Category Archives: Healthcare Reform

Fortnightly Healthtech Update #8

Potentially very cost effective – using a smart speaker to monitor respiration of sleeping babies. I wonder if this is something that could be adapted for chronically sick Medicare beneficiaries?

Philips joins physIQCurrent Health, and Isansys – among others – in using machine learning for early detection of patient deterioration. And also works with the DoD to detect infection early in active duty personnel.

More AI, improving radiologists ability to spot breast cancer. One of the goals is to reduce the number of biopsies required. Great in theory, probably not in practice. Imagine the scenario: A patient whose cancer goes undetected until late, sues the radiologist. In court,the lawyer asks the radiologist why they didn’t order a biopsy. Answer, “Because the AI told me not to.” Some medical tests get ordered solely to ward off litigation.

And yet more….Medicare thinks AI could cut fraud. I’m convinced it could – but in my experience, it also takes political will, and that’s not always there in abundance….

Concierge medicine taken to the extreme: The $10,000 dollar all-day physical. Which possibly does more harm that good, with the optional full-body CT scan, since the American College of Radiology advises imaging should only be used when there is a clear medical benefit.

A bit late to the party perhaps, but Fitbit is looking to add apps to help users detect afib. Talking of afib, AliveCor goes to the well again for $6m.

There’s a reason for that: Physician-led ACOs performed better than hospital-led ACOs. Hospitals often stand to make more money from readmitting a patient than they stand to lose in readmission penalties. Physicians have no such conflict of interest.

A very niche solution for patient monitoring, targeting airline passengers who are taken ill during flights. Just how niched..? I’m not sure, Google wouldn’t readily give it up.  But I do know this – I’d readily give up the possibility of in-flight vitals monitoring for an extra inch of legroom.

Working as planned then – Medicare reimbursement and incentives starting to see more patients discharged to home care, fewer to skilled nursing.

Brigham and Women’s experimenting with the Fruit Street Health telemedicine platform to try and ward off dementia.

We often hear about the controversially high price of new, innovative meds. But here’s exploitative pricing for something that’s been around for almost 100 years, the price of insulin increases 600% over 17 years.

Remote patient monitoring continues to show success, with St. Luke’s serving 36,000 patients in the first year.

Maybe I missed it before, but Google’s/Alphabet’s Verily is starting to get more active in population health, working with Atrius in California.

Worryingly, I find myself increasingly skeptical about value-based care. Allegedly, a growing percentage of healthcare payments are tied to value-based care. And yet, very few Medicare ACO’s are taking financial risk, they are in upside only models. In other words, if they beat spending targets, they get a bonus. If they overspend, well, we’ll just let it slide…So, we have value-based care, with payments linked to quality targets, but no penalty if you miss the quality targets. So, where’s the value in that..? Maybe Intermountain Healthcare can restore my faith.

And finally, a couple of new biosensors, from Integrated Device Technology (beware press release), and a team at Duke University.

Fortnightly healthtech update #6

Firefly raises an additional $10m for concierge primary care, bags new CEO.

An incredibly low-tech way to spot patient deterioration early – listen to their loved ones.

A vision for the Internet of Medical Things (IoMT) in the UK

Apple announces three new health studies – but Jessica Baron at Forbes adds a big dollop of caution.

Corvia Medical and PhysIQ team up for a study in heart failure management.

Henry Ford in Detroit has some success cutting re-admissions with remote patient monitoring. Now it’s looking for partners to help it expand and grow.

Picking up on the thread from last time that value-based care might not be just around the corner: Stakeholders push back on bundled payments for oncology. Also, current value-based care models need greater emphasis on specialty care. Hard to argue with that. It’s true, patents with chronic conditions account for the majority of US healthcare spending. But, if we focused on preventative medicine instead of treating sickness – through a single payer system for example – arguably we wouldn’t need so much specialty care now would we.

Rapid advance in medical wearables runs headfirst into reality: Docs call for standards for blood pressure measurement.

