would in person. and we're trying to think outside the box, because i think every state is different, so what would work in maryland, because we are a smaller state, would not work, for example, in alaska or maine. we're actually delivering you are care to pre-existing treatment programs. where all the patients have kourms and y counselors and you get urine drug screens. if you go to alaska or maine and have somebody that's living where there's nobody else, there's not going to be a treatment program they can go to. >> so you are providing the
medication component remotely to a treatment of a larger, multi-disciplinary support services that wrap around -- so you're doing the prescribing. >> right. >> for a system that exists that needed you, because there isn't one in a small town or he retired or she retired. >> exactly. >> but it wasn't -- you have both legal and financial obstacles. >> right. so initially. >> you're a bad guy. >> no. -- so, anyway, there are some -- there were some regulatory issues for those that don't know it. there was a law that was passed wing in 2007 called the ryan hate act. and it was passed because a young man passed away because he was able to buy prescription opioids over the internet without anybody talking to him or even -- and the pharmacist prescribed it to him. so the bottom line is, the current interpretation is that to be able to prescribe controlled substances through
telemedicine, you have to do one in-person evaluation. the law is very conflicted and i've read it a hundred times. i had a different interpretation, but after our -- after an article was published about me in politico, my dean at me talk to our lawyers and they actually took a more conservative video. so we actually were very fortunate. i talked with dea agent, field agent and and they were coming to look at our methadone clinic. and i said, look, we have a problem, can you help me out? and they were actually very, very helpful. my sense was that, obviously, d.a. is a big organization, but as far as the field agents i talked to, they wanted to see us to maintain this -- >> because they had authority to allow this and they had been bottled up, right? >> ting there's two levels of that. when the act was passed, there was an avenue for them to grant
exemptions to physicians to be able to do this. and that's never been done. the new legislation that was passed will allow that to -- will actually says it needs to happen. >> it allows and it mechanisms? >> maryland, again, we're fortunate medicaid is in the state, and we have a very good state authority which reimburs telemedicine. we're close to breaking, even to the way it works, we get paid for our time and bill and collect and return the money to the site. we're getting close to break even. it's better. >> with this new -- if it passes the house and senate, what -- it opens doors. it validates and expands telemedicine. talk about sort of, what is your role in helping do the training, and what do you also worry about if things grow rapidly.
we often know there's always an unintended consequence in health care. do you worry about -- is this just a really good thing and we know how to run with it and we're going to run with it because we learned our mistakes or there are no mistakes or where do you go with te telemedicine. >> there's a couple questions. one is i think we have a model that we feel comfortable with that will not work everywhere in the country. we need to think of innovative models. we got a grant to deliver tel er telemedicine through a mobile unit. but i think every state is going to be different. there are some worries, and i have learned a lot, so every time we do an implement, one colleague of mine who does implementation says every implementation is a different i. lmentation and i learn that, you have to take the cultural component into account. i do worry that, like anything in medicine, that you have to
have quality control. and that, you know, there's profits being made in addiction treatment. we need to make sure that people roll this out in our state in a responsible way so patients can get safe and effective treatment. >> are the health plans moving towards reimbursing more telemedicine and this kind of a situation? >> they are. in the commercial space, certainly. each state's medicaid program has a different policy on reimbursement for telehealth. so it differs slightly in that area. and then the new bill expands the availability in the medicare context. so it really depends on what type of coverage you have. >> how common is it in employment sponsored coverage, most people in the room, watching us, are probably covered through work. someone has a substance abuse problem in a typical american business, how likely is it that they can get the telemedicine?
>> i don't think i know the answer to that. it's very likely they would be able to obtain counseling through a telehealth application, depending on the state regulations and laws. and where the person is, the coverage of that program. >> without knowing all the details, but are you seeing this widening fast? or do you see a lot of resistance still? >> we see it -- the availability widening fast. the uptake is not what we, i think, would hope and expect it would be. we think that will come with time. we find that the results are extremely positive when people use it. it is very high level of satisfaction that there's lower out of pocket cost for the member. and that the results in terms of cost for overall system, when people are accessing care, accessing psychiatric care or
psychological care through the telemedicine are positive. the issue is that most people are not using it yet. >> sam, do you see the telemedicine mostly for prescribing, for the wrap-around services? you know, counselling and other support services. and also, given social dau determinants play a role in all of our health, we know more and more about it. it's one of the buzz words that's here to stay. are you worried about a digital device? >> well, yes, of course. if we're going to move towards a direction where technology is delivering care, you know, you have a massive population of people who are homeless or don't have access to smartphone technology who immediately from the get-go are not going to have access to that care. but i think the doctor had a gray point about counseling versus prescribing.
it's important to differentiate telemedicine. in one case, you need the prescriber on the other end to prescribe the medications and we're so limited in the number of prescribers that are engaged in the states, let alone that are willing to hop on a web cam and prescribe to someone in a different state. so we need to have technology that also supports primary care providers, to link them with addiction specialists to make them feel comfortable in treating the patients in their own community. on the other side, you have a lot of new apps and technologies that are coming out to deliver contingency management or cbt and other, you know, counselling services. and those are fantastic and great. i think being able to deliver behavioral health to people in a way that's receptive to them is critical. but in a lot of cases, that's not going to swap what you might need for treatment. it might not replace needing to talk to a physician. and having a proper assessment
and diagnose and treatment plan from that interaction. >> what are you seeing in terms of -- are you seeing support services also developing more? you're in a model, you described that. you're working with people who are on the ground, who know the patients, who are providing services. and you're providing the medication. as we enter into a period where there will be -- there is more telemedicine and more payment routes, is it -- is there too much risk of fragmentation, this person is doing the counseling, this person is -- are we creating chaos or coordination? >> to that issue, as a clinician, i have worked -- each clinic is different, so for one clinic i found that was happening so we had a team meeting with the head counselor, myself, and we discuss every patient that i'm going to see that day. we're also looking at different platforms. i think consultation is a huge issue where we need to pipe out our extra areas. the state of maryland has
partnered with us. we have developed a phone line, a 40-hour a week phone line where we have addiction experts taking calls from primary care providers around the state to give advice. it was initially focused on the waiver providers because there was clear literature, we saw waiver providers don't tend to prescribe very much. it's kind of difficult for them in a private care practice to take care of active using patients. >> time consuming and complicated. >> yeah, so we're providing kind of a spoke in the hub model where we take calls, give advice over the phone, and write out a consultation for them. there's also patient apps. as you were saying, i heard of one the other day that does contingency management, so my partner was saying that the app actually works by videotape, the patient videotapes himself taking his medication. every time he takes it, he gets some kind of $5 cryptocurrency
into his bank that he can use to spend on something that he wants to. so i'm not sure. i haven't seen the details but things like that are coming out. i think that's another area. even there's apps where you can monitor patients to make sure they're safe after they have taken medications. >> so the apps are not just for the patient. there are now apps developing for the providers. >> a combination, yeah, for providers and patients. >> i just came across a few. how common are these apps? and again, you know, you're concerned with getting people into recovery and keeping them in recovery is really hard. really, really hard. and there's multiple relapses. and you know, when you read these stories of people who are really trying, they're heartbreaking. are the apps -- how worried are you, these apps another tool?
