Health care today is a tale of two systems. One is based on the limitless potential of science and technology to beat disease. The other is the obstacle course of time, access, and cost that sick people experience in getting well. Bridging that divide requires more than incremental change. It requires a fundamental shift in how we think about and provide health care.

Academic teaching hospitals are among America’s greatest engines of innovation. Yet only a few are truly testing the status quo to make the patient experience more accessible and affordable. UPMC is one. A world-class research enterprise, health care provider, new business incubator, and insurer, UPMC includes a network of 40 hospitals, 5,000 physicians, 700 outpatient and community practice facilities, and 3.6 million insurance plan members, in the United States and abroad. That breadth has advantages. Leaving the standard fee-for-service model, UPMC is using data from its various enterprises to plan holistically and unconventionally about how to improve patient care while also lowering costs.

So how does UPMC implement change? Scientific American asked four leaders about how technology, science, and adjusted incentives are transforming the patient experience, and the future of medicine.

The Next Revolution in Health Care

Steven Shapiro, MD, is the Executive Vice President and Chief Medical and Scientific Officer at UPMC. Jeremy Abbate, the publisher of Scientific American, asked for his view on health care today and tomorrow, and how it will take some unconventional thinking to get us where we want to go.

To Steven Shapiro, MD, the Chief Medical and Scientific Officer at UPMC, tomorrow’s healthcare needs to embrace new technologies, payment models, and patient behaviors. Credit: David Kelly

Q: How would you describe the state of health care today?

A: We see this as both the best of times and worst of times for health care. The advances in science and technology are unbelievable. We’re doing things to improve patient care like never before. But, the price is too high and we need to work on affordability and access to care.

Q: How can you place a greater emphasis on affordability without sacrificing quality care?

A: The two often go hand in hand. The higher quality often lowers the cost, but sometimes one pays for what they get. Our job is to know the difference. The incentives are largely misaligned, which is why the government has been working on other models of care. In the meantime, we’re unique in our structure, so as a payer-provider, we can start to deal with these things today. The total cost of care and quality is on us as a system.

Q: If you imagine the hospital of the future, what will it look like?

A: We can bring continuous physiologic monitoring to our patients in their homes. It’s a matter of really coordinating the care, keeping in contact. There will be a need, at least in the foreseeable future, for a brick-and-mortar hospital. But in that hospital, the patients will be sicker. It’ll almost be a big ICU.

Q: If you could change one thing about our health care system, in this country or even globally, what would that be?

A: I talked about affordability, which is big, but we could make the most difference if we focused on healthier lifestyles. A healthy diet, a little exercise, don’t smoke, and maybe sleep a little bit more. Changing behaviors could eliminate the majority of chronic diseases, improving health in our country tremendously.

Q: What’s the next frontier for UPMC?

A: We would like to continue on our payer-provider journey to interlock even more closely with our health plan to deliver higher quality care that’s more affordable for our patients. But with advances in science and technology, we also have the opportunity to develop new therapies that could really make a difference in treating intractable diseases, if not ultimately lead to a cure.

The Promise Of Big Data

To Oscar Marroquin, MD, the Chief Clinical Analytics Officer at UPMC, data could enable a new era of predictive medicine. Credit: David Kelly

Big data is reshaping every aspect of the health care business model. Tools like AI that connect the clinic to the patient have the potential to advance precision medicine and reduce the burden of chronic disease, which accounts for more than 80% of total U.S. health costs.

Despite the optimism, health care institutions have been slow converts to the revolution. Obstacles include a culture of professional autonomy in medicine and the logistics challenge of turning vast amounts of raw, disaggregated data into the knowledge to act.

“It takes more than an app to get that right balance between people and the machine, but if you do, you’ve nailed the future of health care,” says Oscar Marroquin, a cardiologist who oversees the development of UPMC’s large suite of information assets as Chief Clinical Analytics Officer in the Health Services Division.

Marroquin runs a team of data scientists, software engineers, and visualization specialists with a simple mandate: to back clinical decisions with evidence relatable to the whole person, not just the disease.

“We don’t see data as just a research tool but as continuous learning support in patient care,” Marroquin says. “It’s more the bedside than the bench.”

Marroquin’s group is fully funded by UPMC and is embedded within its clinical network, eliminating the distractions of vying for outside research grants common among data crunchers in rival hospital systems.

Among its many projects, Marroquin’s group is using data prospectively to map what’s missing in the patient journey from diagnosis to recovery. With its own insurance plan, UPMC can curate the huge data sets necessary for conducting broader population health assessments linked to “well care” and prevention.

”In medicine we’ve been trained to lump people into fixed therapeutic categories,” Marroquin says, “but we now know that the phenotype of every individual consists of seemingly endless shades of gray. These include social determinants of health status, such as where you live, family background, occupational stress, and mobility issues. Using data from UPMC’s network of acute care and outpatient facilities, we can add these variables to the patient chart and then build highly accurate predictive models to identify those most at risk for adverse outcomes.”