Using a ballistocardiogram to monitor heart failure patients at home. It’s OK, I didn’t know what it was either…

Hospital execs in New Hampshire fret that high deductible health plans might be a barrier to care. Which is really hospital CEO code for “high deductible plans hurt our revenue”. And they’re right – but that’s part of the point. I can tell you from personal experience, a high deductible changes your thinking. If you’re personally paying 100% of the bill for everything It makes you spend only on the “must haves” in healthcare. And that’s OK. If we’re going to rein in healthcare spending – which we must, because it’s not sustainable – we need to give up the “nice to haves”. And providers will feel some of that pain, short term. But there is a perverse incentive with high deductible plans. What happens when you hit the deductible limit? Well, you just pile in and take care of all those “nice to haves” while the insurer is paying for them…

That said, high deductible insurance plans would be more effective if consumers had tools to compare both price and quality when shopping for healthcare. Often, they don’t. But, here’s a study showing that price transparency tools seem to work. Which is interesting, because Walmart just opened it’s first physician-staffed clinic with transparent pricing upfront.

One more reason for healthcare execs to fret: Amazon launches Amazon Careas a pilot for its’ employees. Coming soon to….probably pretty much everyone once they’ve worked out the wrinkles I imagine. It looks like a nice example of focusing on the customer need. Not the more traditional healthcare approach of “What can we do that we’ll get reimbursed for…?”.

And just to pile on the pressure, Sam’s Club (owned by Walmart) is introducing $1 telehealth visits with a subscription. This is interesting too. Telehealth options are usually offered by an employer. This is the first I’m aware of that is D2C. So what’s the target market…? Is it people without health insurance? Or, is it people who have insurance, but want a more cost effective/convenient way to access primary care?

An interesting history lesson: Americans already paid for universal health care. Just not for fellow Americans.

A good summary of how far Medicare has got down the road with value-based care. Not very. Just to reinforce that, although physicians participate in value-based care, most of their revenue come from good ol’ fashioned fee-for-service.

Eko raises $20m for it’s machine learning driven cardiac monitoring.

Also in funding news, InsightRX raises $10m for precision dosing – using data to optimize the therapeutic dose and minimize side effects.

Sad but true: Slowing the growth of healthcare costs – not actually cutting costs – is seen as  a triumph. But at least BCBSMA has achieved that with an 8 year value based program.

A long, but worthy read: How to avoid getting fleeced in the emergency room.

Fortnightly Healthtech Update #4

I love hearing about startups in emerging nations – I think there is so much potential for cross pollination. Here are five from India focused on blood supply, preeclampsia, kidney health, ECG, and chronic disease detection, among other applications.

The NHS in England shows good results with a pilot for the early detection of sepsis, plans a nationwide roll-out.

A fortnight ago I wrote about Deepmind’s progress in detecting kidney failure. Here’s a bit of pushback, citing some challenges for AI in healthcare in general. This phrase jumped out at me: “(clinicians) also rely heavily on human judgment to diagnose…a level of subjectivity that would be nearly impossible to program into every AI algorithm”. It was well argued almost 10 years ago by very respected clinicians that removing some subjectivity and standardizing care processes (free registration required) would help deliver higher quality care at lower cost.  In other industries, we grow productivity by selectively substituting technology for labor. And we do that in healthcare too. In pockets. Just not enough yet to make high quality, lower cost care repeatable at scale. More on that a little further down the page….

Deepmind, on the other hand, is a half a billion dollar deep hole for Alphabet by the way…

Talking of pushback, Visibly has had to pull its mobile app eye test from the market. The American Optometric Association has apparently lobbied hard against Visibly. Taking a big step back, this might be something of a moral dilemma that we need to figure out over the next 10-20 years. The cost of healthcare is still rising. If that continues, an increasing number of people in the US are going to be priced out of conventional healthcare (i.e consulting a doctor, one on one). Telehealth could be an option.  But pushing the argument further, what happens when people can’t afford to see a doctor at all, even virtually. Are we really going to deny them the opportunity to have their health evaluated solely by an algorithm? Even if that offers a less comprehensive examination than a doctor. If the only options you can afford are diagnosis by algorithm, or no diagnosis at all, which would you choose…?