you live in a community that doesn't have enough providers, you don't know where to go, are they providing services? are they a starting point? are they keeping people on track in addition to these kinds of medical services? or is it just like forget it. this is promising something with a quick click and they're going to be dead in two weeks because they didn't do something better? >> i think it's a little bit of both. i'm definitely a skeptic because we have this system in place already that should be delivering evidence-based medical care, and we're not layering on top of that with technology. we're trying to use technology instead of fixing that broken foundation. and so i'm skeptical, but i think anything you can do to help someone, you know, stay within treatment, stay engaged, meet them where they are, change the way they think about their disease, is going to be a step in the right direction. as long as we aren't viewing these as the fix-it for the problem. >> but that also -- but the positive side, because i asked a very skeptical question, could
be if you're in alaska and there's no counselor within, you know, you have to go through eight glaciers, well, there are mountains. bad example. i mean, remote areas. i didn't mean to be flippant. this is serious, but you know. you're in a place where there's nothing else, are we going to be developing -- is it going to be apps or more of this model where you call in to a university clinic where they can give you the care? what do you want to see? or is it going to be a mix? some of these apps are things we were skeptical about a few years ago. they're useful. there are people who do use online services to get heal healthier. >> i think there's different -- it depends on the level at which you're working. right? so project echo is a program that is essentially very similar to the hub and spoke model that was just described that is being used by four of our plans in the
space to train providers who are more remote to access these technologies. so at the health professional level, we have proven out these are useful tools that we use. at the patient level, i think it depends on what you're trying to do, right? so for example, we know that peer support works really well. right? and that alcoholics anonymous has proven in the alcoholism space that having a peer counselor or a peer sponsor that you can call on the phone anytime day or night is a valuable tool. and it certainly is conceivable that an app that does that for peer support model would be something that could be of use to people when they're in crisis. right? is it the be all and end all, the replacement for having a professional relationship with a prescriber and a therapist and the other tools that people need
to recover? probably not, right? it is a tool in an arsenal. >> what else needs to be done? we do have all this -- the ahr, not in their first iteration, but they're not in the greatest iteration. so they're becoming more useful, becoming more interoperable. we're learning how to begin to extract data and not just use them for taking notes. what in this field, i mean, this may be more for liz, but what are you beginning to see or both of you, what are you beginning to see in the records that is adding value as you approach the addiction crisis? and where does the data, you know, if there's a developer here in the audience, what do you want them to know that you need? >> well, our data are primarily coming through claims, not through ahrs. what we're able to see very clearly are prescribing and utilization patterns.
improving but not where you need them to get. >> they are, and even with prescribing data, right, so someone is addicted and i'm sure that you see this every day, somebody is addicted and we have cut off their supply of opioids, that doesn't mean that you have solved their addiction problem. >> black markets, heroin, all sorts of other things come in. >> so where it's very helpful and where you would never see out of claims data is this information about the other factors in their lives, about possible illicit drug use, about other, you know, indicators that either they have a substance use disorder or that they are at risk of it. >> so the work you do, relevant, irrelevant, increasingly relevant? >> i'm not, like i said, a tech guy, but i find them to be very helpful in a couple ways. one is just the amount of information that you can find
out about a patient. in maryland, you can get access to other hospital data. you have the pdmp. before we start patients on other medicines, on controlled substance, so that's important. i think e-prescribing. we don't actually have e-prescribing. i wish that we did. i think all those things are really valuable tools for us. one of the other things is just work flow in a clinic. i'm not -- that's not my thing, but my colleague is kind of trying to figure out what's the best ehr to help everybody that's working with the patient to have a really efficient work flow. those things are all critical. you can bill through ehrs as well. so much better than a paper chart. >> what do you need, doctors or other providers to know about patients they may not know yet? or maybe it's there and they're not looking or is it there?
where do we have to keep developing and making it easy? the pdmp hr integration will help. but where does that have to go? because there's so much data out there, and we don't know what to do with it. >> exactly, and pdmp data is tracking your prescription drugs, and as was mentioned, it's not capturing if you're using illicit drugs, if you might be engaging in risky drinking or other things that you know you go to your doctor's office and you frequently sit down in primary care and fill out your intake form and it asks you how many drinks you have a week. there's not usually a conversation. so information like that, but also when we look at addiction treatment specifically, the fact that most addiction treatment is happening outside of health care, there's no feedback loop. so with certain policies and privacy restrictions, sometimes physicians will call an addiction treatment program that
they referred john doe to and said we want to check on john doe. how is he doing? and the facility has to say who? we don't have -- we don't know about john doe, even if he's there receiving treatment, doing better. if that patient goes back or gets admitted to the emergency department and they have a broken leg and they need an opioid, there's no way for the doctor to know this patient is being treated for a substance use disorder. having that information integrated and available and also having physicians that are comfortable and other medical professionals that are comfortable to talk about those things, if you sit down in the dentist's chair and you're getting a tooth pulled out and you say no, i'm in recovery, that shouldn't be a question of, okay, i'm still going to give you the opioid, which is what we see all the time. having that information integrated and received by the medical team. >> we're going to go to audience questions. while you get ready, i want to ask, how mane of you in the audience have something, either
you or a family member, fairly routine thing in the last year that earlier you might have gotten opioids for but this past year you didn't? i had a sprained ankle. i bet two years ago, they would have sent me home. i had a bad sprained ankle. i should have asked. they gave me, you know, ibuprofen and till naylenol. i was impressed they didn't offer it, but i should have asked. i was really just thinking about my leg. my doctor referred to my ligament in the past tense so i had every reason to complain. i bet they would have given me at least a week two years ago. just quickly, have you had anything that you think you would have gotten an opioid for that you didn't this year. this is not scientific. tooth pulled, whatever. a couple people. yeah. either you have great teeth and none of you have slipped up.
