Fortnightly Healthtech Update #33

In Taiwan, iWEECARE claims the world’s smallest continuous temperature monitor, and $2.5m in seed funding. 

Plenty has been written about Medicare’s bundled payment experiments (mostly known as BPCI). Much less has been written about how commercial payers have been working on bundles too. A review shows some success, but also points out some things which may be a challenge for Medicare. Namely, that tight coordination and data integration between providers and payers is one of the keys to success. In contrast to that, I can remember an executive from Remedy Partners on a podcast maybe 5 years ago. (Remedy Partners was A VC-funded startup launched to help providers adapt to bundled payments). Apparently one of the early challenges that Remedy had was that communication and data sharing from providers was bad. Just to be clear, to improve outcomes and lower costs over a bundle, the entity carrying the risk (ie. Remedy Partners) has to manage the bundle from start to finish. So, for a knee replacement, that would be pre-hab, surgery, and then 30, 60, or 90 days post-discharge – including all the rehab. In the case quoted by the Remedy exec, patients were being discharged from hospital before Remedy was even informed that the patient was one that should be managed in a bundle. End result, most of the money had been committed, and most of the outcome determined, before Remedy had a chance to intervene and affect either. Healthcare reform…? I don’t think so.

Apparently some parts of the health insurance industry have decided that the COVID-19 pandemic is over. Or at least, UnitedHealthcare and Anthem are stopping the waiver of patient co-pays for telehealth that was introduced earlier in the year. What happens if the second wave hits..? Or did the first wave never end….

A fortnight ago I touched on the somewhat meagre savings from the Medicare Shared Savings Program (MSSP). That’s not to say there aren’t valuable lessons from the program, because there are. The use of data, clinical transformation, financial incentives, preventative healthcare, and population health are all part of the success. My point is that we’re not taking these lessons and applying them rapidly – and more widely – to more providers and more Medicare beneficiaries. We’re moving at a glacial pace, and each year we pay more for healthcare.

Advocating for underserved populations: Is remote patient monitoring the answer? Well, it is if we’re smart about how we use it. As I’ve suggested before, telehealth and virtual care solutions provide a golden opportunity to lower the overall cost of care. And that has to be part of the solution to bringing better healthcare to underserved populations. After all, the reason they’re underserved is probably because there’s less money to be made.

New to me from Phili, RTM Vital Signs. The company is working on a number of possible solutions, but first up is a miniature implantable continuous blood pressure monitor.

Researchers investigate the use of a PPG sensor in a smartphone to measure blood oxygenation and find that it does really rather well.

Hearing tests by smartphone for underserved communities.

Plenty of gushing articles have been written about the potential for consumer wearables to move into the healthcare space. Less virtual ink devoted to the problem of false positives. So now news that the Apple Watch abnormal pulse feature generates 6 false alarms for every genuine situation it catches. That’s frustrating for overworked doctors staring down burnout. But, healthcare CFO’s must be rubbing their hands, it’s all billable. There’s potential for wearables to play a powerful role in preventive medicine, enabling early intervention, reducing the need for later, more expensive interventions. But only if they’re much more accurate and reliable than this.

I touched on the BodyCompass contactless monitoring approach from MIT in issue #32. Over in Switzerland, Sleepiz just received a CE mark for contactless sleep monitoring using millimeter wave technology

Biobeat releases a clinical study that compares its cuffless blood pressure monitor favorably to traditional solutions.

I’ve also written about Clover Health in the past.The company just announced it’s going public with a $3.7bn valuation. I have a bit of an issue with the CEO’s claim that “this is the ultimate healthcare disruptor”. It’s bread-and-butter is serving Medicare Advantage beneficiaries better, so really more incremental improvement than disruptive. That said, the company sees a future in direct contracting to grow quickly. The investor pitch deck is 111 slides. It makes very generous use of white space, and could’ve been done in a third of that. It’s still worth skimming through.

Fortnightly Healthtech Update #32

It’s all good: Medicare ACOs saved $1.2bn in 2019. At least it’s all good until you remember that annual Medicare spend is north of $750bn. I’ll save you the trouble of doing the math, that’s 0.16% shaved off the total budget. We’re eight years into the Medicare Shared Savings Program, Medicare’s primary accountable care experiment. I think it’s fair to say we still have a long way to go.

The other big Medicare value-based payment experiment, bundled payments, is struggling against a headwind too. Major changes coming to bundles and target prices because it’s been bleeding cash so far. This includes a move to make bundles mandatory, instead of allowing providers to cherry pick. A few years ago, Medicare tried to make comprehensive joint replacement (CJR) bundles mandatory. It didn’t end well.

An ultrathin sensor for blood oxygenation, has potential for ear buds among other things, the developers feel. For me though, I think the better applications might lie in better monitoring of chronic conditions. The benefits of SpO2 monitoring for healthy people and wellness applications are not obvious to me. For patients with asthma or COPD though, easier, less obtrusive monitoring to establish baselines and oxygenation during episodes, absolutely.