The American Heart Association is launching a pilot with LifePod Solutions to help care for people with chronic cardiac conditions at home. Also in the remote patient monitoring game, Biotricity reports strong quarter to quarter growth.

Rumors abound that all is not happy in the world of Apple health. But, that hasn’t stopped it expanding use of Apple Health Records to embrace Allscripts. And in not unexpected news, AliveCor has dropped its KardiaBand accessory for the Apple Watch. AliveCor has been pushing into more specialized territory with its 6-lead ECG anyway. But does a 6-lead ECG take AliveCor away from the direct-to-consumer (D2C) model…? I think it might. Meanwhile, if you do see anyone with both hands on a device – while simultaneously pressing it to their left knee or ankle –  you’ll know exactly what they’re doing

Things seem to be quite peachy at not for profit hospitals, with Mayo growing profits by almost 300%.

Researchers are working on a biosensor that uses interstitial fluid and might be used in place of blood draws in the future.

Biobeat gets FDA clearance for cuff-less non-invasive blood pressure. This has potential. First of all, cuff-less non-invasive BP should mean it’s more comfortable for the patient. That could be especially great in the home for chronic conditions. Second, in my experience there aren’t many wireless BP devices cleared for use in the hospital. There are two unknowns for me that are crucial to success down the road. First, does it fit easily into the clinicians workflow? If not, that’s going to make adoption in the hospital an uphill battle. And second, do the economics work? If it’s more expensive overall than existing approaches, it’s probably not going to fly, however much more comfortable it may be for patients.

In the land of mobile appointment bookings, doc’s choke on Zocdoc’s new pricing model.

I think Remedy Partners really needs this merger with Signify Health. Remedy Partners is arguably the most important player in Medicare bundled payment pilots. It “owns” more episodes of care than any other entity, and in some cases took on the financial risk instead of the providers. But, most of the cost variation in each bundle is driven by post-acute care (slide 16 onward). That is, what happens after the patient is discharged from the hospital. Without a good way to monitor patients post-discharge, that creates a huge financial risk for Remedy. This merger with Signify Health can help to fix that. 

Two chairs aims to take the stress out of finding a therapist.

Strong preventative healthcare is woefully lacking in the US. As Amy Brown of SpringBuk says, incentives for preventative care are not aligned. Honestly, I think there are limits to how much analytics can help with that. There are two massively fragmented, multi-trillion dollar industries here (payers and providers are two different industries, they just share a value chain). There’s a bigger piece here about preventative care that needs to come together in my head, I’ll try and get it written in the next week or two.

And last but not least, Isansys pilot shows that heart rate variability could predict 90 day mortality in patients with cirrhosis of the liver.

Fortnightly Healthtech Update #3

Google’s Deepmind shows promise in early detection of kidney failure…and immediate takes heat for using an almost all-male training data set. I can definitely understand people’s concerns with that. On the other hand, I’m not sure there’s a deliberate gender bias here. It’s a machine learning project. Start with the data you can easily get, then refine with better data later. If you wait for the perfect data set, you might never get started.

This might be huge, CMS commits to puff up remote patient monitoring. CMS introduced new reimbursements for remote patient monitoring at the start of 2019. But astonishingly, managed to overlook the need for a precise definition of what services and devices would actually be reimbursable. Bit of an oversight that. This is going to get fixed for 2020.  Also stepping up to the plate is the granite state, providing Medicaid coverage for telehealth and remote patient monitoring. What a great way to provide better care for a rural population that is often under served because of the low reimbursement rates. As if to make my case, here’s another example of using telehealth to bring badly needed help to the patient, instead of forcing the patient to travel. And legislators are increasingly seeing telehealth as a way to help rural moms. Here’s an example of telehealth for preemies and newborns that need special care

Those new remote monitoring CPT codes really are catnip aren’t they…? New to me DynoSense, jumps in with FDA clearance for…I’m not quite sure what actually. The press release isn’t clear, but then press releases often aren’t. In the promo video, it looks like a direct to consumer offer. In any case, the sensor appears to yield lots of useful data for not much effort on the part of the patient. And that is going to be one of the keys for successful remote monitoring of chronic conditions.

