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tv   Politico Discussion on Opioid Abuse Diabetes  CSPAN  November 21, 2018 5:55pm-8:02pm EST

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and around the country. c-span is brought to you by your cable or satellite provider. fda commissioner doctor gottlieb recently talked about his agency's efforts in combating the opioid epidemic hosted by politico in washington dc which included a series of panel discussions on the role of innovation and technology intrigue opioid addiction as well as type i and type ii diabetes. this is just over 2 hours. good morning. i'm joanne kenen. i am the chair for healthcare political. we want to thank you for joining us for this event. thank you for those of you on the lifestream today. we are glad you can join us. it is a timely conversation.
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we have two huge public health crises in the country. unrelated, but we will find some common themes. diabetes and the opioid crisis. will 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 prediabetes. an estimated 115 people are dying every day because of opioid abuse. that's a lot. today we will focus on new approaches that the public and private sectors can explore to address these problems. our conversation will take place in three parts. first i will be joined by the fda -- the fda commissioner scott gottlieb to discuss the opioid crisis in the united states from the perspective of the federal government and the fda. he has been an active commissioner. we just had an interesting conversation.
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next a panel of health and technology experts including clinicians to talk about what is working and what is still needed. then my friend and colleague the el editor will be joined by a panel of health experts to explore the role of digital help in dieting -- diabetes technology to improve prevention and treatment of diabetes. as you follow this on stage join the conversation using the hashtag politohealth. before we begin i would like to thank our sponsor, anthem, in their support for making this possible. here to stay -- to say a few words is doctor friedhoff -- welcome. good morning, everyone. on behalf of and some i want to
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welcome you to our discussion on a tale of two crises -- on doctor stephen friedhoff. we are talking about how to use technology to combat two of the most complex challenges in healthcare -- the growing diabetes and opioid disorder. >> surprisingly they have several characteristics in common. they have become more creative if they can help society can address these healthcare epidemics. the crises are multifactorial. the solution, therefore, with equally complex requiring a fundamental shift in how we support individuals affected by these two different conditions. we must learn to see people and much more holistic terms that we have. this includes where they live
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and work and not simply as needing treatment with medication in a doctors office. the time people spend interacting with their providers is important. it represents the tiniest fraction of a person's lived experience throughout their life. given the human toll, the economic cost and speed with which these epidemics have been progressing the implications are simply too great to ignore. is crises often do, the sense of emergency has sparked a remarkable amount of innovation and we have an opportunity today and in the future to leverage new technologies to tackle these problems as yet another lever in our approach. and honored to be here today with some very important experts who can look at these two epidemics different dissent shared their perspectives with you. and they will give us an update on some of the innovations available in our ammunition.
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one of my reasons to being here is to share optimism. i'm acreage because we've seen a unprecedented degree of collaboration between communities and industries and technology. all these innovative approaches and fresh thinking have begun to produce some early, measurable results. as a health benefits company that serves more than one out of eight americans we at and some have an opportunity and a responsibility to create a better healthcare future. our reach in our relationships allows us to bring together a variety of stakeholders to address complex conditions. this enables us to improve lives, empower communities and simple for healthcare which is at the heart of everything we do. all of us are familiar with the statistics. they are stark reminders in our neighborhoods and in the news every single day. according to the cdc between 2000-2014 we saw 200% increase
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in the rate of overdose deaths involving opioids. the daily headlines remind us that that increase over those four years was just the beginning. beyond the human consequences the economic sequences are estimated at over $78 billion per year and they are growing quickly. as for diabetes the latest data shows that is the seventh leading cause of death in the u.s. the annual cost of care is exceeds over $300 billion. these numbers don't capture the human toll. for that to get a true glimpse we see it when someone we love mrs. their site, their ability to walk, or their freedom when they are committed to dialysis as a result of diabetes. as a family physician i know it's important for people to have access to doctors and treatments. that is just a part of the picture. and spite of our medical model the health outcomes are determined by the care that people receive which represents
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a small portion of what drives health outcomes. it is primarily driven by genetics and social economic circumstances and their life choices they make and ultimately by the zip code they live in. for many years when i was teaching 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, society and many physicians to -- continue to see them separately. this is not the reality and it is certainly not the way that patients see themselves. when we begin to see the patient as a whole person and truly think about the various doctors that affect their health and wellness and ultimate outcomes we will be more successful at invention and early intervention and removing barriers to healthy living. this may not sound like the conventional thinking of a health benefits company but this is how we are taking about
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complex conditions. we truly believe that industry stake holders have a responsibility to address the opioid epidemic and we are taking an integrated approach that supports prevention, treatment, and recovery and deterrence. from a preventative standpoint whenever major august areas has been around decreasing the number of you start ascriptions filled up on the seats for opioids. a few years ago we set a goal of reducing the number by 30%. 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 and our health plans including medicaid members starting new prescriptions. i'm happy to say that we reached this target two years ahead of schedule and we are seeing a 40% reduction in the number of prescriptions filled for opioids. peoples medicine cabinets with potential abuse for drug abuse -- they could continue to use these longer than the
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prescriber intended. in terms of physicians we want to be able to give them additional tools to assess with judicious prescribing. for example, by using analytics we can 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 when they are utilizing opiate medication. we have provided training to physicians and experts -- as well as medication -assisted treatment and advice on how to be additionally reimbursed while providing services to patients. earlier i mentioned need two more holistic approach to care. we have a more nuanced understanding of how important it is to partner these therapies and better behavioral health counseling. two years ago we looked at, say medical claims and realized that
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less than 20% of consumers taking medication -assisted therapy to treat their opioid use disorder were actually receiving your health counseling. that is much too low of a number. we now have efforts underway to double the amount of counseling that they are receiving when they also receive medication treatment for substance abuse disorders. this has already led to innovation. this builds gaps in absence of counseling -- and we have expended our capabilities to provide consumers with remote access to qualified therapists via telehealth. on the diabetes front we have taken this same approach to prevention and treatment. this enables us to develop more innovative interventions for people at risk of or struggling with diabetes. for example, for people with diabetes managing their condition requires an
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incredible amount of time and attention even if not in the doctor's office. recognizing this need we provide more day-to-day support when and where it is needed. this includes individual health coaches and various digital tools that help individuals and provide guidance on things like nutrition and meal choices. as with opioid -related issues we are providing greater support for depression and other conditions related to diabetes. as many of you know when an individual has an underlying comorbidity of a behavioral health diagnosis it is former 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 is difficult to manage the condition and an integral part of this is dietary management. for that reason we are compiling programs with things like vouchers that can be redeemed for fruits and vegetables and cooking classes
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and nutrition education for individuals at risk. >> everything i've been describing goes beyond the medical model however the causes of these conditions similar -- similarly go far beyond the traditional model and i firmly believe that we can only be successful in combating diabetes and opioid abuse epidemics if we continue to take a holistic approach. >> in closing, i want to emphasize how much i appreciate the opportunity to be here with you today. it is exciting for me to hear your ideas on how we can leverage innovation and technology and tackle what are two of the most pressing healthcare epidemics facing the u.s. today. we talk a lot about a brighter healthcare future and working together is the only way that we can get there. thank you very much for your time and attention this morning. >> [ applause ] >> please welcome back politico's joanne kenen and the fda commissioner, scott
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gottlieb. >> [ applause ] >> thank you, doctor friedhoff. the q2 anthem and scott gottlieb -- and thank you to scott gottlieb. he keeps us busy. >> let's just dive in. i told him before we came that when i was told i had this event -- my first response was, what does this have to do with it? that's not what i thought about when i thought about the opioid epidemic and then i thought who will we invite? i came up with a list of 20 things. one is, the starting point for at least part of this epidemic -- prescribing.