Also on the wearability theme, porous silicone to allow wearable sensors to transmit sweat.

Should be good for both patients and cost savings, Medicare finalizes new care models for those managing kidney failure. This model encourages home dialysis, which, given how much time dialysis takes, is a massive improvement in quality of life. It’s like giving someone their life back. Note that Fresenius and Davita have almost 7,000 outpatient dialysis centers between them. So a move to home dialysis is a clear existential threat. Fair to say that Fesenius saw the writing on the wall when they acquired NxStage in 2019. 

Another CMS experiment, the ET3 model for emergency services is back on the schedule for January 2021. ET3 aims to provide more flexibility for EMS, moving beyond the typical stabilize and transport to an emergency room. ET3 adds options such as transport to a primary care doc, and providing treatment in place, to the standard EMS charter. The ultimate goal is to deliver a better patient experience at lower overall cost. Note that some providers (such as Northwell) have been doing this for a while as a CMS pilot with good results.

Rita Numerof at Forbes has a point: Why should hospitals get a bailout for a failed business model.

In case you missed it, the MedCity INVEST Digital health virtual conference has come and gone, with some interesting startups showcased. I’d missed that Current Health had relocated its HQ from Edinburgh to Boston. Also missed that it had made significant improvements in form factor and (presumably) comfort, from this to this.

Wellness sleep monitoring has become a niche market over the last few years. Now from MIT, BodyCompass is a contact-less, camera-less solution that uses RF to track body movement and posture during sleep. Designed for the home, but there are applications for this in long-term care and skilled nursing I think. When patients are (mostly) immobile in bed, nurses have to turn them periodically to prevent pressure ulcers. Wearables from companies like Leaf Healthcare have been designed to help nurses track who they need to move, when. That can deliver both better patient care and more productive nursing. No reason off the top of my head why BodyCompass couldn’t provide the same kind of insights.

McKinsey has been writing a lot about healthcare lately, which is probably no coincidence. The latest article is making healthcare more affordable through scalable automation. As you’d expect from McKinsey, it’s well researched, thoughtful, and has data behind it. And the research found plenty of scope for automation, especially in payers. With probably 700,000 people employed in the healthcare insurance industry, that’s a lot of middle class jobs at risk. The Kaiser Family Foundation pushes further, describing a single payer system as a healthcare overhaul could kill 2million jobs, and that’s OK. So estimate a $100k annual cost for a fully loaded employee, that’s an overhead cost of $200bn every year. Or $1,670 per US household if you prefer. That’s a lot of groceries. In reality, incumbents are never going to let those jobs evaporate. Which is where tech innovation and startups come in, deploying technology from the get go in place of admin labor. Direct primary care practices typically avoid insurance, slashing their admin costs. Oscar Health uses a mobile app to cut admin costs, and provide a better customer experience. Amazon is piloting a virtual care first model for its employees. Rock Health has written a longer piece about what it calls next generation providers and payers.

Fortnightly Healthtech Update #31

The consumer wearables/wannabe medical devices just keep coming: Withings new ScanWatch captures ECG, respiration and blood oxygenation – and will have a CE mark. By the by, Withings has an interesting history – sold to Nokia and then bought back by the founder at presumably a fire-sale price.

Also filed under wrist-worn wearables, VitalTracer from Canada. Sounds like it’s still a year or two  from being market ready.

A couple of healthcare industry execs opine on Forbes: Healthcare Transformation Accelerates With Covid-19. No, not really. What you’re talking about is not healthcare transformation. It’s billing for different things in a fee-for-service model. Meaningful healthcare transformation is large scale value based care. It’s using technology to increase clinician productivity to lower the cost of healthcare delivery. Anything else is just going to keep jacking the cost up.

Related to that, CMS plans to tighten up on telehealth usage post-pandemic. Notably, it seems providers have been billing separately for every remote monitoring device used on a patient. Under the proposal, there would be a single reimbursement payment for a period of monitoring, regardless of how many devices were used. That would be much more in-line with value-based care. Allowing providers to bill separately for every device seems like a license to continue the over testing problems we already have.

In Singapore, researchers create a wearable that fits inside a face mask to monitor COVID-19 patients.

Much, much closer to home, researchers at Wayne State develop a wireless vital signs wearable for premies in the NICU.

Gaming the system, fraud, or just capitalism: 617,000 Medicare Advantage patients were adjusted into a higher risk group without their doctor present. Why does that matter? If they’re higher risk, the health plans get a larger payment from Medicare. In one case, those payments exceeded $50k for a single patient. But wait, it gets worse. Although 460 Medicare Advantage plans played this game, over half the money went to a mere 10 of them. So, gaming the system, fraud, or capitalism? Either way, it’s all coming out of our taxes.

A medtech company with some success among the Medicare Advantage world is CareSignal. Using automated phone calls and text messages to patients with chronic conditions, the company seems to deliver a pretty solid ROI.