but there are a few hands. questions. hands up? no questions? no audience questions? did we give you coffee? if you think -- here we go. one over here. can you identify yourself and make sure it's a question, not a speech, because i'm tougher than i look. >> my name is ben. i work in opioid communications in the commonwealth of virginia. i'm wondering if you all can explain a little bit about the role of medicaid expansion and the cons and pros it has toward combatting this epidemic. as many of you know, virginia has voted to do the same. i'm wondering what to expect. >> take a first stab. >> we know medicaid expansion is providing necessary health coverage for individuals who don't otherwise have access to it. and creating a pathway to treatment. i think virginia is actually a
really interesting case study because virginia, in addition to expanding medicaid, has established their arts program, which is they have completely revamped the opioid treatment system. and they have increased their reimbursement rates for providers. they got providers delivering medication assisted treatment and established that infrastructure. they have already seen a huge uptick in the usage of medication assisted treatment, and that's before expansion. so i imagine once expansion takes hold and you have populations that previously didn't have access to health care coverage like single adult males, you're going to see these systems increase more. it's absolutely critical. >> i think regardless of expansion, right, you have seen one medicaid program. you have sort of seen one medicaid program. i think there's a lot of -- i'm very hopeful now that the new legislation that's been passed by congress addresses to some extent this imd exception,
because i don't think you can create a continuum of care without having that deep end part of the system available. >> which is in-patient. it means the obstacles in medicaid paying for in-patient treatment, and this will relieve it, it won't eliminate it, but it creates more ways of getting payment. >> a small window, but it also requires that states continue their level of effort on whatever their level of effort was, and that they make available a community-based continuum of care in order to avail themselves of that greater flexibility. and so -- >> so as she pointed out, not everybody needs in-patient treatment, which is what i thought. i thought you had to start there, which i now learned you don't. but for those who do need it at least to get themselves started on a path to recovery or in a crisis, that you have that option. >> correct. >> medicaid can pay for it. >> so all states, whether they choose to expand or not, will have this greater broader
flexibility. so you know, i think that it's not a uniform system. that's the benefit and burden of medicaid. but this is a great opportunity. >> and you have been doing this treatment, the remote treatment for how many years? >> three now. >> you didn't see a change because medicaid care already expanded. >> we were basically -- i have to be honest with you. working with medicaid has been easier than working with commercial insurance plans. the preauthorizations are kind of diverse and very complicated, while medicaid has one system that we have become familiar with. i think there really needs to be work on the commercial payers and how they treat opioid use and do preauthorizations for use. >> there she is. >> you probably know more about it. i don't know about the detail. all i know is when i have a commercial patient, i say oh, no. here we go again. instead of just having a one-minute phone call and having the authorization through
medicaid. >> you're working in a medicaid expansion state. you don't have the gap where there are people who do not have any way of getting this paid for. >> the way our state has been managed, anybody really is eligible for medicaid. >> other audience questions? time for one more. back here. >> hi, there. tommy ratlife. i think the example you were alluding to was around the 42 cfr part 2 issue. i wonder, i mean, we saw that legislation pass the house with a huge bipartisan number, and it's sitting in the senate. what the debate seems to be around the stigma of that data getting out versus truly kind of moving it to a medical model, right, and being able to see the full medical record. can you elaborate more or the opinion of the panel on how do we follow on that and being able to see that substance use disorder record? >> yeah, i think, you know, the reason that 42 cfr part 2
exists. >> which is the most clumsy name. >> is because at the time it was created in the '70s, i think, it was meant to protect people with addiction from, you know, all of these misconceptions. possibly be thrown in jail, a lot of times losing their kids. and those fears are not gone. we're still dealing with those. so we need to make sure that individuals with substance use disorders which are chronic medical conditions are not discriminated against because of their disease. substance use is a disease that hijacks the brain and do things that might upset their friends and family and get them into trouble. it's still a huge risk, but it's inhibiting that care coordination in a way you don't see with other diseases. so there needs to be that back and forth and be able to communicate and care for an individual. we released our national principles of care last year, and care coordination for medical and behavioral health is one of those principles. and so, you know, preventing
prescribers and other treatment providers from doing that, you know, it's a huge barrier. >> anyone want to add to that? >> we strongly support that legislation. >> okay, so we're going to move to our diabetes conversation in a minute, but i want to circle back, because when i began learning about this, we have three tasks. we need to prevent addiction. and we have talked about ways that data can help us find people at risk and data and electr electronic tools can help us reduce that initial fewer, shorter, less intense, initial prescriptions. the second task is recovery. and that's really hard. someone tweeted in saying please remind them how hard it is. you're all reminded. and we're seeing ways in which data is helping both treat people in recovery through medication remotely and also the ways that you're beginning to find data to help people, guide people toward good treatment paths. and ultimately, is this going to help save lives, which is what
the whole fight is about, because the numbers are staggering. and really staggering. i looked them up the other day compared to wars we have fought. these are staggering, horrible numbers. so i guess we will know in a year or two whether these good apps and we figure out which ones are the good ones and doctors who are treating patients who really have no other access. we will begin to see whether we are helping us along with determination and care, start making a difference. so thank you, sam, eric, and liz. thank you for joining us here. thank you for your insights, and we're going to get off the stage and i'm going to make room for my colleague, arthur allen, to talk about diabetes. [ applause ]
>> hi, everybody. i'm arthur allen. i'm the e-health editor at politico. so you heard this morning from fda commissioner gottlieb and this wonderful panel on opioids. on the wonderful subject of opioids. sorry. so we're now going to turn to a different health crisis, also that has genetic and behavioral components, and that's diabetes. both type 1 and type 2 diabetes. we're going to discuss how patients and companies as well as groups like the ymca are working to improve treatment and prevention. we're joined by heather hodge, senior director of evidence-based health interventions at the ymca, josh riff is ceo of unduo. and dana lewis is leader of the open source -- #openaps.