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tell us where you are going with that? >> thank you for having me. i reached out to you because we wanted to talk about this subject. >> i was just making fun of you. >> we have authority from congress and we have been saying for about 18 months that the rate of new addiction is a function of describing. this is a crisis that started in the medical setting and many people became medical addicted to opioids and in many cases they were legitimate prescriptions. this was written for medical purposes and people became conditioned to opioids and a certain percentage became addicted. the way that we will address this is to try to cut down on exposure in the medical setting. this crisis is shifting and is becoming more of a crisis of illicit drugs and there is addiction in medical settings and the question is, how can we rationalize prescribing and cut down on doses and cut down on the strength of the doses.
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technology can play an important role. we think if we can shift to more electronic prescribing of opioids and have migration with hr and noble when people are getting prescribed opioids it will allow allow doctor to have better visibility and what people are being dispensed and allow help and and health systems to have better visibility and make it easy to operationalize things like manage medication. we have made a number of pushes to have mandatory medication and it was stymied for a variety of reasons in 2009. if we have better technology and a fully electronic prescribing system it will make the limitation of mandatory education much easier. in the new legislation there is a mandate that prescribing medicare part d for opiates need to be done electronically
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and by 2021. that will drive a lot of implementation across the market. i think once part d has that mandate plays other systems will have to go toward fully electronic prescribing. >> what are the barriers to getting the doctors to switch to this? >> the cause. you must have the systems in place. there are barriers with physicians who are not accustomed to prescribing that way. in some states you have electronic prescribing and other states are doing this. in certain practices all the prescribing is electronic. is not ubiquitous. there are a lot of older, smaller practices that still don't have the tools to do this. i think that we are getting to a point now where there is a critical mass of providers that do. in the providers that don't do it they will have to opt out or make a conversion. that has been the historical barrier. having the tools and the wherewithal to do it. >> when opioids came on the market, the default became a 30
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day prescription. it was well-intentioned but went wrong. it was supposed to be easy. doctors didn't want to have the patient come in to pick up five different paper prescriptions. they didn't want to deal with telephone tag. the patient's prescription -- it quickly evolved and the insurance industry but they were doing something helpful to make it a 30 day. i thought it was safe to make it 30 days. we all know that became a part of the disaster. how do you shift to that? you have these guidelines. some health plans have mandates. how do you push that 30-day? >> we are working to develop evidence-based guidelines. we had a meeting -- we have a
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meeting november 13 two do this. there is a direction from congress for us to do this. evidence-based guidelines are different from other guidelines. consensus guidelines are important but evidence-based guidelines are based on retrospectively or prospectively gathered evidence about what the appropriate duration of use by indication. when we look at the evidence laparoscopic appendectomy should be a one-day prescription. post mastectomy looks like about two days. arthur presley looks like about five days. -- arthroplasty looks like about five days. >> this could be used to regulate what is being dispensed by provider systems and by insurers. what we want to do -- this is one of the things i want to talk about -- we will make an early implementation of unit- does patch pitching. -- packaging.
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like blister packs. the should be a one or two day package. 90% of all prescribing of the immediate release formulations -- a lot of times they will default to a two-week or 30 day supply for a minor procedure. nobody should get 30 days for a wisdom tooth extraction. we think there is a one-2 day pack available what positions will default to this. we will mandate that the companies need to make these available. this is something that we will do quickly in terms of the new authorities. you can partner this with electronic prescribing. if doctors want to they can describe the one-2 or 5-day pack on the market. you have three different durations of use available and the doctor can prescribe those. if you want to go to a 30 day prescription you have to go to mandatory education. there is another gate. some providers will go through
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the mandatory education. if you are an oncologist or cardiac surgeon you may have to write longer durations. for most physicians they don't. >> what is cabbage? >> it is bypass surgery. >> most physicians will say -- i only need to prescribe one-2 days. i don't need to go through hoops to get permission to be able to prescribe longer duration. if you have that kind of system that technology help to facilitate the implementation because it can make -- the education to be online and you could do a check on whether the condition qualifies for the longer duration. so, that is what we envision for the future. doctor friedhoff mentioned this -- there is all this information hr -- electronic health record. we have not been great at
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figuring out how to -- just writing stuff down -- how to extract the knowledge. how are we beginning to be able to use data and analytics and new technology tools to look at patients and see where the red flags are earlier? >> yes, we have talked to some intermediaries including one medical society that is developing what you could call a risk score for a patient's risk of developing opioid abuse disorder. they are doing what you are describing. there are tools like that being developed. this is not something that we would regulate. this would fallen within the practice of medicine. there are opportunities for that when you have prescribing online in an electronic prescribing integrated within the ehr. there are risk factors that help identify patients at
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higher risk of developing a potential use disorder. as physicians sometimes we aren't good at being mindful of that. that information is not readily available at this point of care when you see the patient. i used to practice in an acute care setting and the er and we would take the history but it was hard to extract the past history that might've revealed some indications that they would be at high risk of developing an addiction from the prescription. >> so, through the ehr as it evolves, it will be hooked into the electronic prescribing, right? >> yes, and the pmp is becoming integrated. these systems allow you to look at the multistate way to see if a patient is getting prescriptions out of state. it is now becoming more interoperable with the ehr. >> so, the pdm p -- they are state regulated.
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you can't force a state -- there is nothing in that new federal legislation that makes this mandatory for doctors, is there? >> no, that would be the state medical board. there is legislation that requires interoperability, i believe. we have been working with congress on the provisions around the pdmp. >> you have the pdmp here and the ehr here. you had to click in and click out of two systems they are beginning to emerge. >> yes. >> that will -- this is one of the ways that the pdmp -- originally it was a law enforcement tool and they were trying to manage public health. >> is, this requires physicians to do a check before prescriptions. some pharmacies are required to look. this is by becoming more ubiquitous. >> it doesn't do much good if nobody checks. >> yes, this was started 19 months ago -- there were very
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few pdmp that were interoperable. the national board of the pharmacies has created a system much more integration between state pmp's. >> so, it will be easier for doctors -- easier interaction. it will be useful because then going into the ehr you will have these connections to the guidelines as they develop. it will override. right -- is you have -- if you have a one-day procedure -- the actual ehr and electronic providing -- if you try to do 30 days it will let you? >> yes. if you have evidence base guidelines you can enter this into the ehr. with this we will have more uncertainty. -- certainty. the health system will be more comfortable if we can build these into place. the pdmp is a tool to evaluate
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whether a patient is getting multiple prescriptions. these are the patients and in some cases are looking around for drugs. we still have to be mindful of the first prescription in the treatment-naove patient and the fact that a certain percentage of patients starting on opioids will develop long-term use and dependency. a certain percentage of them will develop to meet the qualification for opioid abuse disorder. is not just about the number of prescriptions written and pills dispensed -- will be will talk more about is the morphine equivalent -- the potency. there is a lot of data that shows people start on higher dose opioids at the outset they are more likely to develop long- term dependency. there are more likely to develop a risk of addiction to the opioids. when you prescribe is not just about making sure that the patient is clearly indicated and you dispensed 10 pills when 10 will do and not 30 pills, but also -- >> the dose.