Insurance startup Decent plays in an underserved niche, the self-employed – freelancers and the gig economy. By aggregating those individuals together, it can leverage economies of scale. But the most interesting part for me is that it leverages direct primary care, providing unlimited primary care to beneficiaries.

Cybersecurity concerns aren’t just for startups leveraging new technologies. The FDA issued a warning on Medtronic insulin pumps last year, now Philips is called out for vulnerabilities in patient monitors

I wrote about the demise of Proteus Digital Health back in June. Here’s a deeper look which fortunately pretty much comes to the same conclusion as my speculative opinion: As product strategists would say, lack of product/market fit.

I’ve come across smart bandages that detect infection before, but this one pumps ozone over the wound to prevent infection and help it heal faster.

Seven years old, but still relevant: As of 2012, providers in the US now have 10 administrators for every doctor. Since that overhead is mostly dealing with the complexities of health insurance, I doubt things have improved.

Fortnightly Healthtech Update #30

New to me Vocalis Health uses machine learning to analyze breathing and vocal patterns for signs of disease.

Also respiratory-related, CurieAI continuously monitors breathing patterns for signs of deterioration. Good for conditions like COPD, the company is now seeing early success with COVID-19.

I touched on back in June. Forbes has a longer piece on the company’s vision and business model.

Not sure how I feel about this application of leading edge tech, but it was bound to happen: Sift Healthcare raised $3m to apply AI to healthcare billing (the revenue cycle). If it’s a way to help providers cut their processing costs and speed the flow of cash from payers that’s one thing. But then there are marketing messages like “The 10% of patients least likely to pay their bills account for 50%+ of outstanding patient payment bills, and pay less than 5% of their bills”. Don’t know about you, but that doesn’t make me feel all warm and fuzzy inside.

Delivery of prescription meds is potentially caught up in the USPS political wrangle. Uber partly steps into the void, partnering with NimbleRX to provide delivery. As noted, this solution helps to fill a COVID-19 shaped hole where virtual visits have become norm. That might persist, post-pandemic. Either way, if you’re in rural American without Uber coverage, I guess you’re out of luck.

Does not compute: Large employers expect to pay 5.3% more per employee for health insurance next year. OK, so telehealth usage is up. But….shouldn’t telehealth help to increase the productivity of clinicians, so dropping costs overall? We need to use virtual visits to re-invent how clinicians work with their patients to grow productivity. How can we use telehealth to enable a doc to consult with 5 patients in the time they would previously have seen 4? Or 10, in the time they would have seen 1…? That’s the promise and opportunity of telehealth. If all we’re going to do with telehealth is layer it over the existing models of medical practice, we’re just adding another layer of cost. Bloomberg has more on that topic, with management consultant Oliver Wyman suggesting the cost to deliver a telehealth visit is about half of an in-person visit.

Just to pull on that thread a little more, that would also be my concern with solutions like Vocalis Health, CurieAI, and at the top of this note. Med device innovation is great if we can get better outcomes. But, if we’re still working within a fee-for-service model, we’re adding on another layer of cost each time. In a value-based care framework, we should be able to get better outcomes and lower costs overall. My concern is that we’re just not setup to do that. Because it really seems to have stalled: There’s been no real change in the amount of revenue at risk in value-based care from 2018 to 2019. Almost half of execs taking part in the survey say 10% or less of their revenue is linked to value-based contracts. The risk of financial loss is what’s holding them back apparently. And there was me thinking that was the whole point.

Still plenty of business activity around telehealth, Amwell takes a strategic $100m from Google and files for IPO. With almost 3m telehealth visits in the first half of the year, can’t argue that it’s a good time for investors to cash in. Telehealth bubble, anyone…?

The clinical data on the early detection of sepsis using automated patient monitoring is mixed. The key quote for me is this one: “…as with manual screening tools, a patient monitoring system (PMS) will only be effective if the system has a high level of sensitivity and specificity, to engender clinician trust and reduce false-positive alerts. However, the nonspecific nature of sepsis makes achieving a highly predictive system difficult, whether on paper or in an automated PMS.” Sounds like a problem for lots of data and machine learning to me.

More Google, with Verily moving into the employer self-insured market. Many people worry about big tech’s use of data and possible invasion of privacy. Honestly, I’m not sure if those are genuine concerns, or just a smokescreen put up by those with an interest in maintaining the status quo. Personally, if Amazon or Google can drop my healthcare costs by oh, 10 or 20% a year, by making better use of my data I’m fine with that. It’s way past time my healthcare data was used to bring value to me, not just to create a margin for someone else.

And what about all those elective surgeries that have been postponed this year? Well, payers are making too much money now, so they have to give some back. Meanwhile, the Commonwealth Fund warns of an impending insurance crisis resulting from mass unemployment among other factors. Then, in 2021/22, I imagine we’ll see the backlog of elective surgeries landing, so premiums will go up again…

This is really the way ACOs were meant to work, but I can see this being a problem for people going forward. Cleveland Clinic and Aetna setup an ACO and suggest employers could save 10% over conventional plans. ACOs by definition offer a narrower network of providers. People with long memories will recall that was one of the concerns with managed care organizations from the past. Honestly, I think we’re at a point where there will start to be a much greater divergence in what insurance covers and the premium charged. We already have that in the different plans offered by employers, but I think it will become more pronounced.

