Healthcare Innovation Leader, Dr. Jack Lord Provides an Insurer's Perspective

by Hannah Deming and Kira Maker

As the healthcare field tries to anticipate what a post-Affordable Care Act (ACA) America will look like, we had the privilege of speaking with healthcare innovation leader Dr. Jonathan “Jack” Lord. From 2000 to 2009, Dr. Lord was the first Chief Innovation Officer and Senior VP at Humana, one of the nation’s largest health insurers with about 10.6 million members during his tenure. He introduced SmartSummary Rx, the US’ first monthly prescription benefits summary tailored to individual Medicare members. Additionally, he developed patient-centered wellness initiatives, including national bike-sharing programs; HealthMiles, a fitness rewards program, partnering with Virgin Group; and Games4Health, a series of mobile apps designed to help people engage in healthy activities. He is currently the chairman of Dexcom’s Board of Directors. Dr. Lord is also a forensic pathologist with over 20 years of medical-practice experience.

Drawing on these diverse experiences, Dr. Lord gave us plenty of insight into changes in health care coverage and reimbursement, especially from an insurance company’s perspective. His discussion included how decisions about treatment should be made, health care reform, what is needed for better reimbursement of diabetes technology, and how digital tools can be used to improve health. By the end of the interview, we came to have a deeper appreciation of the challenge in Dr. Lord’s simple five-word mantra for all new therapies and technologies – “be better and cost less” – and the complexities entrenched in the three little letters A-C-A.

Coverage and Prescription Decisions

The hope is that with personalized medicine, we could deliver the right medication at the right dose to the right patient more accurately than we do now.

Hannah: The New York Times had an article in which Kaiser Permanente CEO, George Halverson said, “We think the future of healthcare is going to be rationing or reengineering.” Would you agree with that?

Dr. Lord: We’re going to have to figure out what’s the right method for saying which care gets supported, which care gets paid for, and which care is the right care for individuals.

The hope is that with personalized medicine, we could deliver the right medication at the right dose to the right patient more accurately than we do now – depending on how it gets implemented in the healthcare system. That is one hope. But again, I think it is a very, very complex world. It’s not simple and it will take some real conviction to make fundamental changes in the healthcare system.

Hannah: The FDA places a lot of focus on randomized controlled trials, which often aren’t very true to real life. It seems like there is a difference in what the FDA is looking for vs. what insurers want to see. How can we move forward to reconcile this difference?

Dr. Lord: Well, it’s a fabulous question, and it’s one of those public policy issues that needs to be brought to light. I think that we would all benefit from the development of simulation models. I always like to point out that when designing new airplanes, we know how well a plane will fly before it ever takes off the ground because the Federal Aviation Administration worked with the industry to develop simulators to show what wing designs, engine designs, etc. look like.

In healthcare, we probably need to move beyond the randomized controlled trial and develop simulations that not only look at a drug or device in isolation, but also look at what happens in actual practice with different ages and cultures to understand the effectiveness of these options. That’s a completely different model; it will take a very long time for that to come into play, but I think it’s a great question and an important policy issue to service.

Hannah: In your opinion, what should the relationship be between insurers, healthcare providers, and patients when making treatment choices?

Dr. Lord: I’ve always believed that patients need to be full partners in the decision-making process. One of the things that need to change is that patients aren’t getting to make a complete choice of what they get.

At Humana, one of the benefit designs we implemented was Rx Impact, a pharmaceutical benefit where patients were actually given an amount of money for prescriptions. If they could find prescriptions that cost less, we would let them keep whatever money they saved; and if they found prescriptions that cost more, they would pay the difference out of pocket. In that way, the insurance plan got out of the middle.

Hannah: We hear that sometimes private insurers are uncertain of the value of doing preventative work with their patients; that they are concerned Medicare will reap the benefit of that preventative work as opposed to themselves. How true is that characterization, and what are possible ways to address this issue?

Dr. Lord: First, the private insurer field has a pretty wide variety of entities; there are probably about 900 private insurers in the country. I think that among the major players – the United Healthcare, Aetnas, and Humanas of the world – that conversation doesn’t come up.

As much as the health plans have been criticized for focusing on profits over patients, the reality is that plans are trying to do the right thing in a world where the right thing is balancing the costs that companies or individuals pay for health insurance with what services are provided. I’ve never been a part of a conversation that said, “We don’t want to do something, because the longer-term beneficiary is going to be Medicare.” I’ve just never seen that play out.