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>> right. vicodin isn't the same as percocet there are different strengths. if you prescribe 2 percocets every six hours you reach what is considered a safe daily limit quickly. so, doctors should be mindful of that. we will talk much more going forward -- the fda will -- about the dose being dispensed. the get about morphine equivalent. that is another thing that technology enables. most providers don't know -- they don't do a conversion -- if you look at the drug label we try to be careful to provide conversions. it's obligated and most providers don't know about the equivalency of different drugs. this is information that will be made available. >> i want also to talk about the apps. there are a number of online programs which go through the fda for certification. some are just out there. there are some self-help
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programs. use this program and you will get off your opioids. talk about what you regulate. how a consumer can tell when they google something that it is being abused by a love one. their role in terms of support. the medication -assisted treatment is the gold standard for most people but what else do people need and where does the online component -- so you don't regulate telemedicine -- not cms -- i guess the question i have is, how much is a tool and how much is a toy? how much could be a dangerous toy? where does the fda come in and try to separate this? >> we have approved some digital health tools as supportive tools for patients with an opioid use disorder.
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it is effective in the context of psychosocial support. a tool that can help patients provide support. this could be effective and there are some digital health tools approved for these purposes. anything that makes a claim as a standalone device -- >> yes, online -- >> that is not fda approved and something that we would take action against if we thought. we have taken action against products making unapproved claims particularly dietary supplements. some claiming they can be used for opioid abuse disorder. there are some tools that could be helpful in the context of a copperheads of approach to treatment. this couples drug therapy with psychosocial support. >> that could be useful in rural areas when there is not enough providers to provide support. people who are just -- they
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don't want to go to a clinic. they have a role -- should it say fda approved? >> i would say -- i'm not sure i would approve anything on the internet. they should be fda cleared. go to our website. we have a landing page that has a collection of medical devices set up and approved for help in the treatment of opioid use disorder. that would be an fda-cleared device. you are talking about digital health tools. it depends on the claim -- i'm not sure. >> what are the tools we don't have? going forward -- some tools are probably in the rudimentary form. what else do you and cms and everyone else -- it's a
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complicated epidemic. there is the heroin component and the black-market component and the overprescribing and now fentanyl. what do you see that we can pull in? >> the challenge for me is the integration. between the different tools -- we have good technology. it's not ubiquitous and not integrated. this is something we have been working on. the vision i had where you can marry the evidence base guidelines with the blister packs and couple it with mandatory education and a cut off for prescribing -- if we can implement this kind of system i think we can sharply cut down on overall exposure and help rationalize prescribing. this will create some hurdles but reasonable hurdles. it would be overly burdensome because they are using technology to facilitate this. this will require better integration.
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i will tell you that in the 18 months we have been working on this we are further along than i thought we would be. the legislation was important. this will give an important nudge to the market. we are not quite there but the first thing we will do is the list of pack. we will mandate this. >> -- the blister pack. >> how expensive are they? >> they are pretty cheap. they are generic. that is the problem -- some saver formulations are not generic and they are expensive and there is a lot of default prescribing because of the cheap ones. this will increase the cost because there is a packaging cost. >> but not crazy? >> no. it will go from five cents a pill to tense of the pill and you will report a 100% increase. it's still a lot of money in the scheme of things. i think it is manageable.
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ultimately i think it will have a big public health impact. >> the last bastion -- there is a lot of research being done in the industry for a safe and killer. -- painkiller. will we be skeptical when someone comes along and says this one is a safe? >> we are skeptical. the problem is, there has been no free lunch. every drug ever approved for long-term management of pain has had liabilities associated with it. whether it is side effects or abuse liability. with drugs like gabapentin we see ms. use of these. there is not a free lunch. this has made us skeptical. there is a lot of early innovation of products that look like they could have the
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same analgesic effect as opioids without the same level of addictive qualities. >> how many years out is that? >> i don't think it is 10 years but more than a couple of years. things look promising. it is in the early stage of development. >> we are out of time. i'm delighted that you came. it was great to have you. with that, while we change panels i want to remind everyone in the audience to tweet your questions. >> [ applause ] >> use the hashtag politohealth. >> i would like to introduce our panel for the next segment. >> this is the director of national treatment at shatterproof. doctor weintraub is an associate professor at the university of maryland school a medic in. he is a tele-treater.
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doctor goodman is the executive president of government affairs and innovation in america's health insurance plans. let's jump in. >> >> one thing -- when i started to think about this, other than telemedicine and pdmp i didn't -- initially i was having trouble thinking about this. we have different areas here of expertise. let's talk about what you are doing with tech innovation and where to go with it. >> some, you work at shatterproof, a treatment advocacy and education organization. one thing that we've been talking about and you have been taking about is -- we have a
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need for treatment and a test a lot of money going into treatment. how do you know what's good? let's talk about this and then we will come back and have a bigger discussion. >> great point. when you think about addiction treatment, people have an idea of what the treatment looks like. a lot of times it's the best way to treat addiction. there are a lot of misconceptions that addiction must be treated in a 28 day residential rehab program. that is true for some individuals depending on the level of severity and the care they need. not for everyone. there is also a lot of different viewpoints on how addiction is treated in an outpatient setting and all settings. one of the best practices in treating opioid abuse disorder is medication -assisted treatment. , only 40% of the addiction
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facilities in the u.s. offer even one of the medications used to treat this. when you look at all three the number drops to 3%. some are just offering medications for withdraw management. you have people looking for addiction treatment they are in crisis. what do they do? they don't usually go to the primary care and ask for help because of the shame and stigma. the usually turn to google or they heard the neighbor had an addiction. and went to a rehab program in florida. they don't use the same channels. there is no standard of how treatment is delivered. what we set up to do is a system that creates a standard and measures treatment programs on their compliance with best practices. using reliable, valid measures gathered through provider
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surveys and hospitals and also including the consumer experience of care. this is to say this treatment program delivers this quality of care. to be able to have this in a way that consumers can search and find care as well as to provide this to payers and employers and other groups to align market forces with better quality to drive the entire system to adopt best practices. >> to become like the good house -- good housekeeping seal? a way to get through the jungle of finding the right place to know and knowing that it's going. >> absolutely. if you think about this -- people know that you want to find a good sunscreen with good protection. it's waterproof and all these things. when you think about addiction treatment you don't know what
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to look for. and you are in crisis. you don't know how to tell if the sunscreen has these things. it's not on the label. a lot of the time now treatment programs are saying that they do things in the website looks great and they have fancy commercials of people sitting on the beach and it looks relaxing. but, it's not going to be medical treatment for a chronic disease. >> let's talk about this. one of the problems, as we heard, from doctor gottlieb is we have overprescribed. >> we are reducing -- we are not there yet. part of it is that insurers have a certain amount of average and in this case maybe some authority to try and bring things down. talk about thou -- how this is
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tracked and any comment on how people will adapt to the blister packs and e prescribing. >> i think the e prescribing, i'm not sure i have an opinion about how quickly people will adopt this. many prescribers have adopted this. >> it's the kind of thing that once you do it you wonder why you didn't do before. >> absolutely. >> i think that some of that -- it's wonderful that it is within the opioid package required. i think it is also one of those things that is part of the -- as the system requires it, and as the pharmacies won't accept it otherwise, that the system will evolve. they have been working on the initiative focusing on save prescribing.