A timely reminder that the practice of medicine is not the same as the business of healthcare: Hospitals still suing patients in coronavirus hotspots

Will consumer wearables ever become medical devices? Following on from the Apple Watch, and the Samsung Galaxy Watch 3 both getting FDA cleared ECG, is Fitbit – and perhaps the Amazon Halo. Fitbit’s latest has ECG, but is awaiting FDA clearance. The Amazon Halo meanwhile doesn’t seem to have any path towards FDA clearance yet. So, what’s the difference between a consumer wearable and a medical device? A smarter man than me explained it like this: It’s pretty easy to get pretty good data from most people, most of the time. But, it’s really difficult to get really good data from anybody, all of the time. That’s the difference between a consumer wearable and a medical device. Really good data, in all circumstances, whatever the body shape, age, gender, or race.

A longer read: McKinsey assesses the path forward for ACOs.

Fortnightly Healthtech Update #29

I came across Tytocare a few years ago and lost track of it. Now, University of Miami hospital is using it for remote monitoring of discharged patients. It’s quite an elegant, yet simple, telehealth solution, enabling loved ones to help in collecting diagnostic information at home. See it in action here. My only observation is Tytocare should sharpen it’s demo script. Not only does mom avoid a late night ER visit, but she most likely avoids a large bill too.

Gabbi, healthcare advice for women, by women.

Docs say “Reimbursement is the key” to growing remote patient monitoring. Which is stating the obvious really, because nobody is going to keep working at something they don’t get paid for. (Side note, it troubles me to keep seeing articles that say the pandemic is the catalyst for the telehealth revolution. Wrong. The pandemic AND providers getting paid for using telehealth is the catalyst). Anyway, back to the article…What is a tad discouraging is that the word “reimbursement” appears in the article four times. The word “value” – as in value-based care – zero times. So, the thinking is still very much focused on getting paid for doing stuff, not for delivering better outcomes at lower cost. We’re not going to get the best from telehealth if we see it as just another way to deliver healthcare as usual. It needs to be more than that. It needs to be a way to deliver better outcomes at lower cost.

Related to that, a UnitedHealth study found that primary care docs paid by capitation outperformed docs paid using traditional fee-for-service on quality metrics. Capitation with quality metrics is pretty much value-based care by another name. So value-based care can get us where we need to go, we just need to get out of first gear already.

And related to that….With a focus on value-based primary care for Medicare patients, Oak Street health IPO’s for $328m. Notably, the article illustrates the advantage of the value-based care model for both providers and patients. For Oak Street, it’s revenue held steady during the pandemic because it’s not dependent on appointments to bring in the cash. Unlike traditional fee for service, it’s subscription healthcare. So, as appointments dropped, Oak Street was able to use vans that were normally used for patient transport for food deliveries to its population instead. Which is exactly what it’s population needed to stay healthy at that time. It’s an all too rare example of aligned incentives in healthcare. Another, more expansive article here. It’s what value-based primary care looks like in my perfect world. 

As opposed to….docs are partly dependent on patients to buy their own devices for remote patient monitoring. In a world where providers are at financial risk for the health of their population – such as an ACO – this wouldn’t happen. In that world, providers would invest in the devices directly  for its patients to avoid acute care costs further down the road. In the fee for services world, that’s less likely to happen because there is no financial incentive to do so.

PhysIQ is on a bit of a tear right now. In May, we saw a contract with the DoD, now it’s part of a plan to monitor discharged patients by NorthShore University HealthSystem.

Digital health continues to grow into mental health as well as physical: Quartet Health is working with SilverCloud Health to use it’s digital cognitive behavioral therapy tools. Also noteworthy, Ginger just added a series D funding round for $50m.

And a sign that telehealth is moving beyond the early adopter phase, Teledoc acquires Livongo. Interesting to wonder if this would have happened without the kick to telehealth from COVID. But investors were less than thrilled, in the short-term at least.

One Medical, a direct primary care startup, beats estimates, and will also offer telehealth only to enter new markets. More on the business model here.

There are a few companies out there developing radar-based vital sign monitoring. Circadia HealthNeteera, and MIT’s Emerald device to name a few. But apparently Google has papers lodged at the European patent office for something similar specifically for babies

Where Apple goes, Samsung often tends to follow: Samsung gets FDA clearance for EKG tracking on its watch.

New to me, smart apparel company Formsense looks for COVID-19 applications.

Lessons learned from a 15 year old ACO type model in Germany. One quote which you think would apply well to the US: “The message of taking responsibility for their own health resonates with communities that value self-reliance.”

More telehealth goodness: AHA study shows that telehealth home monitoring for infants that required cardiac surgery reduced mortality by 40%.

Fortnightly Healthtech Update #28

How telehealth fits into value-based care – especially when your community is a 75 mile boat trip from the mainland.