Identifying the risk factors behind costly postoperative readmissions in UPMC’s network of 40 hospitals has been Marroquin’s priority. Pilot programs in 10 hospitals were conducted in 2018, evaluating millions of discharge records to target patients at highest risk for readmission. The pilot resulted in a 35% to 50% reduction in readmissions compared to prior rates, enough to start deploying the model for use by physicians at the point of care.

Marroquin sees more improvements to come as the data on individual patients deepens. “It is bringing us to the day when the art of medicine is validated by the hard evidence that can prevent disease, not just treat it,” he says.

Breaking the Code on Immune Response

For Tim Billiar, MD, the Chair of the Department of Surgery at the University of Pittsburgh School of Medicine and Scientific Adviser at the UPMC Immune Transplant and Therapy Center (ITTC), immunology is the thread that ties together cancer, chronic disease, aging, and transplants. Credit: David Kelly

For years, immunology, or the study of the immune system, was a sleepy little corner in the otherwise fast-moving world of clinical research. Today, it is one of the hottest fields in medicine and a source for some of the most exciting new therapies in cancer and autoimmune disease.

Research hospitals around the world are working furiously to bring this budding science quickly into the clinic, but some are farther along. “We’ve been far ahead of the crowd in pursuing the translational aspect in ways that benefit patients,” says Tim Billar, Professor and Chair of the Department of Surgery at the University of Pittsburgh School of Medicine, UPMC’s academic partner. Billiar traces UPMC’s involvement in the field to the 1960s, when surgeons opened the field of organ transplantation with a number of firsts. Next came the introduction of effective immune suppression that transformed organ transplants from high-risk experiments to routine procedures. “Now with 20,000 organ transplants and many cancer breakthroughs,” Billiar says, “we’ve been able to move seamlessly to clinical leadership in cancer immunotherapies like CAR T-cell therapy.”

Also in UPMC’s sights are treatments for a growing list of chronic inflammatory disorders. “Chronic inflammatory conditions affect nearly everyone at some point in their lives, are a major productivity drain, and contribute to accelerated aging,” Billiar says.

To consolidate their diverse capabilities in immunotherapy, UPMC and the University of Pittsburgh launched the Immune Transplant and Therapy Center (ITTC) in February 2018. The center’s goal is to advance the science of immunology to create innovations in four areas: cancer, chronic disease, aging, and transplant.

Ongoing projects include a clinical trial to infuse regulatory dendritic cells in liver transplant patients prior to surgery, with the hope of putting an end to toxic immunosuppression regimens. Another is a prospective trial using the diabetes drug metformin to see if it improves outcomes following high-risk surgery. Work is also progressing to explore bone marrow transplants as a novel pathway to treating debilitating conditions like refractory inflammatory bowel disease (IBD). The ITTC currently has five trials in motion.

Billiar, who serves as the center’s co-director and scientific lead, contends that the ITTC can help what ails the health research enterprise. “ITTC can rely on its position as part of UPMC’s own in-house business incubator, UPMC Enterprises, which commercializes what comes out of our labs,” Billar says. “Together, we’ve already had a hand in funding 30 projects and creating five start-up companies. Seeing our science come to life gives me a reason to think differently about the future of health care. From our perspective, the view looks promising.”

The Premium is Prevention

To Joon S. Lee, MD, the Chief Medical Officer at UPMC’s Insurance Services Division, the promise of outcome-based healthcare is being realized today. Credit: David Kelly

In health care circles, the notion of value-based medicine has been around for some time. Rather than a “sick care” model, the thinking goes, we should move to a “well care” one, where value and outcomes are the priority. The vision is tantalizing, but realizing it has been slow.

Joon S. Lee, the Chief Medical Officer of UPMC’s Insurance Services Division, which administers the nation’s second largest provider-owned health plan, is challenging that status quo. “Our health plan is transitioning from traditional fee-for-service payments to a system where getting paid depends on the outcome, such as lowering hospital readmissions or optimally managing co-morbidities like hypertension,” he says.

The centerpiece of this transition is a “shared savings” physician reimbursement formula that allows each practice to keep a percentage of the money saved from observing treatment guidelines to lower the total cost of care. “More than half of UPMC Health Plan patients are now under a shared savings contract,” Lee says. “We expect that number to rise as we move it from primary care to the specialty side.”

Lee is also looking at new ways to leverage UPMC’s connection to patients to improve preventive health measures. He cites his experience in directing UPMC’s Heart and Vascular Institute, one of the largest integrated cardiovascular delivery programs. “A decade ago we began to see that, despite all the new technology, deaths from heart disease were inching up again,” Lee says. “We were failing to control for risk factors linked to unhealthy lifestyle behaviors like obesity and smoking.”

In response, the Institute worked with the UPMC Health Plan to create a patient-centered coaching program called Prescription for Wellness, utilizing UPMC’s vast community outreach capabilities in managing heart care from a whole person perspective.

Though there is much yet to be done, Lee says that in the end, integrated care is a puzzle where the pieces fit. “Through the coordinated approach we minimize expensive hospital care. But when it’s necessary, UPMC offers the best there is. We meet the patient in the community to seed healthy behaviors, improve outcomes, and keep our insurance rates down. It’s a trifecta win, for the payer, the provider, and the member.”

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