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many of our members have set prescribing goals to reduce the number of opioid prescribed. many of them have achieved them. one of the biggest thing is the top stool -- the stock tool -- this can be used to measure prescribers against one another with respect to their complaints with the cdc guidelines. this initiative is around supporting adoption of the cdc guidelines. >> if i prescribed 30 days of the strongest stuff i can and another doctor gives two days of a smaller dose, what happens to me? do i get publicly shamed? do i get a note? how do i become a good, healthy responsible provider? >> most of our members -- i don't know for certain if all of them but those participating with this are limiting the amount of opioid prescribed on a first dosage. >> to be clear, we are not
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talking about cutting them off -- these are the prescription naove people. >> if you walk in with a broken foot -- do you need an opioid? >> correct. they are putting this in to limit the number of pills that an individual patient could receive on a first-prescription. they are using all the big data described earlier to track prescribing patterns and to look at -- to manage networks anyway you can identify what you talked about. is not public shaming. we don't engage in public shaming. we absolutely can help our members identify doctors who work in a way consistent with our view of what are safe and
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appropriate prescribing practices. >> the idea of mandatory physician education -- right now if you are a doctor you can prescribe opioids is a doctor you can't prescribe the treatment. you need a license and training. you can prescribe opioids to anyone that walks in your office. good doctors don't but somehow. test but some doctors have. there is nothing to stop them. yet, we are in a situation where you need special training to do the treatment. basically, this won't be a licensing in quite the same way -- a containment to the electronic record and the regulations on the health plans and what the ehr tells you. >> it is also critical that health insurers use their
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utilization management tools. the reality is, people don't like prior authorization but to your point about anyone 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 -- watching how the membership is using those drugs and intervening when you see what it looks like it could be an aberrant practice. the other thing that's important is, that the new legislation allowed states consistent with state law to give medicaid managed care plans not all plans we would like for it to be all plans -- access to prescription drug monitoring programs. it is hard if you have people moving between plans or moving between doctors to identify that in absence of the availability of the data. >> even with the ehr, as they
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move toward integration of the pdmp and the ehr, we haven't solved the interoperability issues with the ehr's. as a physician i may not have a complete picture of everything -- the conditions on the drugs and the providers. this may not be what i see when i click the name. >> absolutely. often -- i will let the doctors speak to this -- but there are often drugs prescribed that make the issue worse. someone has a co-occurring disorder of some kind. most people do have a co- occurring disorder. that physician is looking at that patients nickel record from their interaction with that practice. only that practice. now, if they are in a more integrated delivery system
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which is part of the value of moving to you based purchasing when you look at bundles and the bill includes a bundle, or something when they might have an integrated medical record. you might have a better chance of catching those things. but to the extent that the patient is using more than one doctor you will only see the patient's express with that one doctor in the ehr. >> also the ehr will not include addiction treatment. the integration of those -- >> that was part of the debate. the privacy issue. >> it is a demonstration project -- for now they are being incentivized. in the past -- >> the information sharing didn't get into the bill. >> right. they may be incentivized to use electronic health records and that is a small one by because they haven't in the past. but, they will not be able to share the information. >> many of us forget how rural
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maryland is. it is a rural state. a lot of it is. there are not a lot of providers in places like cumberland and hagerstown. talk about what we found out. >> sure. i have been working treating patients with opioid use disorder. for the last--- for the last 15- 20 years it was seen in the urban areas but with this epidemic the rural and suburban areas have been disproportionately impacted. approximately three years ago we had colleagues that are here today that work in hagerstown and they lost their provider. >> you have to be licensed and trained? >> there are three methods --
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methods -- methadone has to be delivered in highly regulated clinics. over 90% are in urban areas. the other must have a waiver and specialized training. they did not have the physician for that. they discovered that they couldn't take care of this. when people are in withdrawal they will not stay in receive counseling. medications are not a cure all but a cornerstone for treatment of opiate use disorder. we are trying to help them out. we say we can't drive out here -- it's one and a half hours. we had a robust telehealth department. we were clinicians. >> yes. >> there are different people that go into telehealth --
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those that are interested in technology and those that stumble into it. we were able to figure out how to deliver care. we set up the videoconferencing system. there were some complexities to doing this. we started to treat patients and at this point we have expanded we started with two 2- hour blocks and now we are in different parts of the state and people keep coming to us because the fine providers. last week one of the providers had significant health problems and he had 90 patients and the health officer said can you help us out? we don't have anyone to take his place. they just published a paper that the work is just as effective as face-to-face based on our numbers. people are retaining treatment and stopping drug use at the same rates as the people in person. we recently -- we are trying to
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think outside the box because every state is different. what would work in maryland -- we are a small estate -- would not work, for example, in alaska or the state of maine. we are delivering our care to pre-existing treatment programs. all the patients have counselors and you get there urine drug screened. >> not dissimilar to a regular clinic. but if you go to alaska or the state of maine they will not be a treatment program. >> you are providing the treatment component -- a larger multidisciplinary support service that wraps around -- you are doing the prescribing for a system that exists because there is not one in the small town or they retired? >> exactly. >> you have both legal and financial obstacles. >> yes. >> that is bad. >> there were some regulatory
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issues for those that don't know. there was a law that was passed in 2007. this was made because a young man passed away because he bought prescription opioids over the internet without anybody talking to him. the pharmacist described it. the bottom line is, the current interpretation is that to be able to prescribe controlled substances through telemedicine you have to have one in person evaluation. the law is complicated. i have read it 100 times. i had a different interpretation. after an article was published in politico, having talked to the lawyers they took a more conservative view. we were fortunate. i talked with the dea agent and they are coming to look at the
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methadone clinic and they said -- i said we have a problem. can you help me out? they were actually helpful. my sense was that it is a big organization but as far as the field agents they wanted us to make this work. >> they have the authority to allow this. right? >> i think there are two levels. on the top level when this act was passed there was an avenue for them to grant exemptions to physicians to be able to do this. that has never been done. the new registration past will allow that -- they say it needs to happen. >> they allow them to incentivize it. >> what is the payment mechanism? >> we are fortunately that they have an expansion state and we have a good state authority which reimburses telemedicine.
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we are close to breaking even. the way it works is, we get paid for our time and we bill and collect and return the money to the site. we are getting close to breaking even. >> with this getting past, -- it opens doors. it expands telemedicine. talk about this. what is your role in helping with this and what do you worry about if things are so rapid -- sometimes there are unintended consequences. do you worry about this? is this a good thing that we know how to do because we learn from our mistakes -- for where you go with telemedicine? both of you can weigh in. we have a model we feel comfortable with that will not work everywhere.