Somatix scores a win in senior living, monitoring residents at the Garden Spot retirement community in Pennsylvania.

Vital sign monitoring wearable company Current Health adds continuous glucose monitoring into the mix by partnering with Dexcom. With diabetes on the rise, and COVID-19 being more perilous for those with comorbidities, this looks like a smart play. The more relevant data you can bring into a single view for overworked nurses, the better.

Wildly controversial I’m sure: Uber offers to help out with contract tracing. So many perspectives….Many American’s would see this as an invasion of privacy no doubt. Although no doubt this data sharing is covered by the broad data sharing agreement that people just blindly swiped through when they signed up. In practice, this will cover a tiny fraction of the population – especially as Uber’s business is down by 80%. But also arguably, the sort of contact tracing action that will be necessary on a massive scale to beat the virus. Individual privacy versus public good, discuss. Personally, having lived in both Europe and the US, I can see the US struggling with the virus for longer than many European countries. The balance between individualism and the public good tilts toward public good in Western Europe.

In update #22, I noted that LifeSignals had gained the CE mark for its vital sign monitoring patch. Now, it has FDA clearance too.

New to me, Transformative gets a seed round for machine learning to predict cardiac arrest form existing monitoring technology.

Pandemic or not, digital health funding is still on a tear, with H1 funding being a record breaker. Two noteworthy trends for me. First, on-demand healthcare services are the most heavily funded. In case you needed to know why, InfiniteMD has a 200% growth in virtual consults. Disease monitoring – which would include remote patient monitoring – has the second highest funding. The fitness and wellness segment drops to fourth, having been one of the most funded segments for five years. I think that’s a fair reflection of how priorities have shifted over the last few months. Second, the emergence of healthcare systems as a source of funding is becoming stronger. Is that a good thing or a bad thing? Too early to tell I think. My concern is healthcare systems might be aiming to monopolize emerging technologies for their own profits, and that might ultimately slow broader adoption of new solutions. In other words, health systems could become even more vertically integrated than they already are.

CB Insights has a chunky report on digital health funding too. Taking more of a global perspective, this report highlights explosive growth in Asia. And, there are 46 healthcare unicorns, and only about half of them in the US – which is maybe not what we would assume.

Expected from Google perhaps, but not a company that’s been around for almost 200 years, Wolters Kluwer uses clinicians searches and other social media data to predict coronavirus hot spots.

Cutely named Sema4 raises $121m to push genomics and clinical data into practice – in areas such as precision oncology.

How long can this go on…? Employers aren’t happy with payers lack of transparency and foot-dragging on value-based care. The short answer is, as long as there are no viable alternatives. Direct primary care (DPC) is in its infancy, covering about 0.1% of the US population. Growing DPC is going to be really slow, as it’s very dependent on doctors making the change. And when docs do switch, they support far few patients by definition. Then there are startups like Oscar and Clover, that promise a different, more personal, but tech enabled experience. And opposing all that innovation, there’s lobbying by BCBS to maintain business as usual.

A proposal for really cheap biosensors from the University of Missouri: Pencil–paper on-skin electronics.

Solutions to the ills of healthcare don’t have to be complicated or expensive: Virtua Health cuts no-shows for oncology by 75% and improves inpatient bed availability by improving ED throughput.

Squarely focused on value-based care, Nutrimedy is kicking off a clinical trial to help people get in shape prior to total knee or hip replacement (TKA/THA). This would be attractive to providers taking financial risk, either as an Accountable Care Organization, or through a bundled payment for an episode of care. Medicare’s latest bundled payment experiment runs through 2023. I don’t have the numbers handy, but in Medicare’s prior bundled payment program hip and knee replacements were by far the most popular bundled taken on by providers. That’s because it was a relatively low risk way to dip a toe in the water of bundled payments. So, long story short: If Nutrimedy can cut the cost of rehab and complications by getting people in shape before surgery (pre-hab) that’s a cost saving for those taking financial risk. So, the provider will keep more money in its pocket.

A longer read: How to fine tune Medicare’s alternative payment model (eg. ACO’s and bundled payments) to grow participation.

Fortnightly Healthtech Update #27

Another shift in the primary care landscape, Walgreen’s aiming to move away from pharmacy to become a “health and wellness destination” by bringing primary care practice into the store. Mostly targeted on underserved populations, so that’s a win-win. I don’t have the data, but I imagine a growing percentage of prescriptions and OTC meds are now fulfilled by mail order or online. In other words, the traditional pharmacy is a dying business. Better then to evolve and wrap a service layer around your product business.

CMS calls for a renewed commitment to value-based care. Contrast with the acknowledgement that the Medicare trust runs out in 2026 from my last update. And why call for it in a press release…? Medicare and Medicaid combined spend is a trillion dollars a year…don’t write a press release, use your muscle to make it happen.

