I will happily trade you the last hospitalization in my life for a course of treatment for Hepatitis C and coverage of Continuous Glucose Monitoring Equipment

AN ECONOMIC MODEL FOR EXCHANGE OF VALUE BETWEEN PATIENT, PROVIDER AND PAYER.

A plea to the American PublicDear America,

I am writing you as a collective since it is your political processes which ultimately determine the policies determining payment for health services and products for American Citizens. Most think they have no control over private and public sector financing of medicine but ‘trust me; this is an illusion. If you are not a patient today, you will be one at some point in your life. So pay attention, empower yourself and forge the change you need.

Right now I HAVE SOME NEEDS so read on…

A little about me:• Just a regular 58 year old fella

• Married to my soul mate

• Physical conditions:

• Diabetes type 1, hepatitis C, Reflex Sympathetic Dystrophy

• Occupation

• Retired Healthcare Executive with 33 years experience in direct care, chronic disease program management, biomedical instrumentation research and the health informatics revolution.

• Currently able to volunteer and work for case rate assisting physicians build practice culture and technology to support PCMH standards.

• I will soon lose this capability due to loss of continuous ambulatory glucose monitoring equipment.

A little more about me• I spent the last 30 years studying the economics of healthcare in the

USA. I worked in all sectors of the industry and frequently needed to justify costs, set prices, assist various non-revenue generating people in health care such as case managers to prove their ROI and use prospective health risk models to define community care coordination needs.

• Basically, I can diagram monetary inflation in our system of care through all levels of care.

• So if you do not mind, I want to review a couple of special characteristics about healthcare cost in America, then make a case to you on how I would like to barter for my life.

Who qualifies for healthcare in AmericaEven after ACA

Our society never considered medical treatment to be a ‘right’ or ‘entitlement’ for its citizens. So where we all have a right to self -determination and our constitution states we are concerned for the welfare of our citizens: Wellness is not something we planed to guarantee.

Regardless of what you want, this is what we get. Well until you are an elder or become disabled, bankrupt or are a poor infant.

In the 1960s the reality of human suffering among ill seniors, ill poor and the disabled was addressed and we created a system of care for that segment of our population; Medicare and Medicaid. So I suppose enough folks changed the system to assure bodies did not accumulate in our streets. (note, the most cost efficient system of care has turned out to be Medicare)

Please hang I with me so you can understand the logic behind my plea.

SO LETS TAKE A LOOK AT AMERICAN HEALTHCARE COSTS

Most other nations considered healthcare a natural right and adopted universal coverage. All we can say is that for some reason they have better healthcare outcomes for ½ the cost per capita. We currently spend $7500 per person per year. I have a business model contrast presentation if folks want more detail. Note, the gap in cost over age of 60 is not due to “death panels”

Health Care Costs from Birth to DeathSociety of ActuariesDale H. Yamamoto June 2013

These data recently compiled by Yamamoto after and exhaustive study of HCC in America reveal average expenses per year of life to assist us with planning. I will use the $130,100 number as an argument for treatment shortly. Essentially I will forfeit the difference between 80 ($250K) and 75 ($130K). If I die before the age of 75 the loss of me from the insured population will save $120,000

This slide illustrates the difference in healthcare cost between those who die and those who survive in any given year between 1977 and 2006. So, If I would have received

normal treatment in 2006, typical cling to life scenario with failing heart and kidneys in end stage diabetes the cost would have been far north of $39,000

So here are my problems• I have been notified by both Medicare and Blue Cross that the

technology I use for tracking my blood sugar trends will no longer be covered. This is a technology that allows me to know that my blood sugar is low, keep my drivers license and have sufficient energy to work a few hours per day. It also allows me to make decisions hour by hour on controlling my blood sugar. My measure of 90 day treatment effectiveness is Hemoglobin A1c. My A1c is 6% with a target of <7%. Essentially I have been rewarded with preservation of my eyesight, kidneys and vascular system.

This technology not only prevents loss of consciousness while driving my car but facilitates long term clinical control which

translates to lower healthcare costs from comorbidity.

Could it be the folks warning us of death panels were correct?

It appears the experts in type 1 diabetes agree that Medicare recipients should be coveredJuvenile Diabetes Research Foundation

Next problem: Hepatitis C• Hepatitis C is the disease of my generation. Suffice it to say, America

has an epidemic of a viral disease that progressively destroys the liver (kind of important organ). I believe I contracted the disease 35 years ago. Until this year I had no hope for treatment since the available therapeutics would cause me to lose my vision. Now I have a 94% chance of a cure due to an incredible new innovation. Direct Acting Anti-Viral therapy.