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we have a grant to deliver telemedicine to a mobile unit to reach out to people in the community. every state is going to be different. there are some worries. i have learned a lot. every time we do this -- a colleague of mine does implementation and he said everything is different and i learned that. you have to have the cultural component into account. i worry that with everything in medicine -- you have to have quality control and there are profits being made and we need to make sure that people will role this out in a safe, responsible way so that the patient gets safe, effective treatment. >> our health plans working toward reimbursing telemedicine in this situation? >> yes. in the commercial space -- each
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state medicaid program has a different policy on reimbursement for telehealth. so, it differs. then, the new bill expands the availability in the medicare context. it depends on the type of coverage you have. >> how common is it in employment sponsored coverage? most people watching probably have coverage to work. if someone has a substance abuse problem with the typical american business, how likely is it they can get the telemedicine? >> i don't think i know. it is very likely they would be able to obtain counseling through a telehealth application. this depends on the state regulation and law. and where the person is. -- the coverage of the program. >> without knowing the details -- are you seeing this widening ? do you see a lot of resistance? >> we see the availability
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widening fast but the uptake is not what we would hope and expect. we think this will come with time. we find that the results are through telemedicine, the issue is that most people are not >> do you see telemedicine mostly for the map prescribing or wraparound services and counseling and other support services and do other determinants play a role including behavioral health. >> it's here to stay.
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back are you worried about a digital divide . >> yes, of course. if were going to move in the direction where technology is delivering care, you have a massive population of people who are homeless or don't have access to smart phone technology , who from the get-go will not have access to care. but i think there was a great point about counseling versus prescribing. it's important to differentiate telemedicine, because in one case you have the prescriber on the other end to prescribe medication. that's critical but were so limited in the number of prescribers that are engaged, let alone willing to hop on a webcam
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>> on the other side you have a lot of abban technologies coming out to contingency management and other counseling services and i think, being able to deliver behavioral health in the way that is receptive but in a lot of cases it's not gonna replace talking to a physician and having a proper assessment and treatment from that interaction . >> are you seeing support services? >> you're working with people on the ground who are providing services, and you are providing the medication .
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>> is there too much risk of fragmentation or chaos or coordination? >> each clinic is a little different we still have a key meeting with the head counselor and we discuss every patient but we also look at different platforms and consultation is a huge issue where we need to pipe out expertise to other areas, the state of maryland has partnered with us and we've developed a phone line, a 40 hour per week phone line with addiction experts taking calls from primary care providers around the state, it was initially focused on the waiver providers .
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>> there's also patient apps, i just heard of one the other day that talks on contingency management. my partner was saying that the app is working by videotape, every time he takes that he get some kind of crypto currency in his bank . >> lots of combination for the providers .
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>> i just came across this, how common are these apps, we read the stories that people are really trying and it's heartbreaking. are the apps another tool, you live in a community that doesn't have enough providers, are they providing services, are they a starting point in keeping people on track in addition to these medical services or is it just forget it, this is promising something and they will be dead in two weeks because they didn't do something better? >> i think it's a little of both. we have this system in place already that should be delivering, anything you can do
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to help someone stay in treatment, change the way they think about their disease, it's going to be a step in the right direction, as long as were not using it as a fix-it for the problem. >> the positive side, could be that if you're in alaska and there's no counselor, you have to go through eight glaciers, it's more of this model where you call in to a university clinic, what do you want to see
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, or is it going to be a mix , things that we are skeptical about, so, i think it depends on the level at which you are working. so, project echo is a program that is essentially very similar to the hub and spoke model just described that is used by four plans to train providers who are more remote to access these technologies. it's a health professional level , these are absolutely useful tools that we know work. at the member level, we know that peer support works really well, and that alcoholics anonymous has proven, in the
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alcoholism space that having a peer counselor or peer sponsor, you can call on the phone anytime day or night is a valuable tool. it certainly is conceivable that an app that does that for a peer support model will be something of use to people in crisis. is at the be-all and end-all replacement for having a professional relationship with the prescriber, it's a tool in an arsenal . >> we do have -- it's not the first generation but not in their greatest iteration. there becoming more useful and we are learning how to begin to extract data cannot just use it for picking up.
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what in this field and this may be more for liz, but what are you beginning to see, what do you begin to see in the records as you approach the addiction crisis? >> if there's a developer where would you want them to know that you need . >> even with prescribing data, so someone is addicted and i'm sure you see this every day, someone is addicted and leave cut off their supply of opioids, it doesn't mean you've solved their addiction problem . >> so where the ehr is very helpful and where you would never see out of claims data,
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is this information about the other factors in their lives about other indicators that either they have a substance use disorder or the they are -- >> for the work that you do are relevant, irrelevant, increasingly irrelevant, but you still want added . >> yes, i'm still not a tech guy but i found them to be helpful in a couple ways. one is the amount of information you can find out about a patient . >> in maryland you can get access to other holiday -- data. were not mandated to check the program before we start, that's important. we don't have e prescribing, i wish we did, so i think all those things are really valuable tools for us.
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one of the other things is just workflow, that's not my thing but my colleague is trying to figure out everybody with an efficient workflow. think these are critical, you can build through the ehr as well, much better than a paper chart . >> there's so much data out there, tracking the prescription drugs. and as mentioned it not capturing if you're using illicit drugs, if you might be engaging in drinking or other
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things that you go to your doctor's office and you fill out your intake form and ask how many drinks you have a week, there's not usually a conversation so, information like that when you look at addiction treatment, the fact that most addiction treatment is happening outside of healthcare, there's no feedback. so with certain policies and privacy restrictions, physicians will call and say we just want to check on john doe, how's he doing? and then we say who, we don't have john doe, even if he's there receiving treatment and doing better, they have a broken leg and need an opioid, there's no need for the doctor to know that they're being treated for substance abuse disorder, having the information
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and medical professionals comfortable to talk about these things, if you sit in the dentist chair and they want to give you opioids, you say that in recovery, it shouldn't be a question, we hear this all the time so having this integrated and received by the medical team . >> we will go to audience questions. while they get ready, how many of you in the audience have had something, either you and a family member, something that's fairly routine, that earlier you might have gotten opioids for the this past year you didn't ask i had a sprained ankle, i bet two years ago they would have sent me home. >> they gave the ibuprofen and tylenol, i should've asked. i
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bet they would've given me a week two years ago. just quickly, if you have anything that you think you would have gotten opioid for but you didn't . >> questions? my name is ben and i work in
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virginia, can you explain a little about the role of medicaid expansion, the pros and cons and has, because as many of you know, virginia recently voted on what to expect . >> i can take a stab at that. we know the medicaid expansion is providing necessary health coverage for individuals who don't otherwise have access, it's creating a pathway to treatment. i think virginia is an interesting case study because virginia, in addition to extending medicaid, they've increased and revamped their opioid program. dave established an infrastructure and this is
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absolutely critical . >> regardless of expansion you've seen one medicaid program so you seen one medicaid program. i'm very hopeful now that you can create a continuum of care, with the deep end of the system available . >> it means there are obstacles and this will relieve that, it won't eliminate but it creates more ways of getting payment . >> a small window. it also that they continue their level of effort or whatever it was and that they
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make available a community- based continuum of care in order to avail themselves of that greater flexibility. >> not everybody needs inpatient treatment.