Or, maybe it is…? CMS proposes to make COVID-19 telehealth changes permanent for home health agencies. I hesitate to say it, but this could be the silver lining to the pandemic. First, CMS makes the reimbursement for telehealth and remote monitoring permanent, so providers start using it routinely. That helps manage the pandemic in the short-term. Most likely, in the medium term, this will cost CMS more, because in-person visits will return at some point. When they do, the healthcare business being what it is, many providers will bill for both remote monitoring and in-person visits if they can do so. But then, as full capitation kicks-in (eg. ACOs) and providers are carrying financial risk, they will see remote monitoring and telehealth as a way to cut costs and keep more money in their pockets. So maybe this is the way we get to value-based care that delivers both better outcomes *and* lower costs. 

Philips partners with Biointellisense for in-home vital signs monitoring. I imagine the big attraction for Philips was the 30 day life of the device. Philips’ recently released in-hospital wearable is fully disposable, and good for up to 5 days. In the home, that shorter life is inconvenient for patients, and also more costly, everything else being equal. Surely no coincidence either that providers get paid for a 30 day remote monitoring period under the reimbursement codes introduced 18 months ago. So, Biointellisense is very smart, because it’s just as important for medtech companies to focus on how they will get paid as it is to deliver clinical value. Deliver a 25 day device when providers get reimbursed for 30 days of monitoring and you’ll find yourself with a dud on your hands.

A first for EarlySense I think, providing patient monitoring for a detox center in Texas. Acute care hospitals, skilled nursing, and long term care are where the company has mostly scored in the past as far as I know.

Can surgery analytics be used for operating room performance enhancement? Of course! But you have to be willing to take action on the insights you get from the data. And that’s usually the hard bit.

Not to beat on insurers any further, but….profits surged at UnitedHealth. The culprit apparently is the cancellation of elective surgeries that is pushing many hospitals to the brink. The fact that hospitals are so dependent on elective surgeries for revenue is another story. A functioning healthcare system just shouldn’t be that way.Amazon tries direct primary care clinics for its employees. As the article notes, not the first company to do this by any means. Some tech companies have been doing this for a long time as “a benefit”. A benefit that also minimizes working time lost to doctors visits. But I think this is a growing trend. There’s a growing realization that primary care via health insurance doesn’t work. There’s no reason that preventative care should go through insurance. First, insurance just adds a margin to something that really isn’t an insurance risk, it’s routine maintenance. Second, insurers have no incentive to spend on preventative care, it’s just a cost to them.

Another glimmer of hope for Medicare ACOs, almost 70% are using, or plan to use, home health agencies. Related to that, some concern that value-based care is going to drive smaller home health agencies out of business. That’s because smaller providers don’t have the resources to adjust to new processes and deal with the reporting burden that comes along with it. That’s unfortunate, but probably necessary. Don Berwick argued a decade ago that healthcare needed to move on from being a cottage industry to become more industrialized. That is more repeatable, more scalable, more efficient. That article is 10 years old, and we’re still mostly waiting for that.

But, on the subject of driving care processes through data, differences in care for the over 80’s having a total hip replacement. Not many as it happens, but good that somebody studied it.

Vitls gets FDA clearance for a 6-day wireless wearable with continuous remote monitoring. Looks like the company is seed funded and runs a very small team. So it’ll be interesting to see what the go-to-market model is, because the company doesn’t seem to have the resources to go it alone..

Not too many startups focus on the less wealthy end of the healthcare business, but here’s one: CityBlock Health raises $54m to bring primary care and behavioral health to low-income communities. Especially important, the company includes a focus on the all important social determinants of health. More on the company’s business model here.

Fortnightly Healthtech Update #26

A two year research project to develop a wearable specifically for patients in emergency air transportation.

The pandemic is stalling the rollout of Accountable Care Organizations (ACOs) in many places, but accelerating it in others. Visionary hospitals, such as Intermountain and Mayo Clinic are pushing ahead with hospital at home models. There are no payment details in that article, so I’m thinking the only financial incentive for the health systems is cost saving as part of an ACO. Also looking at treating people in their homes, DispatchHealth raises $136m for its model of delivering a medical team promptly to someone’s home. A service that I think would be attractive for ACOs.

By the by, perhaps one of the problems with Medicare ACOs is that participation can be relatively short-lived. It’s a five year minimum for the Medicare Shared Saving Program. Five years is fine for a bit of tinkering around the edges. But, is it really enough to get providers to commit to the deep, radical changes in care delivery that are needed? Like changing clinical practices and investing in telehealth to keep people with chronic conditions at home. Because according to the Medicare Payment Advisory Commission, we’re almost out of time to keep the ship off the rocks. The Medicare Part A trust fund will be empty in 2026. So a more rapid pivot to Accountable Care Organizations is highly recommended.

Circadia Health gets FDA clearance for contactless respiration rate monitoring using low-power radar. Can’t be a better time to release something that monitors a key vital sign while protecting caregivers and limiting opportunities for cross-contamination. The company suggests providers use the new remote monitoring billing codes introduced by CMS at the start of 2019. These codes can work well for reusable devices, but are going to be an economic challenge for disposable devices. In a healthcare facility, single use helps to limit cross-contamination and cut equipment cleaning work. In the home, that doesn’t matter so much, so disposable devices just add cost.