we're going to start out by introducing everybody and getting a sense of what they're doing in innovative ways. dana, you created your own artificial pancreas. system in 2013, i believe. so can you just tell us briefly what that is and tell us a little bit about what your current project with robert woods johnson foundation and then maybe go on to talk about what impact the diy patient community is having on the development of technology and drugs by companies. >> absolutely. so i'm talking a little bit from the perspective of a person who lived with type 1 diabetes for 16 years. type 1 diabetes, i had access to an insulin pump and a continuing glucose monitor, but these devices aren't perfect. it wouldn't wake me up at night if my blood sugar was low or high. that's what got me into the diy space. i have to do something, i can't change the device. what can i do?
i found somebody's code that allowed me to get my data off the code, and that allowed me to do a drop box and add a louder alarm, and then i found the ability to track what i waseding. as a result of that, we were able to build a simple but effective algorithm that would predict what was going to happen to the blood sugar every five minutes as precise as i wanted to be. that was helpful in shifting from reactive to predicting into the future what was going to happen and alerting me so if i was going to go on a panel, for example, it would say in 72 minutes, you're going to go high, but if you take action now, you'll go less lie or less low, for example. and others started sharing how this was working for me because i kno struggled with their devices as well. we realized you could take a small computer and radio and talk to the cgm and the pump and bridge the gap between the
devices that were previously interoperable. that's what became the hybrid close loop system, this little computer that would talk between my pump and my cgm. that's whaumet we call an artificial pancreas. we decided to share this with other people. as a result of sharing with other people with diabetes but also talking with other patients and other disease communities about what we did and we we shared an open source, i realized there's actually, we're not the exception. we're just the undiscovered rule. people with conditions are hacking and innovating and developing things all the time to basically make our lives better. and so that's what my project with the robert johnson woods foundation was looking at the barriers and obstacles patients are facing. when they come up with an idea like this, white are patients told to stop doing this, stop making their lives better. to your question about what are companies doing about this diy movement, some of them are ignoring it. i think that's to their detriment. others are listening and embracing it. i'm pleased to say at least one
diabetes company has taken the code we wrote, open source for a reason. we like to get it so both companies and individuals can use it, and they're putting it in their product. i expect when their product reaches the market will be a lot better than the first generation of devices that came out that didn't take advantage of the learnings we had. >> is this an established company? >> yes. so you kind of see a spectrum of ignoring it and sticking your head in the stand and really embracing it. you have some companies in the middle who are hiring people from the community and really listening in different ways. it's really promising. >> that's really amazing. we're going to get back to some of that. josh, first, i wanted to mention that anthem, which is sponsoring this event is your former employer and a member of the blue cross blue shield which is partnering with your company. so you have got, you're in charge of one of these gigantic super well funded googly things that we're all fascinated and
confused about. and you're creating virtual diabetes using a lot of high-tech tools. tell us what you're doing. and you know, you have a pilot started, and maybe you can talk a little bit about the results have been. >> absolutely. so josh riff, ceo for a company called unduo, a joint venture. what we're really trying to do is how can we deliver better care for people with chronic diseases. and i like to say that people with chronic disease require chronic solutions. and the way our traditional health care system is set up, it's just not great for managing people between visits. and so when we look at different conditions, right now we're looking at diabetes, different people might need different things. some people might need a visit every couple weeks. other people might need a couple visits a year. some people need their hands to be held. other people just need some medication adjustments.
what we're trying to do is create the ideal system to, one, give the person as much care as they need, but two, remove inefficiencies or wasted resources. so when we talk about continuous glucose monitors, this is usually a very expensive device reserved for only those who have the thickest, highest needs. we're saying actually, if you use it slightly differently, for shorter periods of time, you could get somebody really actionable insight. those are some of the things we're doing. we're leveraging software in the form of telemedicine, in our apps. people in forms of coaches and educators as well as doctors, and then hardware in the forms of continuous glucose monitors or home monitors to help deliver that care longitudinally. we talk a lot about two problems we're solving. one is the calendar. if i'm a person with diabetes, why do i only have to get help four times a year? why can't it be on any day where i need it?
so that's the calendar problem we solve. for the clinicians, the average primary care doctor has 8 to 15 minutes with a patient to deal with all of their problems. and so what we say is between visits, or before a visit, we can help you gather data to make your 15 minutes really, really effective. and so onduo, we exist to help people with diabetes and their doctors solve the calendar and clock problem. >> you have a pilot, about 3,000 people in it. we'll get back to it, talking about some of the results. heather, you are working sort of upstream of these two people. you're working with pre-diabetes. and the y now has, what, 1100 different sites, physical brick and mortar locations around the country. but this is also an innovative program. might not be using a lot of gadgets, but tell us a little bit about, like, you know, how the y got into this and what sort of research and experience goes into your program. >> sure.