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medicaid has one system we've become familiar with and they work with commercial payers and how they do pre-authorizations for medicaid . >> there she is. [ laughter ] >> i don't know about the detail, when i have a commercial patient i say here we go again. [ laughter ] instead of a one minute phone call . >> you are working in a medicaid state . >> right. >> samantha, i think the example
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you are alluding to is around the 42 cfr part two issue, we saw the legislation passed the house and it sitting in the senate. moving it to a medical model and seeing full medical record, can you elaborate more, how do we follow on that and see the substance use disorder record? >> >> at the time it was created in the 70s, it was meant to protect people with addiction from all the misconceptions, possibly being thrown in jail. those fears are not gone. we are still dealing with those, so we have to make sure that individuals are not
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discriminated against because of their disease, especially because there's a disease that hijacks the brain and makes him do things that upsets their friends or families are gets them in trouble. it's a huge risk but it's inhibiting the care coordination in a way you don't see with other diseases. there needs to be the back and forth to be able to communicate and care for an individual. we release care coordination for medical and behavioral health, it's one of those principles. so preventing prescribers and other treatment providers from doing that. >> we strongly support this legislation . >> if you want to circle back, when i began learning about this, we have three tasks we need to prevent addiction and we talked about ways data is can assign the risk and it can help
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us reduce the initial cost fewer shorter time of initial prescriptions for the second task is recovery, that's really hard and someone tweeted in saying remind them how hard it is so you are all reminded. the ways you will find data and guide people to a good treatment path. ultimately, it's going to help save lives which is what the whole fight is about so i guess, we will know in a year or two to figure out which one is a good one and doctors i have no other access, we will begin to see whether they help us along with this determination and care so thank
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you, sam eric and liz, thank you for joining us here and we will get off the stage and make room for our colleague to talk about diabetes. >> hi everybody, i'm arthur allen the e health editor at politico. on this wonderful topic of opioids and we will talk about
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type i and type ii diabetes, we will discuss how patients and companies as well as groups like the ymca are working to improve treatment and prevention. we are joined by heather hodge for evidence-based health, the ceo, josh and dana lewis founder of the open-source artificial pancreas system movement #open ats. so, we will start off by introducing everybody and getting a sense of what they're doing in innovative ways, you created your own artificial pancreas system in 2013, can you just tell us briefly what that is and tell us about your current project with robert woods, the johnson foundation and go on to talk about the impact that the diy is having
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on the development of drugs by companies. >> i'm talking from the perspective of the person who's lived with type i diabetes for 61 years -- for 16 years. i had access to insulin and glucose monitor but these devices would wake me up at night. i found a code that allowed me to get glucose data in real time allowing me to send it to the cloud and down to my phone for an alarm. i started adding other features like remote monitoring and tracking my food and insulin. we were able to build a pretty simple algorithm that predicted in the future and what would happen to blood sugar, every five minutes. that was really helpful in shifting from
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reacting to your blood sugar already being high or low but predicting the future and alerting me. so if i was going on a panel, it would tell me what to do to prevent it. other people on social media saw how this is working and other people struggled with devices and we met people who figured out how to communicate with the insulin pump. you can take a small radio and computer and talk to the pump and bridge the gap that was previously interoperable. it was the hybrid core loop system, this computer that would talk between my pump and cgm and that's it we call the artificial pancreas, we decided to share this with other people and as a result of sharing with other people and talking with other patients and other disease communities about what we did, we are not the exception, where the
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undiscovered rule, people with conditions are hacking and innovating and developing things all the time to basically make our lives better. that is what my project is doing , looking at the barriers and obstacles patient face. when they come up with an idea, why are patients told to stop what they're doing? so, the question is what are companies doing, some of them are ignoring it but that's to their detriment. others listen and embrace at least one diabetes company has taken the code we wrote and it's open source for reason and are actually putting it into my -- air products. >> you have companies in the
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middle hiring people from the community and listening in different ways and i think it's really promising . >> were going to get back to some of that. josh, first i want to mention that anthem is your former employer in the interest of full disclosure. you are in charge of one of these super well-funded googly things we are all fascinated and confused about and creating virtual diabetes using high- tech tools, tell us what you doing. you have a pilot started, talk a little about what your results have been . >> absolutely. we are a joint venture, what we are trying to do is how can we
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deliver better care for people with chronic diseases and i like to say that people with chronic disease require chronic solutions. the way the healthcare system is set up, it's not great for managing people between visits. so, when we look at different conditions, right now we are looking at diabetes, different people might need different things, some people might need different every couple weeks and some a couple times a year, some need hands held and others need medication adjustments. we are trying to get the person as much care as they need and remove inefficiencies or wasted resources. when we talk about continuous glucose monitors, it's a very expensive device reserved for those with the highest needs. what we are seeing is if you use it differently for shorter periods of time, you can get real insights. these are some of the things we
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are doing, leveraging software in the form of telemedicine, people, educators and doctors and hardware in glucose monitors , to help deliver the care longitudinally. we talked a lot, 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 needed, then for clinicians, the average primary care doctor has 8 to 15 minutes with the patient to deal with all the problems. so, between visits before a visit we can gather data to make your 15 minutes effective. so we exist to help people . >> you are the pilot with about 3000 people, heather, you are
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working upstream of these two, you're working with prediabetes and there are now 1100 different sites, physical, brick-and-mortar locations across the country. but, this is also an innovative program, tell us about how you got into this and what kind of research and experience goes into this program . >> the national institutes of health, in the mid-90s, they convened a study looking at could type ii diabetes be prevented, could we slow the progression, and, the trial showed that yes, lifestyle changes were twice as effect than metformin which is what is typically used. they had the proven intervention but sometimes what
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happens is you have this affective thing that takes so long to get to market, or it sits there because you can't find the right distribution channels. the great thing is one researcher at the university happened to be at a meeting talking about this and said, it's a coaching program, maybe there's a way to do this more cost-effectively and then in indianapolis they said what about us. let's talk about this, that started to take the dpp from a clinical environment into the ymca setting, we use ymca trained coaches in that format, we were able to do that for a fraction of the cost and still help people prevent the onset of type ii diabetes. through the work we've been scaling for almost the last 10 years and we've done so in partnership with the cdc and other stakeholders and we look at how can we get this proven intervention out into communities. we do that through a brick-and-
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mortar approach, there's about 1100 program locations right now , those program locations have served about 62,000 people. that may seem like a drop in the bucket there are 84 million americans living with prediabetes and only 10% of them know it. it's only a drop in the bucket and we have more work to do but it will take a lot of organizations working together including with healthcare partners, technology, in order to see an impact . >> so far, these have been up and running for a couple years, is there anything you've learned about what works or doesn't work , that's different from the pilot? and also, if you're finding that basic we are having success in the programs and their helping people, do you then -- does the fact that you are a drop in the bucket,
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does that lead you to think that maybe the cms has been holding up the approval of these diabetes prevention programs. would you like to see these moved faster or another component? >> yes. there were a couple questions in their. what folks are working on is the weight loss goal, to reduce their weight by 5 to 7% and increase physical activity. it's not a significant change but it's a lifestyle change and that's the core tenant, teaching folks how through eating and increasing physical activity and dealing with social and emotional things that can get in the way, stress, smells that make them want to eat, all these challenges can impact the ability to change our lifestyle. so, the core
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tenants of the program, we are definitely getting to people to the weight loss and we do see weight loss in participants. it's 25 sessions over the course of the year. it's intensive, there's a lot of support in making the change. but, 84 million americans, no single mode of delivery will ever really see and prevent people so they may not need some of the interventions that have been previously discussed. we are really excited that medicaid is paying for the diabetes program and serving medicare beneficiaries, we will need everybody working together so, we do help that in the future medicare considers multiple modes of delivery . >> you only get paid if you
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show up . >> we are always being held to the standard that no one asks for my quality as a position that we have physicians not getting paid for outcomes but almost digital -- almost every digital health company i know hold ourselves to the reimbursement standard . >> what outcomes are you required to reach? >> so for dpp you have to be on track for 5% of your weight loss, we have different outcome measures but it could be anything from a1c, and what we want to get to is the holy grail which is cost. so, for all of these programs,
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this is why cms and other entities have concerns around digital health, because they are still scalable. the idea is that if your dr.'s office here at capacity, how many patients could you see a day, you're building it for scale, then the theory is do you have access use, i think the way you combat that is by tying it to very well validated study outcomes and you only get reimbursed for the outcomes cost of the equation for anyone thinking about doing anything in healthcare especially digital healthcare should be outcomes divided by dollars. if you can do a better, cheaper, faster, then digital is just another medium . >> i've noticed and fascinated by the fact that sanofi put up a couple hundred million dollars , talk a little about this. one of the measures of success is actually getting people off
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some of the medicines, reconciling medications. so, why would sanofi want to be part of the program that's gonna lead to people taking fewer of their drugs? >> you'd have to speak to sanofi, but i can hypothesize in my argument, suing google -- so google decides to get into healthcare and say we will build a better program for people with diabetes, lots of people pay attention.