Masimo steps into new territory with Centroid, measuring respiratory rate, orientation and detecting falls. New territory because Masimo is most famous for measuring blood oxygenation and related parameters. On the face of it though, this device doesn’t seem to offer anything different to VitalConnect, the Philips biosensor, or the Biointellisence BioSticker.

A bit of a tangent, vital sign monitoring underwear for race car drivers.

Hospitals lost the latest (but not the last) round of court battles over price transparency. While they ready an appeal, the hospitals’ position is that it would be a bad idea to force them to implement it during a pandemic. Maybe, but they could have complied last year instead of fighting it all the way. I don’t think this will help much in itself, but it’s a start. Transparency for the big expenses isn’t just down to the hospital. For surgery, there’s the surgeon. Easy enough to find out if they are in-network ahead of time. But the other really expensive skill in the room, the anesthesiologist, the patient rarely knows who that is going to be until a couple of hours before surgery. In-network or out, you know nothing about arguably the second most important person in the OR (after you). Oh, and Aetna’s handy advice on avoiding surprise bills includes patients should know the billing codes for everything beforehand. So, really no chance for the average person to get a fair shake at a reasonable healthcare bill then.

Not the most comfortable looking design perhaps, but Kyocera helps develop wearable for remote rehab monitoring.

Apple is set to make arguable its biggest healthcare contribution to date, introducing watch functions that are broadly relevant for senior health. If this can truly be used for remote medical monitoring, the reimbursement codes noted above for Circadia Health are probably the likely path to revenue for providers. But healthcare costs overall are only going to drop if that remote monitoring means in-person visits can be avoided.

A couple of longer reads: First, The promise and the perils of virtual health care. The author asks, “is virtual care a future we want?” If it makes healthcare more affordable, absolutely it is! Second, McKinsey chimes in with the implications of COVID-19 for value-based care. The biggest point is very valid, that value-based care is fine for steady-state healthcare. Not fine for a pandemic – but then neither is the traditional fee-for-service payment model. More tellingly for me is confirmation of the glacial pace of payment reform. A quoted report states that only 6% of payments have downside risk for providers. And that percentage hasn’t changed in 5 years. By my reckoning, that means payment reform has either stalled, or it was just a fiction all along. Fiddling while Rome burns springs to mind.

Fortnightly Healthtech Update #25

Docs fleeing Medicare into direct primary care provides many opportunities for technology to take up the slack and help to grow productivity in healthcare. Better patient access to their records would be one, telehealth and remote monitoring of chronic conditions would be others. For that to happen, the emergency order to reimburse virtual visits the same as to face-to-face – or something like it – would need to be permanent. So interesting insights on the future of value-based care from Dr. Alexander Vaccaro at  Rothman Orthopaedics. I’m inclined to agree, if we want the telehealth boom to continue post-pandemic, push population health and then the providers have a bigger reason to drive out cost.

The pandemic isn’t helping either, as primary care docs see their visits dry up. As the article notes, one option is to be swallowed by a larger health system. We are all wise with hindsight. But direct primary care practices – subscription based, rather than fee for service – have a more stable revenue stream. Direct primary care may potentially get a legal boost, with the IRS proposing that direct primary care be treated as a qualifying expense for some type of flexible spending account. In the meantime though, some PCP’s are lobbying congress for direct financial support.

Open source comes to wearables, with the Open Wearables Initiative releasing a step count algorithm, and sets its eyes on gait.

I almost feel like I should put a disclaimer on this one: Israeli missile maker claims AI tech can predict virus patients’ deterioration. Fair enough, but I wonder how many physicians would agree with the quote “In data science, it doesn’t really matter whether its data from a satellite or blood measurements of a patient. You put data in and you get predictions out.”

Evidence – if it were needed – that providing patients with frequent, actionable health data can lead to better outcomes: FreeStyle Libre Glucose Monitor Reduces Hospitalizations in Diabetes. I’ve personally found this device very helpful. Although not diabetic, I have a sweet tooth and my blood glucose tends to run higher than ideal. With continuous glucose monitoring (CGM), I had real-time feedback on how specific foods affected my body. In the US, this device only available on prescription. Elsewhere, it’s over the counter. Not sure why…Wouldn’t it be better to help people avoid becoming diabetic than merely helping them to manage the condition further down the road? But which is more lucrative I wonder…?

Medicare ACO’s appear to be driving productivity growth, with the percentage of non-physician practitioners growing significantly. Which is good to see, the kind of changes that we should see., the Israeli video-based monitoring group, raises a $13.5m B round. Are comparisons to the Star Trek legendary tricorder helpful? Probably not.

Sensors in clothing might be bubbling, with MIT pursuing a research project. Also from MIT, an update on something we’ve seen before, using wireless signals to monitor vital signs. I do have a bit of an issue with the statement “While healthcare facilities obviously employ a number of different measures to monitor resident and patient vital signs over time…” Theoretically true perhaps, but if it were consistently done well in practice, organizations like the Patient Safety Movement wouldn’t exist.