the national institutes of health in the mid-'90s really convened a study to look at could type 2 diabetes be prevented. could we slow diabetes with individuals with the greatest risk. the trial showed that yes, lifestyle change was twice as effective as met formen, which is typically used in that instance. while they know they had proven intervention, sometimes what happened in research is you get this great, effective thing and it takes so long to get to market or it sits there because you couldn't find the right -- and the great thing is one of the researchers, a couple of the researchers at indiana university school of medicine happened to be in a meeting talk about this and said there's a lifestyle intervention, a coaching program. we have been using clinicians but maybe there's a way to do this more cost effectively, and the ymca of greater indianapolis said what about us? that's what started to take the dpp from a clinical environment into the ymca showing, and we were able to show using trained
lifestyle coaches in the group based format, we were audible to do that for the fraction of the cost and still help people prevent or delay the onset of type 2 diabetes. through that work, then, we have been scaling for almost the last ten years the diabetes prevention program. we have done so in partnership with cdc and other stakeholders to look at how can we get this proven intervention out into communities. through the ymca, we do that through a brick and mortar approach. we have 2700 ymcas all over the country. about 1100 program locations right now. those program locations have served about 62,000 people. that may seem like a drop in the bucket, it may seem impressive, but there are 84 million americans living with prediabetes and only about 10% know it. we only -- it is only a drop in the bucket. we have much more work to do to do that, and it's going to take a lot of organizations working together including with health care partners, with technology, with other community based
organizations in order to see an impact. >> so so far, these have been up and running for a couple years. is there anything you have learned about sort of what works or doesn't work, you know, that's different from the pilot? and also, i mean, if you're finding that basically you're having success in these programs and they're helping people, maybe you can talk about what the measure of success is, but also, do you then -- does frankly, you are a drop in the bucket. does that lead you to think that maybe we need -- i mean, the cms is sort of been holding up the approval of these virtual diabetes prevention programs. would you like to see that move faster as sort of an adjunct to what you're doing or another component? >> yes, so there's a couple questions in there. so what folks are working on in the diabetes prevention program is a weight loss goal. they're working to reduce their weight by 5% to 7% and increase
their physical activity at 150 minutes per week. it's not a significant change, but it is work. it's a lifestyle change. that's really the core tenant of the program. teaching folks how through healthier eating, increasing physical activity, and dealing with a lot of the social and emotional challenges that can get in the way. stress, cues, things that, you know, smells that make us want to eat. all those challenges can impact our ability to change our lifestyle and reduce our weight and reduce our risk for developing type 2 diabetes. the core tenants of the program, we are getting people to the weight loss at the end of the program year. we're seeing about 5.5% weight loss in our participants. it's a year long, so an hourly session, 25 sessions that happen over that course of that year. so it's intensive as well. there's a lot of support in making the change. but with 84 million americans, no single organization or no single mode of delivery is ever going to really prevent people or delay people so they might not need the interventions that
have been previously discussed. we need all types of modes in order to do that. while we're really excited that medicare is paying for the diabetes prevention program and ymca is going through that process right now, we're going to need everybody working together to really impact that. so yeah, we do actually hope in the future that the medicare considers multiple modes of delivery for covering this. >> one thing i'll add to that, and correct me if i'm wrong with your programs. almost every digital health or dpp program, you only get paid if you're showing outcomes and results. so for unduo, we basically answer the same type of outcome based reimbursement. as a physician, i loof at that when we're always held to the standard that you only get paid if you get outcomes. i have to hang a shingle and noenchd asks for my quality as a physician. we have tens of thousands of physicians that are not getting paid for outcomes, but i'll argue almost every digital health company i know is we hold
ourselves to outcome based reimbursement and outcome based standards. >> what outcomes are you required to reach before you get -- >> so for dpp, i believe you have to be on track for 5% of your weight loss. for somebody like onduo, we have different outcome measures but it would be from a1c, and we want to get to the holy grail, which is cost. for all of these programs, and i think this is why cms and other entities have concerns around digital health, is because they're so scalable. the idea is that if you could then -- if you're a doctor's office, you have capacity. how many patients can you see a day? if you're digital health, we're building it for scale, so the fear is do you have excess use or unnecessary use? the way you combat that is by tying it to well validated studied outcomes and you get reimbursed for the outcomes. the equation for anyone here
thinking about doing anything in health care, but especially digital health care, should be outcomes divided by dollars. if you can't do it better, cheaper, faster, than digital is just another medium. >> i noticed, i was fascinated by the fact that sanofi put up a couple hundred million dollars to found your company with google. talk a little bit about this. one of the measures of success that you have is actually getting people off some of their medicines. or what's the word? >> reconciling. >> reconciling their medications so maybe not getting off of them, but getting them on the right combination, which often involved cutting this out, because our system of care is so fragmented that somebody can get prescribed one drug and then another doctor sees them and they prescribe something else and they're not keeping track of how this all works together. so i with sanofi would want to
be part of a program that's going to lead to people taking view fewer of their drugs. >> you would have to speak to sanofi, but i can hypothesize. google was the one, it was their idea. and so when google decides to get the to health care and says hey, we're going to help build a better program for people with diabetes, a lot of people pay attention. i love to play instructive, and if you're sanofi and said if goi google is going to get into health care, especially diabetes care, we risk being disrupted. how about we own half of that so we hedge our bets? and as half my board is composed of sanofi and they're wonderful because it's never about what's the next drug or how do i get our drugs in. it's simply how do we take care of the whole person with diabetes, regardless of drugs. they have the same goal as us. which is outcomes divided by dollars.
>> you think mars might be an investor? >> mars, the candy? they're a wonderful employer and company, but we haven't gotten a call from them yet. >> so and you're going to be taking -- you have this pilot going on now, and you're working on developing a trial, but it sounds like you got some informal, unpublished non-peer reviewed data that's impressive. >> we launched in january with a couple blue cross blue shield plans, in march with anthem. so for us, we had a couple thousand users now and it's really fascinating. you break -- you could break our groups into basically two different categories. one is types of things that motivate them and the other is clinical risk. and what we're finding, almost across the board, anyone with a high a1c, and that's a measure
for how much glucose is basically precipitating out and causing damage, we see really unbelievable outcomes for that group. and then for the people who have an a1c less than eight, we focus more about their control and their confidence in managing the disease. so we're seeing great outcomes in terms of confidence as well as a1c reduction. then the flip side is when we look at types of users, we see basically three different groups. some people love tracking. they want to take pictures of all their food and they want all their steps and they're super engaged. other people just want veenls. they're saying how can i get access to some information, and where want to do the least amount of work for the greatest amount of return. and then the third group we like to call chatters and braggers. these are people that they test our coaches all day long and they want to know, you know, our coaches know how their dogs are doing, how their grandkids are doing, but this is a really important thing. in health care, it's about trust. why do you need a physician who
might make $200, $300,000 a year trying to build that trust. why can't you have somebody they like, lower cost, more efficient use, and if they could build that bond, i don't mind if they chat all day as long as that leads to them taking their medicine or doing the other things they have to do. >> right. that's a growing area of our economy, right? all the ancillary parts of m medicine that are probably more important than doctoring in a lot of cases. dana, to change the subject a little bit, but you know, you run marathons. you code, you diy like crazy. and i think you said on one of your blog posts that there are like 600 people in -- >> 900 now. >> 900 now, but still, how many type 1 diabetes are there -- patients with diabetes are there? >> a lot. >> so i don't know, so what's relevant to what you're doing to other more sort of normal human beings? >> i think normal is a setting
on a washing machine. >> all right. >> and to recognize that, your comment about a drop in the bucket. we're a molecule of the type 1 diabetes community, but that doesn't mean what we're learning is not applicable to the broader community. we have been able to use the data, use our attention to understanding how the body is working with these devices to learn things that traditional medical community hasn't discovered yet. we have been -- >> like what? >> understanding how insulin peaking before the meal and getting your liver ready to accept the glucose will lower your glucose levels after the male regardless of what you eat. it's basic how the body works phenomenon we're able toeshplore in data that people didn't have the data or devices to track. this device right here tracks and calculates a lot of things every five minutes in a way traditional devices don't. so a lot of data that we're using are applicable to the broader type 1 population. not everyone is going to want to go on this closed-loop
technology. some people want to do their multiple daily injections. that's fine. but a lot of what we're learning is translatable back to that population and it's also translatable back to the type 2 population. >> talk about that a little bit. >> one of the first things i had done with my kind of smart alarm system was realize that before that, if you would ask me to lock something, i would laugh at you because there's no point. >> first of all, maybe explain to people what's different in how you treat type 2 and type 1. >> in type 1, you'll die without insulin. if i don't get insulin, i'll die. with type 2, some people go on oral medications. some people can manage with diet and exercise. type 1, you need insulin or you'll die. you're responsible for dosing your insulin every day, and that's a lethal drug. and traditionally, we didn't vt the tools to manage it. you might test your blood sugar a couple times a day. you might be lucky enough to have a cgm, but that's still not good enough because insulin is complex.