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half my board is composed of sanofi and they are wonderful, it's never about what is the next drug or how do we 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, outcome divided by dollars . >> so, you will be able to this pilot going on that you're developing, it sounds like you have informal nonpublished peer
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review data that's pretty impressive . >> we launched in january the couple plans, so, we've had a couple thousand users and it's really fascinating. you can break our groups into two different categories, one is types of things that motivate them and the other is clinical risk, what were finding that on the flipside we look at users and we see three different groups, some people will love track and want to
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take pictures of the food and the steps and they are super engaged in other people just want convenience and they say how can i get access to some information the least amount of work for the greatest amount of return, the third group we like to call chatters and breakers , a test all day long and they want to know how the dogs are doing, but these are a really important thing, healthcare, why do you need a physician if they could build the bond, i don't mind if they chat all day, as long as that leaves for them to take their medicine or do the other things they have to do . >> that's the growing area of our economy, all the ancillary parts of medicine are more important than doctoring in a lot of cases.
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>> to change the subject a little bit, you run marathons, you diy like crazy and i think you said on one of your blog post that there were like 600 people -- >> 900 now . >> 900 now, how many type one diabetes are there? >> i think -- >> i don't know, what is relevant to what you're doing to other more normal human beings . >> i think normal is a setting on a washing machine. to recognize that, we are a molecule of the diabetes community but that doesn't mean that what were doing is not able to use data that we've used it to understand how the body is working with these devices, learning things the traditional medical community is not discovered yet. understanding how insulin
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peaking before the meal and ready to set -- and readying yourself for glucose can regulate how much you eat or how much insulin you dose. were able to explore in the data , people didn't have the information to track. this device tracks and calculates things in a way that traditional devices do not. lots of data we are using are applicable to type one devices. not everyone wants this technology, some people just want to do multiple injections. a lot of what were learning is translatable back to the type to population . >> one of the first things that i've done with my smart alarm system is realize that before that, if you asked me to lock something i would laugh at you. there's no point . >> explain what's different and how you treat type i and type ii . >> type i you will die without
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insulin. with type ii your body doesn't necessarily work well with the insulin, some people go on medicine, some people manage with diet and exercise but type when you need or you will die. you are responsible for measuring your blood sugar every day, it's a lethal drug. traditionally we didn't have the tools to manage it. you might test your blood sugar and be lucky enough to have a cgm but that's still not good enough because it's complex, not instantaneous, it doesn't peek for 60 to 90 minutes. i will be playing catch-up, it's really complex, the way the timing works, even if i log what i eat and what i take, unless i have some tracking what happens in the next couple hours, i don't have feedback if what i ate was good or better healthy, so, there's no way to
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provide the feedback. one of the first things i learned was that i was the world's greatest logger because it gave me actionable feedback. that's really applicable to people with type ii and other chronic diseases, recognizing that if you have the data, don't do it for clinicians conduit for the patient, that helps people start being able to take action to understand the cause-and-effect. in some cases it's hard but you do peel back layers of the onion to understand. . >> i will add on that, a drop or molecule in the bucket but it's incredibly important, crystallizing, but we did
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dozens of focus groups and we said what can we build for you . >> that's a question i had, when you're talking about diet and tracking, it's an awful lot of not forgetting that you're trying to lose weight or control your diabetes, so in these areas of digital innovation, when it comes down to personal engagement, a lot of it seems to go in the opposite direction from what you are saying your patients want . >> go ahead .
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>> i will say it, it totally depends on the person, i love to think about how do we arise -- uberize healthcare. when i called my uber to catch my flight, the anxiety i used to have to call a cab it's gone so what huber and lift did is create a trust through transparency, and that's what our companies are trying to do which is how can you build trust give them better data it's about collecting just enough data to help them accomplish their goal and for some people they track every morsel of food to help me optimize to be the top 1% of what could be and for others
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it's to help me understand if i can exercise for 50 minutes or get away with 20 minutes cause i could use 40 minutes to do other stuff . >> one important thing to think about is it's a lifelong condition. even if you're able to come off with medication for type ii it's still something to be aware of. people have different needs, i was diagnosed at 14, what i needed as a teenager i don't know what i would be considered now, and adult, what i need and my motivation is different not just on lifecycle moment but i've been traveling back to back and when i'm at home and eat healthy and exercise, i think a lot of solutions are designed for you have the motive is station -- you have the motivation but it didn't fit
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for them and that particular time. >> you have to make it easy for the individual. i think all the types of disciplines described that we've seen in folks who will prevent type ii diabetes. , we support them in the thing that works for them in the moment, it gets them to their individual choice, the technology tools that individuals use for tracking berries on everything, pictures of food, we've seen that happen , so it's about being accountable for the behavior change and what happens next . >> i'm curious, do people who
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are doing more tracking with electronic devices or keeping careful logs, to they have more success? >> they are more successful. it's foundational, at least in the dpp they are more successful . >> your motivation has to be track, it has to come into flesh , some kind of numbers and figures, it can't just be in your head . >> it's a readiness piece. if anyone has ever tried to change her behavior, it's about being ready to make the change at that time as well, you have to assess all of that and understand that these are the core cuts that can help you be successful. if you aren't able to do that now your success will vary as an adult . >> the idea that there is a personality that tracks i think it's great.