Video games as therapy: Akili Interactive gets FDA clearance to treat ADHD.

Highly valued startup, Proteus Digital Health, files for bankruptcy protection. There seems to be a lot of surprise about this, I’m not sure why. The majority of VC funded companies never make it at the best of times. Plus, digital health has been a bubble for a couple of years now. Ultimately though, however strong the company may be, healthcare is a supremely tough market to find product/market fit. Because “market” is a complex mash of clinician, patient, health system, and payer. If they don’t all align, it’s a problem. Focused on using sensors to track medication adherence, the first product was a smart version of Abilify. Granted, physicians would love to know that their patients suffering from mental illness are taking their meds. But asking those patients to effectively spy on themselves may have been a tough ask. The added challenge in healthcare is to try and find alignment of financial incentives in a crazy broken reimbursement system. Which begs the question, who on the provider side makes money if patients are more compliant with their meds…? There’s no obvious answer to that for me. So that’s always going to be an uphill battle. Because even if physicians love your product, there still needs to be a way for providers to make money from it in the US. And payers willing to support that, which takes time. In other countries, where delivering care cost-effectively matters, the path may be easier.

On the topic of patient compliance, I’m curious how well the Neopenda neoGuard is tolerated by patients. I’ve worn a few hideously uncomfortable prototype medical watches before, but newborns are at least limited in their ability to complain.

A longer read: It’s time for a new kind of Electronic Health Record, one that is more forward looking.

Fortnightly Healthtech Update #24

New to me Siren raises a $12m C round for it’s sensors-embedded-in-fabric monitoring technology. Ultimately, I think approaches like this have huge potential for monitoring chronic conditions in the elderly. Monitoring that is completely unobtrusive, and requires (almost) zero changes in behaviour. Such as sensors in clothing, or radar based vital sign monitoring.

Gotta love low-cost healthcare innovation: Higi raises series B funding of $30m to further it’s kiosk-based preventative care model. Aimed squarely at organizations taking risk for a population (eg. ACOs), the kiosks are free to use. If things look amiss, they can connect the consumer to a clinician. So far, Higi has been used by 62m people. Lowering the cost of preventative care to zero is good for consumers, and good for the provider taking financial risk for a population too. Looks like it’s working for Higi too….

More on accountable care, with COVID-19 set to disrupt the modest progress that has been made with Medicare ACO’s so far. ACOs are, not unreasonably, concerned about the financial impact of the pandemic.

Philips brings a new wearable biosensor to market, with some nimble footwork to address the COVID-19 monitoring opportunity. Compare and contrast with the earlier wearable biosensor here.

A rising tide lifts all boats, so predictably AI in healthcare gets a boost from the pandemic too.

Very early days, but Surrey University in the UK has an implantable sensor that is powered by the body’s movement.

A new clinical study finds that EarlySense is capable of detecting acute pulmonary embolism

New to me Vtuls offers 3 months free service to UK care homes, a hotbed for COVID-19 infections for many reasons. Hopefully that offer is as genuine as it sounds and comes with no strings attached – like a 3 years paid subscription tacked onto the free.

Evidence that the direct primary care (DPC) model can drive diabetes care costs lower with good preventative medicine. I think direct primary care will evolve to be a major component of employer-provider healthcare. DPC puts the primary care focus on what primary care should be. Preventative medicine and the management of chronic conditions. And there’s no reason why any of that should go through health insurance. Routine servicing on my car doesn’t go through my insurance. Routine servicing on my body shouldn’t either. For that, the insurer is just adding a layer of admin and taking a margin that consumers really don’t need to give up. So I can see more employers carving out primary care (“direct to employer care”) to work with practices like Iora Health. Some states, such as North Carolina, are clearing the legal path for that.

Will the cost savings be passed onto consumers, or will CVS pocket them: CVS to deliver prescriptions with autonomous vehicles.

A length academic-ish article on why innovation isn’t reducing healthcare costs. The conclusion is we need to innovate for cost-reduction, not innovate for novelty. True, but it’s more than that. Before we get to that step, we need to incentivize cost-reduction.

McKinsey is speculating – and I choose that word carefully – that the telehealth market could grow to $250bn a year, post pandemic. Wisely, McKinsey places a question mark at the end of the article’s title. For good reason in my view. The article has lots of good strategic advice on how practitioners can plan for a telehealth world. And it does also touch on the elephant in the room. Reimbursement. There may be many good clinical reasons for telehealth to grow. Telehealth may be embraced enthusiastically by clinicians. But, if the healthcare industry can bill $1,000 an hour for in-person visits, but can only bill $800 an hour for telehealth, change is going to be very slow in coming. (All numbers made up just to illustrate). Unless telehealth segments and increasingly becomes a direct-to-consumer play, like this example. And if I could do eggs over easy like that I’d be a proud man….