This week’s episode is about optimal medical therapy, a term used to describe the best possible medical treatment for patients with the goal of improving their health and reducing the risk of complications. William Bestermann discusses the fact that optimal medical therapy is not currently provided in the US, despite there being a large amount of evidence supporting its effectiveness.
Bill is a board-certified internist with a focus on optimal medical therapy for chronic diseases. He is known for being a fresh thinker in the industry, has been actively involved in bringing about new ideas in the industry, and has written thought-provoking columns on the subject.
What You’ll Learn From This Episode:
1:45 Bill's motivation for getting involved in cardiovascular and related conditions.
4:20 What is optimal medical therapy, and why isn’t it currently provided in the US?
6:47 Efforts to develop the push to overcome the financial pushback.
13:23 Why the cheapest care is the best care?
15:34 What is the cost of not having optimal medical therapy in place?
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And now here's your host, StoryBrand certified Guide and Chief Transformation Strategist, a Chief Shaer Strategies David Saltzman.David Saltzman:
And we are pleased to have William Erman Jr. Md, otherwise known as Bill. He's a board certified internist. He's been heavily involved for the past 20 years in bringing about new thinking in healthcare. His specialty these days is around optimal medical therapy for chronic disease. And if you wanna read more, please, and I'll talk about this at the end of the interview, but please go check him out on ck His columns are thought-provoking and interesting and he's a fresh thinker in the industry and we could sure use a whole lot of that. Welcome Bill. Thanks for joining us.Bill Bestermann, MD:
Pleasure to be here.David Saltzman:
So tell us a little bit briefly about your journey and how you ended up kind of doing what you're doing.Bill Bestermann, MD:
Sure. Well, I was crazy enough when I started in internal medicine to go to a small South Carolina town, Beaufort, South Carolina as the first full-time internist. And little did I realize I really hadn't done my due diligence. There was no I C U there and the nearest, uh, tertiary hospital was an hour away on two-lane country roads, and half the people were dying of heart attacks and strokes. So right away I was faced with a huge challenge. We stood up in I C u, I was medical director for eight years, and I faced way too many wives and husbands with awful news about their spouses. Awful news about parents. And that really motivated me such that I've been very much involved in cardiovascular and related conditions ever since. I sent hundreds of people to have bypasses and stents, and most disconcertingly really in 1995, I'd been at it for about 15 years there in Beaufort. And articles began to come out that said, bypasses and stints don't keep you from having a heart attack. It's best practice medical treatment in stable patients that keeps them from having an heart attack. And subsequent trials. In 2008, the GERD trial showed that optimal medical therapy alone in stable angina patients was just as good as optimal medical therapy plus a stent. And there have been 15 trials since then that showed that same thing. So there's just a, a mountain of good evidence published in the New England Journal and places like that that documents this fact that medical therapy is what keeps you from dying or having an heart attack. Well, the problem is that's been adopted in places like Great Britain. So primary care doctors in Great Britain provide optimal medical therapy to stable angina patients. And they refer to cardiology when there's unacceptable chest pain despite the medical therapy. That's when they're referred. But in this country, even professionals have not heard of optimal medical therapy.David Saltzman:
Would you define that for us and and give us, uh, kind of some insight for the layperson into what that means?Bill Bestermann, MD:
Yeah. Well, it's really very simple. If you have a high risk for cardiovascular disease, if you have known cardiovascular disease, if you have diabetes, there are five things that you need to accomplish. It's a blood pressure of one 30 over 80, a hemoglobin a1c of seven or less. If you're diabetic, an LDL cholesterol of 70 or less, you should stop smoking cigarettes. And if you're higher risk, you should take an aspirin. Furthermore, we know that lisinopril or losartan a player known or spiral lactone for blood pressure, metformin for glucose and statins for cholesterol don't just lower the target risk factor. It's really amazing. They are antioxidants and anti-inflammatories that protect every cell and every organ in the body. So in fact, if you're on optimal medical therapy compared with the care that most people get, you live eight years longer and complications are delayed eight years. We have a study in diabetes that goes for 21 years now. So we've got 21 years of follow up comparing what I just described with usual care. And it's just, the difference is just crazy. I mean, the optimal therapy people in diabetes have a fourth as many heart attacks, the fifth as many, many strokes, the sixth as many go on dialysis. And yet nobody in the United States is teaching it. And nobody in the United States is consciously and systematically providing it. WhichDavid Saltzman:
Begs the question, why is that? Why aren't we teaching it? Why aren't we providing it here in the states?Bill Bestermann, MD:
Well, I think that's a pretty ugly story. Years ago, I was one that thought if you developed a better mouse trap, uh, people would beat a path to your door. But there's not much money in primary care and office visits. There's a ton of money in bypasses, stents, implantable defibrillators and those kind of things. And perverse financial incentives stand in the way. That's the way I would assess it.David Saltzman:
How do we start moving past that? Or is there actually a way to start moving past that?Bill Bestermann, MD:
Well, yes, there are a good number of people who are trying to develop the push to overcome the financial pushback. And we're gaining slow grudging traction. There's a moving to value alliance in Connecticut, but has brought together over 250 people who are afflicted like I am with this drive to improve health and lower cost. So that's 250 people in one organization and I'm working with a number of people to develop the systems to support practices in providing optimal medical therapy. And we've, we've got good solutions available. They're also some governmental changes. One of the biggest is the fact that there's this new act, you may know about it, the c a a mm-hmm.<affirmative>, I can't remember what the initials stands for. TheDavid Saltzman:
Consolidated Appropriations Act.Bill Bestermann, MD:
That's it. Absolutely. And what that says is that if you're an employer providing insurance for your employees, you have a fiduciary obligation to see that they're getting proper care, best practice, care care that is excellent and as low in cost as it can be. And that's a legal fiduciary responsibility. And there's another provision of that act that those people have to have data that's transparent so that they can look at it and actually ascertain if they're meeting their obligations under this c aa. And, you know, that's a legal obligation and I don't see how you can claim to be ma meeting the provisions of that act if you're not providing optimal medical therapy for the most common conditions that kill us and disable us earlier in life. Does that make sense to you?David Saltzman:
It it, it does. And, and that, that, obviously I won't say obviously that applies to ERISA plans. Those are, uh, self-funded plans, right. Where they've always had a fiduciary responsibility to act in the best interest of the plan, which always seemed kind of counterproductive to me or counterintuitive right. To me. So I'm, I'm glad that there's this clarification out there. You mentioned primary care physicians, and I know there, there are a lot of primary care docs who are now out starting these direct primary care practices because they want to be able to practice differently. And point of fact, a bunch of them are internists. Right? What's their role in helping to move this along and and how do we educate those folks?Bill Bestermann, MD:
Well, as I said, for reasons that are not clear to me, this is not at all well known among professional people. I'm working with some diabetic coaches, so we're doing real work now. And the diabetic coaches that I work with have all, all read my CK material and they've taken the continuing education course that I spoke about. But one of'em is just a terrific gal who coached diabetic patients for six years before we got together. And she's got a master's degree in public health, lives in New England. Never heard of optimal medical therapy until we discussed it two or three months ago. And so that's the huge barrier. I mean, it's not being taught and you only see what you know, right? You only teach what you know. You only engage in what you know and treat what you know. And so that's the huge gap that stands in the way of even a beginning. But it's not really a barrier now because I've written on this for a year and a half on CK and we've got material on a learning management system for patients, health executives and provider teams so that anybody who's interested in moving to that next new thing and leading the charge can easily do that. And we're, we're happy to help them. We've also developed a platform that enables us to go to the tpa, identify the high risk cost patients, support them with protocols and identify care gaps. We can identify for the provider teams who's not at goal, who hasn't achieved those targets. We talked about who's not on the right medicine, who's smoking, who's not taking an aspirin. And we can just serve that up to the nurse coaches to help close those gaps. So it's really gotten pretty sophisticated. The immensely frustrating thing is we're still developing and not doing a lot. We're doing some working, but not nearly enough.David Saltzman:
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Sure. I mean, almost by definition, well, let's say this, the best care is the cheapest care. So if you're really providing patient-centered care, which everybody talks about and almost nobody does, if you're providing patient-centered care care, you're preventing hospitalizations, ER visits, urgent care visits, people are not having events. People are not needing rehabilitation and nursing homes as often. And so the best care is the least expensive care. And that's hard for people to realize. And when you're, so, you know, I just told you earlier that bypasses and stents and stable patients don't add anything except risk and cost. So how much waste is that? That's just that one thing. And with diabetes, diabetics who are pre-diabetic can develop blindness, chronic kidney disease, neuropathy, heart attacks, strokes. So the same thing that kills the cells and the pancreas that make insulin the same. Molecular biology, epigenetics, excess oxidant production, inflammation, the same thing that increases the risk factor also causes the complications. And if the impact on the organ out runs the effect on the risk factor, you know, you can have these disastrous events before the sugar even gets very high. Did I explain that? So it's understandable?David Saltzman:
Yeah. Well I understand it, which means my audience will understand it cuz they're all way smarter than I am.Bill Bestermann, MD:
There you go. Okay.David Saltzman:
Your research and in your work, have you had any idea, have you been able to calculate even a rough idea of what not having this optimal medical therapy in in place is costing the system?Bill Bestermann, MD:
Sure. Well, we've dug into the trucking industry a little bit. So we've had a, a perspective client that's a long haul trucker, right? And we did this analysis where we identified their drivers and families who were afflicted with these high risk, high cost cardiometabolic problems. And what we found was 60% of their cost is related to cardiometabolic disease. And keep in mind, none of these trucking companies can find enough people to drive. So when people drop out because they develop some complication or because they need insulin. So if your diabetes progresses to the point that you need insulin, you can't drive because of a fear of low sugar attacks and and losing consciousness. So it has a huge impact. But if you think about the life of a long haul trucker, he's on the road. He can't sit two hours in a primary care office waiting for the doctor to show up. He has poor control of what he eats and he's sedentary. So the answer there would be to have remote primary care and coaches helping these folks understand how they can make the best of a tough situation, get their meds on the road, get instruction on the road, and have their therapy changed. Uh, they can measure their sugar and blood pressure on the road. But that's a gr just a great example, because they aren't, I'm satisfied that that 60% could be dramatically reduced if we applied what I'm talking about systematically.David Saltzman:
So if, if I fit this kind of a profile or one of my listeners does, and we go to our doc and we say, Hey, you know, I, I heard this really interesting podcast with this really smart doctor and he was talking about how, how things like metformin might be helpful to me. I, I think I'd like to try that. What kind of pushback are we likely to get?Bill Bestermann, MD:
Well, there's confusion about metformin, but by guideline, metformin first is the drug that we should use. And the guideline even says regardless of what the blood sugar reading is. So even if your blood sugar reading is within the normal range and not in the diabetic range, and you have had the diagnosis of diabetes for the reasons that I talked about, you should be taking metformin. And the phrase is no or should have known, that's the legal phrase, right? Right. And so they shouldn't get pushback, but it's confusing. So normal kidney function's about a hundred. You start to have serious risk when you get down to about 60, dialysis is 15. So if you're kidney function's about 30, metformin can accumulate in the body and that needs to be taken into consideration. But, but even professionals hear that and they think Metformin damages kidneys. No, it doesn't damage kidneys, it protects kidneys. And that's why I think it's so important. You know, we have primary care doctors that are hospitalists. We have primary care doctors who are in urgent care. So primary care has already begun to focus on special operations. I kind of call'em medical special operations units. Mm-hmm.<affirmative>. And it's just crazy that 86% of the cost comes from patients with chronic disease. And we don't have chronic disease teams. And if you're doing this all day every day, uh, if you're dealing with type two diabetics all day every day, then you understand metformin, you, you can't escape it. So I think that's some model that these big groups ought to adopt. They ought to have a, a team within their organization. Kaiser does that. They have a collaborative coronary care service that addresses patients with coronary artery disease and they reduce mortality by 90% over four and a half years and save$20,000 per patient per year. So it's baffling to me, it's a little crazy why this has taken so long.David Saltzman:
Well, as it develops, we're about out of time for today, but it, as it develops, we hope you'll come back and, and share some more wisdom with us. It certainly is a fascinating conversation that I don't think enough people are having.Bill Bestermann, MD:
Well, I'm delighted to have, uh, the platform to speak with people. And I'll be back if you invite me for sure.David Saltzman:
We will definitely invite you, Dr. Bill Besman, who is one of the leading authorities in this, this country, at least on optimal medical theory and therapy. And, um, lots of change needs to happen. And it's all those perverse incentives that always seem to be where we trip up. And maybe we'll get smarter rather than greedy or one of these days. We'll see. Bill, thank you so much for sharing your expertise with the audience. My pleasure. Absolutely.Announcer:
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