it's not snainious. if i ate something right now and dosed my insulin, i would be playing catch up, so it's really complex, and the way that timing works, even if i log what i eat and log what i take, unless i have something that's tracking what's happening throughout the next couple hours and then presenting that report to me, i don't have any feedback of did what i eat was good or bad or healthy or not or just that the insulin timing was off. there was no way to provide that feedback. i turned into the world's best logger. a great guinea pig for entering everything i did into the system because it would give me real actionable feedback. that's what's really applicable to people with type 2 and other diseases, if you design the data to go to the patient, don't do it for the company, for the clinician. if you do it for the patient, that helps people start being able to take action and understand the cause and effect of the correlation of behaviors. in some cases, bad outcomes, you
have diabetes, it's hard, and you don't know, but we're starting to peel back the layers of the onion to understand, if you do this, you get this outcome. it really empowers people to understand what behaviors they're doing and they can make the choice. >> i'll just add on that, you call yourself a drop or a molecule in the bucket, but it's an incredibly important crystallizing effect then. in that you showed people that it's possible. and when we started onduo, we did dozens and donees of focus groups. we showed them the article about the amount of money raised and who our partners are and we said what can we build for you? the answer every time was build me something to let me forget i have diabetes. and if you spend some time with somebody with type 1 diabetes, all day long they're managing their disease, chasing their glucose and dosing insulin, literally all day long. then what you get to do for people, which is beautiful, is you actually get to forget about it for a while. >> that's a question i had,
because there's this -- when you're talking about, especially about diet and tracking, there's an awful lot of not forgetting that you're trying to lose weight or trying to control your diabetes or whatever. so i mean, in this area of, you know, digital innovation, when it comes down to personal engagement, a lot of it seems to be going in the opposite direction from what you're saying your patients want. i don't know -- go ahead. >> i'll say it, it actually totally depends on the person. i love to think about how do we lyft or uberize health care. what uber did for me, two things for me. when i called my uber this morning at 5:00 a.m. to catch my flight, my anxiety that i used to get when i would call the cab company waiting would they show up 50% of the time, they never showed up. that anxiety is now gone. >> i have the same.
>> right, so what uber and lyft did is created a trust through transparency. i think that's what our companies are trying to do. which is how can you build that trust? give them better data when you can, but it's not about collecting all the data. it's about collecting just enough data to help them accomplish their goal. for some people, it's track every morsel of food and help me optimize because i want to be in the top 1% of who i could be. and for others, they're saying help me figure out, do i really need to exercise for 60 minutes or could i get away with 20 minutes? because i could use 40 minutes to do other stuff. >> and i think one important thing to think about for both type 1 and type 2 diabetes is to recognize that people are all different. not every person with type 1 is the same, not every person with type 2 is the same. it's a lifestyle condition. there's no cure. even if you're able to come off medication with type 2, it's still something you have to be aware of. people have different needs and motivations throughout their lives. i was diagnosed at the age of 14. what i needed as a teenager and
then as a young adult and now as a slightly, i don't know what i would be considered now, an adult, what i need in my motivations differ not only on the life cycle moments but also on a week to week basis. when i have been traveling back to back this week, i need something totally different than when i'm at home and say i'm going to exercise and eat healthy and pay attention to everything. a lot of solutions are often designed, you have this motivation and you're classified as that forever. it's easy to kick people out or have them fail at whatever their goal is because it didn't fit in a particular moment of time and not have the flexibility to understand real life diabetes and real people. >> one thing that ties across all of this is that you have to make it easy for the individual. right? so lifestyle change is hard. all of this involved some form of championing. all of the participants josh described, we have seen even in folks who are trying to prevent the onset of type 2 diabetes. the main thing is and the way we approach it in the y is if folks have found a digital tracking tool that works for them, whether it's my fitness pal or
something else, we just support them in the thing that works for them at that moment. it may work for them now and not work in the future. it gets them to their individual choice, so we have the technology tools that individuals use for tracking have varied from everything, you said pictures of food. we have seen that happen. we have seen on the flipside, folks come in with very detailed logs. it's about giving the consumer the choice. ultimately, they're the ones accountable for the behavior change and what happens next. >> i'm kind of curious. do people who are doing more tracking, either with electronic devices or keeping really careful logs in a notebook, have more success? >> they are more successful, yes. it's foundational to some of the core tenants, at least in the dpp, they're more successful. >> your motivation has to be sort of tracked somehow. it has to be -- it has to come into flesh in some kind of numbers and figures. it can't be just in your head? >> it can't, and some of it is a readiness piece. if anybody has tried to change a
behavior for anything, it's about being ready to make that change at that time as well. and so this is -- you have to assess all of that and then understand that if these are the core practs that can help you be successful, if you aren't able to do that right now, your success levels will vary as a result. >> i'll respectfully disagree. >> that's fine. >> i think the idea of there is a personality that tracks, and i think that's great. i think there's a whole other cohorts that will never track, but they can still get great outcomes. so i was reviewing one of our cases that we did frequently, and it was just somebody who overate at night. we never asked them to track. all they did was put a picture of their kid on the fridge because that was why they wanted to get healthier. and they're not tracking their food, but every time they go to the fridge at midnight, they see the picture of their kid, and one out of every three times they don't open it. no tracking, just about different motivation levels. >> i think the hard thing is you
