Several years ago, Gerard Folse, a 76-year-old shrimp fisherman from a bayou outside New Orleans was diagnosed with end-stage renal disease (ESRD) as he battled several other chronic diseases, including vascular disease, hypertension, and heart failure. His doctors told him he needed dialysis, sobering news given the additional strain the treatment can bring: traveling three days a week to a center, fatigue from the treatment, transportation challenges, hours in a waiting room, and piles of paperwork.
Instead, Gerard and his wife were trained in how to do in-home dialysis by Monogram Health and, since starting, both his kidneys and all his pre-existing conditions have improved. Gerard still receives dialysis, but he does so at home, conveniently supported by a virtual care team, remote monitoring, and regular in-home visits with a clinician.
Gerard’s success is one example of what we can achieve when we evaluate the whole patient and treat multiple conditions where the patient feels most comfortable: at home. Rather than make patients sit in waiting rooms, this model offers a simpler, proactive, technology-enabled approach that meets patients where they are. We now have the tools – and partnerships – to make it possible.
AI and data analytics help identify risk of acute conditions and trigger a proactive clinical intervention before a crisis occurs. Digital capabilities and virtual platforms allow clinicians to check on patients between visits and enable a myriad of treatments for chronic conditions to be delivered safely and effectively to a patient’s home.
Certain levels of process, paperwork and – yes – waiting rooms will not disappear because of what some procedures and centers demand. But the waiting room should not be the symbol of American health care.
Gerard is one of a growing number of aging Americans who demand more to stay healthy. U.S. Census Bureau projections show that by 2034, for the first time ever, older adults (65+) will outnumber children (under 18). This challenge is compounded for older Americans with multiple chronic illnesses — the fastest-growing segment of our population. By 2030, 83.4 million people in the U.S. will have three or more chronic diseases, nearly triple that from 2015.
As seniors continue to battle conditions such as heart failure, COPD, kidney disease, and diabetes, they may see half a dozen specialists a year, leaving them to juggle conflicting advice, confusing processes, long wait times, and complicated medication lists. As physicians, we have seen the problem up close.
The good news is that, with better tools, a new approach to patient care is here. Through our partnership, Aetna and Monogram are reimagining healthcare —slowing disease progression, delivering comprehensive, holistic care and treatment in the home – which in turn can reduce ER visits and hospitalizations. This simpler approach results in more affordable care for patients.
And our optimism is supported by results. Last year our partnership delivered 33,975 completed clinical treatments that span pulmonary disorder, heart failure, diabetes and related conditions. Among patients who were enrolled for at least 13 months, there was a 32% decline in readmissions and a 16% decline in emergency room visits. [Outcome data cited in this article is self-reported by Aetna and Monogram and is not independently verified by Fortune.]
To truly redesign the delivery of care, providers and payers must “stack hands” and share accountability for outcomes. Providers bring clinical expertise, trust, and in-person experience with their patients while payers have data, predictive analytics, and population-based engagement tools.
Policy also plays a role in accelerating change. There is momentum from several federal policy changes over the past few years that have enabled health plans to deliver integrated services at scale. For example, Medicare Advantage now accepts all ESRD beneficiaries, opening the door for MA plans to offer coordinated kidney care, out-of-pocket caps, and disease-specific supplemental benefits.
Looking ahead, more needs to be done. Congress and CMS can further expand and enhance value-based models that reward integrated chronic care by making telehealth expansion permanent and ensuring Medicare Advantage is stable for all beneficiaries. Investments in broadband, caregiver support, and home-based technologies will also go a long way to ensure no patient is left behind.
Gerard is back to enjoying what he loves – fishing, boating and seeing his family – not because of a cure or a specific therapy, but because of a personalized approach. He has not been admitted to a hospital in over seven years.
Gerard’s story is the future of healthcare. Millions of seniors can get access to treatment and care similarly if we are willing to transform the care model into a simpler, more personalized approach that puts the patient at the center.
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