Voluntis gets FDA clearance for app to help cancer patients self-manage their daily life. Interesting how in this deeper look, Romain Marmot the COO, says that oncology is basically a chronic disease in its own right that needs to be managed better. I like that perspective, thinking about one leg of the quadruple aim that perhaps does not get as much love as the others. And, I wonder how many providers think about quality of life for cancer patients when they are living day to day, outside the treatment center…?

In a somewhat similar direction, this article discusses how smart homes can become the epicenter for self-care. I mostly like where this is going, but only up to a point. I could take issue with phrases like “In the near future, smart homes will be primary care.” No, not in the near future on any significant scale in the US. There are 3 ways this scenario can become a reality: First, the widespread adoption of ACO-type payment models that shift the focus onto preventative care. Second, a large number of people go down the direct primary care path – and I think that’s really only an option for the reasonably well heeled. Third, primary care delivered via the smart home could take off if there’s a reimbursement code for it. And that means alignment between telehealth and/or remote monitoring billing codes and smart home solutions. In the rest of the world, it’s a different story. Where single payer systems dominate, preventative care has a much stronger focus. I can see much faster adoption of smart homes being used for healthcare in Western Europe than in the US. I’d love to be proved wrong on that, but I really can’t see it. And let’s be fair, Alexa’s latest skills are a long way from actually delivering primary care in the home. Those skills are really just nibbling around the edges of the healthcare problem.

OK, now I’ve flirted with the murky subject of the broken US healthcare system, we might as well get this out of the way: 40% of patients face surprise out of network bills. Many of those unpleasant surprises come from bills for ambulances. As that second article notes, many ambulance providers are out-of-network “because they couldn’t agree on a fair rate” with the health insurance companies. A more cynical person might feel that they were deliberately out of network so they could bill large sums to people who are at their most vulnerable and in no position to argue. Especially as that article also notes that ambulance services in the US used to be a public service, yet are now increasingly a for-profit enterprise. The whole idea that a company can provide services to an individual without their explicit consent and then just bill them whatever they want….that just doesn’t feel right now, does it.

When if comes to “wireless”, it’s all relative I guess…Helen DeVos Children’s Hospital in Michigan introduces a wireless solution for monitoring epilepsy. Not as wireless as the devices that I’m used to working with, but if it gets you down the path to better management of epilepsy, all power to you.

On the topic of wireless devices, I promised a deeper piece on iRhythm’s Q2 results and the 12 words that change everything for iRhythm and similar holter monitor competitors, such as BardyDX.

In patient monitoring, over-alarming is an ongoing problem, with 63% of alarms in the ER going unattended. I fully anticipate that machine learning is going to bring a huge improvement into the quality of patient monitoring in the next few years. Startups like PhysIQ are pushing down this path.  And HBR has a review of Current Health being piloted in remote patient monitoring – in the UK, so no reimbursement code change required to incentivize the change.

Fortnightly Healthtech Update #2

Does the accountable care organization work? Yes!  The ACO model is leading healthcare providers to focus on cost saving through preventative health. Lower healthcare costs, fewer people getting sick, I love that.  Oh, it definitely works – at least it does for Blue Cross Blue Shield of Massachusetts. Or, not so much…. “Why would I ever take away the volume from those two facilities to a lower-cost setting?” The lack of aligned incentives means that some healthcare organizations are going to (understandable) drag their collective feet in the transition to value-based care. Are they playing a smart game, or are they going to be on the losing end ultimately…? Only time will tell. But, I’ll tell you one thing for sure. American’s simply cannot keep paying more and more for healthcare. Basic economics will dictate that, the money’s just not there.  Something will change.