• Having this illness is like living with a wet wool blanket wrapped around your body. It is a sense of constant discomfort in ones own skin. People who are ill-informed (many) are frightened of the patient (my boss in 2006 asked me not to share my dx when telling my story and he was an MD). On many days it is difficult to muster sufficient energy to get out of bed (lethargy and depression)

• I have been notified by both Medicare and Blue Cross that the antiviral medications which have been approved for the general public to cure Hepatitis C will not be covered.

US Prevalence 3.2 million livesUS Incidence 17,000 cases per year

THANKS TO WEB MD!!

As you can see it is a costly disease just due to the volume of people seeking treatment.

Enter HARVONI to save my life!

$1000 per pill or $85K to treat an American

After 20 years of research

DRUM ROLL PLEASE

These patients had failed treatment using the most effective medicines available.

They experienced a cure rate of 93-100% when placed on Harvoni

How is it the treatment will cost $85,000 in the USA yet the manufacturer will assist other countries to provide the treatment for $300

The manufacturer insists that cost will not prevent access. As it has for its HIV drugs, Gilead plans to provide patient assistance within the U.S., to license the drug (for a fee) to select generic manufacturers outside the U.S., and to lower prices in low- and middle-income countries. In Egypt, which has the world's highest rate of hepatitis C, sofosbuvir costs $300 for a 28-day supply.

How long do I need to wait if the medication is available in Egypt for $300.00?

WHY IS IT 283X more expensive?Does it have to do anything with geopolitics or geo commerce?

My proposal• I would like to negotiate for coverage of these technologies using my history as a

patient and known economic data regarding the cost of care at the end of life as a proposed value exchange. Essentially, you will never incur the expense of caring for me in the last year as I will refuse intubation and ICU care involving life support past the age of 75.

• Looking at last years Blue Cross data I realize they operated at a negative profit margin with regard to my single case (they call me a member) but keep in mind that this diabetic has self managed since the age of 10 through tight care coordination with multiple providers. I never use your disease management services since my physician is thrilled with the results of my self-management (A1c=6%). I have no use for the refrigerator magnets that remind me to check my blood sugar they serve no use save choking my dog Bodie. I have never been hospitalized or used the ER for diabetes related services.

• On the next slide you will see that most of your costs are from pharmacy. I imagine these will decrease as America wakes up to the disparity in costs between countries. However: Since I will continue to experience few hospitalization and ER events through tight diabetic control and will never require a liver transplant your expenses will continue to be low in the medical care cost category for this chronic disease patient.

Blue Cross Data Member Jeffrey Harris

2014

Our exchange in value• If you cover my continuous glucose monitoring and treatment for

hepatitis C I will offer a minimum of $250,000 in cost reduction to my care In the future by forfeiting certain services in the future as described below. I will also provide labor if necessary.

• I will prepare an advanced directive refusing expensive care associated with the last year of life in the slides above.

• I am sure your actuaries will agree with the table presented above describing cost per year of life beyond the age of 65. I am 58, when I was 19 my predicted longevity age 45. I imagine that I will save you a minimum of $130,000 by having a sound exit strategy before the age of 75.

• If you need a direct need to “get something now” I will provide you with 1000 hours of service in any program whether it be data crunching in your predictive modeling department, systems integration combing insurance and medical home patient portals, community education or whatever else you might have in mind.

All I want is to feel well, add value, love and be loved and not be subjected to so many hassles “fighting for my health in America”

• Since I do not reside in a country with universal coverage that has managed to offer-up large populations to scant insurance organizations thereby diluting the cost of care per capita I need a model that works here.

• Since I am entitled to be a self determined man I elect to:

• Stay as healthy as possible within using only appropriate technologies and not extending my natural greed for life into the intensive care unit while my family argues about my capacity to be self determining in that moment.

• So far in my life my statistics concerning my wellness have been quite accurate. When My wife and I were married I told her that mid to late fifties would be the time for onset of diabetic comorbid complications. I was correct.

• I promise to honor my contract regardless of scientific advances.

• I want wellness NOW, and if you do not cover my therapy I will become less active, have poor diabetic control and experience liver failure. Do you really want that bill. Not only that, I might require a LIVER TRANSPLANT!

So long and thanks for all the fish Douglas Adams

Me self managingSorting EOBS5 Health Portals2 calendars2 insurance portals

LOTS OF STARBUCKS