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there are lots of cohorts that will never track but they can get great outcomes. so, i was reviewing one of our cases that we did frequently, it was someone who over eight at night, whenever asked them to track things they just put a picture of their kid on the fridge because that is why they wanted to get healthier. they are not tracking food but every time they get up at midnight they see the picture of their kid and one out of every three times they don't open it. so there tracking but it's about a different motivation level . >> the hard thing with type i is you don't have a choice, you have to take your insulin and track your blood sugar. there's people who would love to forget it and for my own example, people can do everything right but it still may not have a great outcome, both types are still complex and we don't know what causes it , were still discovering and it's important to keep in mind, even when people try to track and do things right, we have to recognize that .
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>> if you don't track and you have type i, it doesn't go well . >> right . >> there is a fundamental behavioral aspect to all of these, in particular . >> yes you can track three or four times a day and be okay, but, you are high and low and high and low and there's lots of clinical outcomes but also the time, range and quality of life and how do you feel you are managing . >> let's talk a little about the government role, first i want to ask about what you think fda is doing since we have the commissioner here, they're doing a lot in the digital space , let's start with diy. .
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>> they read my blog. >> are they paying attention? >> i'm speaking primarily of the diabetes team who are amazing individuals, we've had conversations and they worked closely with the community to understand what were doing and why were doing it in understanding what open source to truly means. i have to give them a lot of credit for how they're working with companies, they said submit your submissions, there are three or four devices that are approved so quickly. i think they're doing a good job, meaning the speed issue. >> we say we are not waiting,
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were not going to wait either but we won't do our job when we bring it forward. we see that when companies bring their devices in for submission and it speeds up the whole process. i've been pretty happy . >> you not worried that the devices that involve a lot of software that there won't be unintended consequences or failures, as a result of moving them along too fast through the process? >> most of the companies still design software and it takes five years to bring something in, they need to separate the mindset of designing software and in order to process and doing rapid release, if they find a problem they can get it out to people instead of we found a bug in it will take us two years to fix it . >> at the precertification program there are lots of
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participants and they will bring more to market sooner and we move away from half where inside where and separate that for software approvals, whether it's software for medical devices or other mobile devices . >> josh, what is your take what's going on? >> can you say something critical, please. [ laughter ] >> the former commissioner is on my board, so, it's part of the research program that's novel, there's a continuous glucose partner with the system that's novel and what they're doing is recognizing that software is in the cell, it's hard to change a pill in the market, you can change and update software and i think the knowledge has led to really great innovations and i think it's the right mix of being safe and secure as well as
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innovative, the other thing that surprised me is how human the update is. for any who have been involved find a way to work with the company, they can meet with you in person and give you advice, it's pretty wonderful to work with. medicare is what we will all pay for if we don't manage prediabetes now or people with diabetes today. so, it's reimbursement where i think it's the holy grail . >> do you see your company, or
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are you are approaching them or you figure you will after you have more data or cracks >> it's a little bit of a combination. we start out as a decently funded set up and we go to the process but it's a process getting through medicare. but, once you get through the process, the question is with these new digital tools as it reimbursed or not, going back to the comments made before, were built for scale and when you're managing the country scale -- >> is it complicated to get them to reimburse a program that's multimodal with different pieces and it? or are you just getting paid for result ? >> it's a little bit of both i think, in the last seven or eight years, we've seen massive change, at least with medicare getting much more innovative,
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reimbursing some digital care. i do think, similar to your question, there has to be a body of evidence to support us and we are in that phase of gathering evidence and justifying our solution so it's not scale and fee-for-service but value-based reimbursement . >> i think through the diabetes prevention program, the ymca did a medicare medicaid project and we looked at serving medicare and beneficiaries and were able to collect outcomes so they can follow the cost for those individuals and that's how cms certified cost savings, which led to medicare coverage of the program. so, you can build the evidence base and work to drive the channels that can lead to payments at least for the dpp and how we got where we are
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today. >> what we see naturally exciting is, while not serving medicare we do serve people in different age ranges, especially women in their 50s and 60s, over index registering and using our program. you get a lot of advice from the trackers, but it's not necessarily true. i think it's perfectly positioned to serve the population . >> we could talk a lot about digital and devices but we have to remember the fact that people will with type i diabetes will die without insulin and its unaffordable and and accessible to a lot of people so we need to figure out how to stop people with type i from dying in our country . >> if there are inches put on our insurance one way or another , through the government
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medicaid programs, getting tighter, as well as the acc, to be overturned with insurance being dicier for some people, do you think this new wave of technology and entrepreneurship can step into the breach it all for people who don't have the resources to pay for this? >> i would say yes and no. yes in terms of the fact that the innovation, software and digital health can reduce cost, and the fact that you can have a gray app but -- back yes and no . >> it depends on the solution, if the solution is about the next gadget or widget the answer is no.
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i think a lot of companies are not playing a role in medicaid yet, they are perfectly positioned, so i think it's a question of working with payers and government to figure out what the model is . >> we are a charity that's been around for 170 years working in communities to deliver programs and services, so, the reimbursement for us helps to offset costs with more reach, so will there be an impact to potential volume? of course but the ymca's committed to doing this will work with anything and help them participate in the programs a
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>> when i called my work and said, what about this device he says, it totally works. he said well you are not a sports guy or a athlete. so like, always ask what else can i do? research, you have to as a
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caregiver and a patient you have to become empowered in your own care it's sad to say, you aren't put at the center of everything because there's a whole system around you so you have to advocate for yourself. >> so that's another thing with diabetes or another chronic condition, you have to learn so i would say educate our fellow people living with healthcare conditions and to do that and take the next step and go the step further. it's hard to constantly push at the barrier but it's really valuable. >> i would like to think our guests, i think we got some of the amazing things happening in technology. from creative patients to companies that are -- that have all this google brainpower behind it. the
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grassroots work behind organizations that are doing things with less technology but just as much, you know energy and focus and research behind what they are doing. and i think that probably, the same is true with opioids and we have to focus on you know, just all of the, there's a reason while on one hand we have all of this incredible technology, going on, changing things, the biggest growth in the healthcare is, people don't necessarily have to have more than a high school education to do that, that's the important part of caretaking and social work and all of that. so thanks everyone who has been here today and thank you for being here. [ music ]
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>> cspan, where history unfolds daily. in 1979, tran was created as a public service by america's cable television company. and today, we continue to bring you unfiltered coverage of the white house the supreme court and public-policy events in washington dc and around the country c-span is brought to you by your cable or satellite provider -- brought to you by your satellite or cable provider. >> coming up in american history tv, programs on world war ii, we begin with a look back at the tuskegee airmen who were the first african-american
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fighter groups, six were part of an event working the 75th anniversary of their deployment in 1943. they talked about some of the most dangerous missions and one of them -- and what it was like to serve in a segregated military. this is american history tv on c-span 3. >> it's with great pleasure i introduce our panel of american icons, the tuskegee airmen. on the panel mister ron jackson, a third-generation military man currently a tour guide in the u.s. capital. formerly a proud paratrooper in the 87 airborne division. i am from north carolina so i'm exceptionally proud of the 82nd and their actions over at fort bragg


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