don't have a choice with insulin. you have to take your insulin. you have to track your blood sugar. there are people who would love to forget it. from my example and other people's data, they can do everything right. and still not get the great outcomes. both type 1 and type 2 diabetes are still unfortunately incredibly complex. we don't know what causes it. we don't everything that's going on. we're still discovering it. that's something to keep in mind. even when people try to track, try to do everything right, it's incredibly hard. >> if you don't track and you have type 1, it doesn't go well. i mean -- >> it doesn't go well. >> so i mean, there's a fundamental behavioral aspect tolito all of these. >> it's hard because you could track say three or four times a day. but you know, you're high and low, high and low. there's the clinical outcomes of what your arx a pch 1c, but also your quality of life and how you're feeling and
psychologically, how are you managing? are you thriving or suffering? >> let's talk about the government role if there is one. i'm sure there is. there always is. first i wanted to ask you two, dana and josh, about what you think the fda is doing since we had the commissioner here. he was talking about opioids. they're doing a lot in the sort of digital space. let's start with diy. are they -- i know you guys -- >> the fda was here? >> they read my blog. we talk all the time. >> are they paying attention to what you're doing, and do they -- does it interest them? do they incorporate it -- >> yeah, so i'm speaking primarily on the diabetes device team who are amazing individuals. we have conversations over the last five years. they worked very closely with the community to understand what are we doing, why are we doing it, understanding what open source means. understanding we're not
distributing any devices. i have to give them a lot of credit for how they're working with the companies. they said bring in your devices. submit your submissions and we'll eview them quickly. there have been three or four devices that it's been approved so quickly, they surprised the companies and they haven't been able to keep up. they're do a good job understanding what the diabetes community needs and meeting the speed issue. >> not too fast? >> i feel like they could go faster. what we do in diy is say we're not waiting. and fda said we're not going to wait either. we're going to do our job when you bring it forward, but it's up to companies to submit their devices. we're seeing companies bring their devices in for submission sooner and it's speeding up the process. i have been pleasantly surprised and pretty happy with them. >> you're not worried that the devices especially that involve a lot of software are being -- that they're, you know, there aren't going to be unintended consequences or failure of the software as a result of going too fast through the process?
>> most of the companies still design software with a hardware process so it takes five years to bring something in for submission in the market. i think they really need to separate the mindset of designing hardware and designing software and have the process of improving and designing and doing rapid release so they can fix it and get it out to people and it's not, we found a bug and it's going to take two years to fix it. >> fda is starting to do, right? >> they have their pre-certification program. a lot of diabetes companies participating in that and i think that will help bring more software to market sooner and move away from hardware and software paired together and separate that so you can do software approval and get software out to people, whether it's for medical devices or other mobile devises. >> josh, what's your take on what's going on in the fda? can you say something critical, please? >> critical? well, dr. kalif, the former commissioner, is on my board. the old fda is awesome and the
new fda is awesome. part of the program that is really novel, our continuous glucose partner now has an icgm system which is really novel. what the fda is doing is recognizing that software isn't a pill. it's hard to change a pill once it's in the market. you can change and update software. that knowledge has led to really great innovations through the fda, and i think it is the right mix of being safe and secure as well as being innovative. and the other thing that really surprised me is just how human the fda is. for any of you who have been involved, if you haven't, i highly encourage you to figure out a way to work with a company that submits. they meet with you in person. they give you advice. it's actually a pretty wonderful organization to work with. now, the flipside, just because you asked about government. medicare/medicaid, i think they have a greatest need for programs like ours.
so the average commercial payer might only have an employer might have an insured for three to five years. if medicare, where we're all going to pay for, if we don't manage pre-diabetes now or people with diabetes today. and so it's government reimbursement for medicare/medicaid programs that i think is the holy grail. >> are you already approaching them or do you figure you will after you have more data? >> no, it's a little bit of a combination. we're a start-up, granted, a decently funded start-up. we're going through the process now. and it's a process. getting through medicare. but once we get through the process, then the next question is with some of these new digital tools, is it reimbursed or not? going back to the comments i made before, we're built for scale. and when you're managing a third of the country's scale --
>> is it complicated to get them to be able to reimburse a multi-modal and has these different pieces in it that -- or is it you're just getting paid for results? >> i think it's a little bit of both, in the last seven, eight years, we've seen massive change at least with medicare getting much more innovative, reimbursing some in digital care. that one, i do think, though, similar to your question with fta, there has to be a body of evidence to support it and so we're in that phase of gathering evidence to justify our solution so that is not just scale and fee for service, but that it's scale with outcomes and value-based reimbursement. >> and i think for the diabetes prevention program the evidence existed when we had the ymca did
for medicare and medicaid innovation project where we were looking with 17 ymcas serving medicare age and medicare beneficiaries and we were able to collect the outcome so we can then follow the cost for those individuals and that's how the cms is actually to help outcomes which led to medicare coverage that led to the diabetes prevention program and you can be working to drive the channels that can lead to payment at least for the dpp where we were able to get where we are today. >> one of the things that we've seen that's really exciting is that while we're not serving medicare, we do serve people of various age ranges and especially women in their 50s and 60s registering and using our program. and so a lot of those biases you get from digital health of oh, we're going to get the trackers and the marathon runners actually isn't necessarily true. so i think digital health is perfectly positioned to serve the medicare and medicaid population.
>> i think we can talk a lot about digital and we can talk a lot about devices and we have to remember the fact that people with diabetes and they're dying and we have to people sure that people with type 1 aren't dying in our country. >> i was going to ask all of you, if there are pinches put on insurance with medicaid programs getting tighter and so on, as well as if the acc were to be, actually, if they were to be actually overturned with insurance just being dicier. do you think this new wave of technology, and you know, entrepreneurship can step into the breach at all for people who don't have the resources to pay?