Healthcare Reform and Delivery

Hannah: Are there particular groups of diabetes patients that will do particularly well with the Affordable Care Act, and others that will be at a disadvantage?

Dr. Lord: I think that it’s too early to tell. Clearly the most important benefit is that people will have access to health insurance through this mechanism.

What should a patient do? Patients and clinicians need to work as partners. They need to focus on managing their care the best that they can and utilize a couple of new technologies and therapies that are available to get to the best clinical state in their life and stay on that track.

At the end of the day, I think this is going to be a movement toward the middle where people who had great coverage and great care will probably have a higher likelihood of experiencing some loss and people who haven't had great care or haven't had access to coverage will reap some benefits.

Hannah: Could healthcare reform result in worse quality of care for those with coverage?

Dr. Lord: I think the thing to worry about is that there will be fewer options for care. On the flip side, there will be more places that people can turn to for benefits, particularly those who haven’t had benefits before. At the end of the day, I think this is going to be a movement toward the middle where people who had great coverage and great care will probably have a higher likelihood of experiencing some loss and people who haven’t had great care or haven’t had access to coverage will reap some benefits.

Hannah: What are your thoughts on measures designed to reduce healthcare costs, such as competitive bidding?

Dr. Lord: I think that those are probably strategies that nibble at the edge. At the core, we need to do more than just study more aggressively the therapy’s true medical economics. The solution probably lies in engaging patients in their care. I think that when patients are fully engaged, they’ll take us down the pathways of the most cost-effective model. I think that when the system insulates patients, either because doctors are making decisions for them or because third parties are paying for things, we’ll continue to have a challenge in place.

The fact that people have better control through the use of new technologies like CGM – hypoglycemic events and emergency-room visits happen much less frequently – supports the fact that patient care costs are lower and outcomes are better.

Reimbursement for Diabetes Technology

Hannah: How do you think that we can bring CGM, or in the future, the artificial pancreas, to all diabetes patients who would benefit from the technology?

Dr. Lord: It seems like there are three pathways for the funds of technology related to diabetes care. One is greater education and engagement of practitioners, and that includes general practitioners as well as specialists.

Second, we need database information that shows that the technologies are actually more effective from the standpoint of both clinical outcomes and medical economics. So the fact that people have better control through the use of new technologies like CGM – hypoglycemic events and emergency-room visits happen much less frequently – supports the fact that patient care costs are lower and outcomes are better.

The third is just general education and awareness on the part of the patient population in terms of their own levels of comfort and experience. One of the things that I always like to point to about the UK – and I think it’s really an important part of their strategy – is that they’ve created a level of individuals called expert patients who have quite a bit of experience in managing their disease; they’re almost master patients. They help newly diagnosed patients begin to learn how to manage their disease and manage the activities of daily living. We really need to have people who started to use things like CGM help teach people who are just getting started with diabetes some of the best practices in the field.

Kira: How do you foster that type of communication?

Dr. Lord: We’re seeing an obvious explosion of social media. I believe that it’s important to get information and engagement, to create mechanisms for people to talk with each other and learn from each other. That is one of the great things about your publications.

One of the things that both providers and regulators have just not done is gotten their heads around trusting patients. My bias is that most of us as individuals know more about our life, our bodies, and our preferences, than most clinicians do. Clinicians may have an expertise with that particular disease. Quite frankly, we need both of those things to work in concert to derive the best outcomes.

Digital Health

Hannah: Can you talk about what role you see social media potentially playing in empowering patients, and how well social media is currently filling this role?

Dr. Lord: The old model of having to go to the doctor’s office, sit in the doctor’s office, wait, see a physician for a few minutes, and then maybe see a nurse or other practitioner, is subject to all sorts of changes. We have the ability to deliver information and connect people in many different ways. I think that we need to help foster the creation of a new environment where patients who have been really successful in managing their disease help others. I think that social media in healthcare is behind social media in other sectors of the economy. We need to discuss how to give people new freedom to share, learn, and manage together.

Hannah: What eHealth or mHealth tools do you think should be held up as models?

Dr. Lord: There are some websites that have done really great work helping patients find each other, connect, and understand the best practices. Dexcom provides some tools for use with the CGM to help people keep track of their disease.

The field is evolving, and we need to continue to highlight in publications like yours those tools that really seem to be helpful for people; and we need to listen to patients themselves. We need to let patients be some of our guides in what works and what doesn’t work.

Hannah: Thank you so much for being so generous with your time and your insight.