Reengineering Healthcare, Community
by Community: Next Generation Diabetes Care
By Kevin Carr, MD
How much is too much when it comes to the cost of
chronic disease? Currently, chronic disease exposures
represent a staggering 86% of healthcare spending in the
United States.1 Does it have to cost that much? Do we
have to evolve the local healthcare ecosystems one at a
time, or should we simply evolve them in more targeted
ways? How do we truly activate patients, rather than move
their data around within the same broken system?
To care for chronic disease patients effectively, healthcare providers are increasingly becoming virtual and using
physical communities of care that extend outward from
hospitals and clinics to be more convenient and affordable. When I was overseas supporting their population
health strategy, I asked a group of doctors what role the
care manager played in their care model. Their answer:
“Why would we have one? Patients and their family
members are responsible for their own health management and navigation services.” Additionally, when training
medical students and medical residents in my previous
career, we taught them how to move patients through
the five stages of change, yet we often struggle across
the country to truly build those lessons into our care and
disease management strategies. Chronic care increasingly
needs to include the traditional team of licensed care providers as well as community, family members, and the individual
in order to deliver a continuous, value-based care model.
Creating a Sustainable Change in South Texas
PwC and an academic medical system are collaborating
to improve health outcomes and lower the cost of chronic
disease management in the Rio Grande Valley (RGV) and
across Texas. The two organizations are designing a new
care delivery model for chronic disease management.
The model expands to all who can deliver care—such
as non-licensed and self-help resources where care is
consumed—like hospitals, primary care facilities, pharmacies, retailers, and community outreach organizations
One of the most underserved and impoverished areas
in the United States, RGV residents have three prob-
lems common to many Americans: Nearly 50% of the
population is obese, almost 30% of adults are diabetic,
and most residents have no insurance. We are using the
DoubleJump TM Interchange to connect data that is required
to make each member of the new care model more
informed and engaged in the south Texas community.
Collaborating to Advance the Pace of Innovation
This sustainable solution includes creating a new
ecosystem-based operating model to enable the expanded care team and care sites to work together effectively.
Other core technology providers are providing cognitive
analytics to synthesize the data and network solutions that
enable communications from cloud to mobile. Payers are
also part of the solution—developing a financial approach
that establishes new payment methods and incentives.
Accelerating true breakthroughs is the idea behind the
DoubleJump TM Interchange. The Interchange is designed
to form person-centered healthcare ecosystems. These
ecosystems extend how and where care is delivered by
engaging new entrants (e.g., retailers, wearable and other
technology providers), local community organizations (e.g.,
home health, educators, and government), and traditional
healthcare stakeholders (e.g., health systems, payers,
and life sciences organizations) to facilitate the sharing of
information and insights within and across organizations.
Most important, we are proving again that scaling personalized care is difficult but not impossible when you put
the right care model and supporting capabilities in place.
Kevin Carr, MD, is a principal in PwC Health Industries.
1. Chronic Disease Prevention & Health Promotion. CDC Website. http://www.cdc.gov/chronicdisease/index.htm. Updated December 7, 2015.
Sponsored Material | Monthly Focus Section to HealthLeaders July/August 2016 MFS- 5
What is the DoubleJump TM Interchange?
• A powerful business solution enabled by a secure platform that
creates a new kind of health data collaboration across the enterprise
or between organizations
• Receives longitudinal and continuous data to build a more complete
view of a person’s health