>> there are tools that will really help people and you can have a great outlet, you can die with type 1 so yes and no. i think it depends what the solution is, if it's about delivering access in for sure, and i think a lot of these companies in digital health companies are playing a role in medicaid yet, but they're perfectly positioned because of how they increase access. so i think it's a question of just working with the pairs and the government to figure out what that model is. >> i think we're a charity that's been around for 170 years and have been offering financial assistance and working to deliver programs and services for that whole period of time. so the reimbursement for us, will there be an impact of
potential volume? of course, i think the ymcas committed to doing this they're not all receiving reimbursement and they'll be able to help them participate in the lifestyle programs that can potentially offset or help delay the conversion, but i think as my counterpart here, the medicine, that's a totally different ball game. >> i take a slightly different view when i was trained in maryland and i practiced until a couple of years ago, and i got paid and paid handsomely for dealing with end stage result, right? the person who came in with diabetes and diabetic ketoacidosis and i would get paid and for a couple hundred dollars for the right program they never would have had to have seen me, and i think that's it looks at where how are we spending our dollars and much more on prevention and much more
on lifestyle and much more on the community and that in itself is an investment and that will allow dollars to be shifted so it is not all episodic. i think that's where the greatest reform and transformation has to occur. >> well, thank you all very much. i was wondering if you had any questions from the audience or discussion points anyone wants to bring up? we've got a couple of more minutes here. here we go. >> hi. thank you all for being here. amanda from politico and to the last point that you made on the dollars, where do you think that the dollars are going to come from and i think it might be different for everyone. where do you think the biggest responsibility lies in providing that kind of support? >> it's a fantastic question. at the end of the day in this country it comes down to whoever
has benefited from the cost reduction and that usually comes out to the pair. there's a very strong argument to say that these are things that consumers should be willing to pay for because if you do the analysis, if you prevent diabetes today for a couple hundred dollars imagine how much you're going to save. we don't have that culture or that mindset here. so at least in my 20 years of health care experience, if it sounds clinical, it sounds like insurance can cover it, if you have insurance it can be covered by your insurance and the innovative pairs out there are looking at what is our total cost of care? and the really smart companies are looking for what are things that can get you return on investments that can get you some things and understanding what the long term is because if we say we have a three to one that comes 20 years from now and the only person paying for the care in 20 years is the
government and we have to figure out within a 12 to 18-month timeframe and so we have to a, be pretty aggressive and eshs fisht in wh efficient in what we do and how we look at different outcomes. >> so does that mean we have to get rid of, in terms of putting the money in the right place and the wellness programs haven't been a huge success, rid? because they're dealing with a much larger population that has -- so if you focused on them more narrowly. >> gretzky, go over the pocket. >> we have 30 million people with diabetes. i used to run the benefits plan for target and the retailer, and we know who -- like, everyone wants to go after how do we prevent the guy who goes after the heart act tack and those are the black swan once in a year, vent. we know who costs $15,000 or $20,000 and they cost $20,000 every single year and go to the
puck and help them now. instead of 20,000, maybe they're 10,000. >> is that possible to do? can you do that without breaking any laws or anything? just focusing on the narrow population like that. >> yeah. yeah. yeah, so, by -- you have to offer it to the entire program, and anyone with diabetes in the population. you can't say i'll just give it to people with diabetes whose name are john in south carolina. >> for wellness, because to your point, the outcomes is what is sort of the proof point in the wellness initiative, so we have employers who are just on an invoice basis because they can get the outcome. >> on terms of cost savings, one thing that i see in type 1 di diabetes is reproving that i have type 1 and to get coverage
for the same thing i get approved for last year, i have to go to a clinic that has fresh chart notes every six months to get approved for the device that can be approved and i see a lot of waste and covering for people. >> other questions? >> well, listen. one more question here. >> hi. i'm a caregiver and i have type 1. where do you think the patient committee should engage in this diabetes crisis and issue? >> i'll say first, there's no such thing as just a caregiver for someone with type 1, so thank you. type 1 has an incredible support system for people that love us. talking with the companies about what we need saying this works and this doesn't. i think we need to do that with
the tech companies and we need to do that with the insurance companies and the regulatory bodies in the government and making sure to join those conversations and sustain those conversations is really important because if we're not there at the table our voices aren't heard. >> i reiterate the first one. for politico, caregiving is probably the fastest growing healthcare need and it's not just a caregiver, but i would argue, don't take the first step as the final word. like, always ask, is there better as both the provider and the caregiver, a patient. i'm always shocked at how if you do a little bit more research there's always something else and so i tell this story they broke my leg, a guy from a dug company call mead and said we have this ultra southbound device that heals your bone faster and here i am a physician
and seeing the top orthopedic surgeon in my neighborhood and i called my orthopod, he said oh, yeah. you're not a sports guy. you're not an athlete. and so, like, never -- always ask, what else could i do? research it and you have to, as a caregiver you have to become empowered in your own care, but sad to say, you're not put at the center of everything because there's a whole system around you and you have to advocate for yourself. >> that's one of the hardships of being diagnosed with diabetes or another chronic condition. you have to learn and i would add one more thing to help educate our fellow people living with healthcare conditions and to go further and help make the phone call and it's incredibly hard to be pushing at the system and pushing at the barriers and it's really valuable. >> and google diabetes a lot.
>> well, i'd like to thank our guests who have been really great. i think we've gotten a good sense today of some of the amazing things that are happening in technology from the level of really ambitious and creative patients to companies that are, you know, have all this google brainpower behind them and also just grassroots work by organizations by the y doing things with less technology, but just as much, you know, energy and focus and research behind what they're doing and so i think that probably the same is true with opioids that we have to focus on, you know, just all of the there's a reason that on the one hand we have this incredible technology and changing things and the biggest growth sector in
the health care is people who don't necessarily have to have more than a high school education to do what they're doing, and that's the important parts of care taking and social work and all of that. so thanks, everybody, who is with us today and thank you all for being here. [ applause ] >> thank you. which party will control the house and senate? watch c-span's live election night coverage starting tonight at 8:00 p.m. eastern as the house comes in for house, senate and governor's races across the country.
hear victory and concession speeches from the candidates and wednesday morning at 7:00 a.m. eastern we'll get your reaction to the election, taking your phone calls live during "washington journal." c-span, your primary source for campaign 2018. congress returns for a lame-duck session. the house will work on legislation and funding the federal government past system december 7th. and it will take a session on coast guard programs and the nomination for the federal reserve board. see the house live on c-span. watch the senate live on c-span2. >> up next here on c-span3, a conversation on the syrian civil war from the center for the national interests, this is about 90 minutes.