Ben Taub dead patient was unmonitored, found passed out in bathroom. If only there was a way to monitor patients vitals continuously in the hospital and know where they are. Oh wait, there mostly is…the Philips Wearable Biosensor, (full disclosure, I used to be the product manager) gets some recognition for the ongoing pilot at Singapore General Hospital.

While we’re riffing on biosensors, there’s Aseptika diverging from COPD with the, ahh, curiously named BuddyWOTCH, promising continuous blood oxygen, heart rate, respiratory rate and temperature for 7 days.

Not a wearable, but competing hard with them every step of the way, Early Sense notches up another win in post-acute rehab.

Skipping back to payment reform, CMS is proposing a new bundled payment model for radiation oncology, with site neutrality being a key element.  Opponents argue this could interfere with established care models – and here’s me thinking, “But, that’s the whole point….”  Obviously not to jeopardize patient care, but to at least figure out how to provide the same quality care in a lower cost setting.  See note above, basic economics etc, something has to change…

Pampers and Verily introduce the diaper that sends an alert to your phone when a change is required.  Personally, I always found the loud and incessant auditory stimulation from my little ones provided all the alerting necessary.  But, I guess for the ear bud generation, maybe an app is the way to go.  Especially perhaps for a post ear bud generation with hearing loss.

Meanwhile, North of the border, paramedics and remote monitoring are being use to reduce unnecessary ER visits.

I think emerging nations can often signpost the way to lower cost healthcare solutions. Here’s a test for anaemia, jaundice, and oxygen saturation from Indiathat costs less than one US cent.

Potentially great news for diabetics, with coaching linked to real-time blood glucose measurements. Surely so much more valuable to have actionable guidance triggered by real-time feedback to drive long-term behavior change.

Data is everything.  All other things being equal, the people with the most data – and a decent strategy to leverage it – will win in the long term.  That’s why Amazon’s PillPack wants it, and SureScripts would rather not share

And while on the subject of Amazon, Amazon and Cerner were apparently able to detect the onset of heart failure 15 months out.  Couple of immediate questions for me.  First, I’m not a clinician, but is 15 months notice really that significant for heart failure?  Isn’t the condition often brought on by decades of lifestyle choices?  If so, can an individual do anything meaningful in 15 months to avert the inevitable?  Assuming they can, this is great news – as long as you don’t live in the United States.  In countries that truly see the economic value of preventative healthcare, this truly could be great.  In the US, we’re slowly changing reimbursement models (read ACO, or single payer…) so we can actually get to the point where providers are paid for preventing disease instead of merely treating it.   Until then, it’s really just a bit of a machine learning novelty.

Ohhh, I like this – 3D printed heart valves.  Faster, better, cheaper – what’s not to love.

Curavi Health is eyeing up adjacent markets methinks.  Originally focused on bringing telehealth to SNF’s, it’s also now piloted a solution for use in the home.  Makes total sense in context of the an article in my previous update, where ACO’s are bypassing SNFs and sending patients straight home when they can.  And remote patient monitoring has a big fan in New Jersey, with Valley Health System driving readmission rates down to 2%.

Can’t quite decide which is the more impressive part of this announcement, but I think there is something in here somewhere….PhysIQ has ambulatory respiration rate.  But maybe more importantly, has hardware independent respiration rate.  Hmmm.

iRhythm, focused on cardiac arrhythmia detection, reported Q2 revenue 50% higher than last year.  But, the most significant thing in the announcement is CEO Kevin King saying “…our CPT code change application was accepted by the AMA for review…”.  That’s a bigger story than I have time for now, but I’ll try and squeeze out another post soon that gets into the nitty gritty about why that’s so important.

Very intrigued by this really stretchy wearable coming out of a collaboration from many US and Korean universities.  The full scientific paper here for the geeks among you…