Category Archives: Healthcare Reform

Fortnightly Healthtech Update #15

An industry analysts pretty jaded view of the state of innovation and meaningful change in healthcare from the JP Morgan Healthcare Conference.

Isansys claims a small deployment down under as the world’s first hospital-wide wireless monitoring install. If you know a better claim to first, please let me know….

The internet of insecure things…..GE has a problem with the security of its patient monitors.

Hips and knees are falling out of favor with participants in Medicare’s bundled payment program. Two reasons are given. First, providers have wrung all the excess cost out of the bundle – primarily by cutting skilled nursing for rehab. Second, the shift to outpatient surgical centers might increase the risk. As noted in the last fortnightly, this saving has been achieved without a drop in quality. Good news is, providers are moving onto more complex bundles. Let’s hope they don’t lose their shirts.

For a well-sourced read on – well, just about everything wrong with US healthcare – thank the American College of Physicians. One of the observations is that an eye-watering 31% of US healthcare spending goes on admin. A number that is so high in my view because of the massive fragmentation of both providers and payers. That complexity just needs so many administrators to coordinate everything – and often still dropping the ball in my personal experience. How can we cut that admin overhead that we all pay…? One way is single payer (aka Medicare For All). Another might be direct primary care with healthcare cost sharing ministries.

More on what the US could learn about universal healthcare from other countries here.

And One Medical, a direct primary care startup, has filed for an IPO. Direct primary care for the price of a latte a week

And yet more on new primary care models here.

The personal health wearables business has another casualty with UnderArmour dropping out.

Plenty of players (eg. Isansys above), but precious little adoption: VivaLNK elbows its way into the wireless vital sign monitoring market.

As does BioIntelliSense, with FDA clearance for a 30 day patch to monitor vitals in the home. The home use and 30 day life position the BioIntelliSense BioSticker squarely in the “readmission prevention” market, so it should appeal to many hospitals. Not clear to me if the device is semi-reusable, but that would help to keep the unit costs down if that’s true. Most interestingly, the company is pursuing a subscription model, with sensors provided free to providers.

Evidence that Medicare is overpaying docs for post-surgical follow-up that never happens. On the face of it, this could be an argument against bundled payments. But it’s not. Bundled payments pay for outcomes. If a doc decides they can achieve a perfect outcome without burdening the patient with unnecessary follow-up visits, good luck to them. Let them keep the extra, because the total price of that bundle should be cut by a fraction each year to encourage innovation in clinical practice.

McKinsey has a piece on what hospital care will look like in 2030. It’s mostly a rosy picture for patients – mhealth apps that avoid hospital visits altogether, online appointment booking, no waiting rooms (just-in-time visits), walls that change color to reflect or enhance a mood etc. It’s all good – but overlooks the obvious question. Why would our healthcare industry pay for any of that when they don’t get reimbursed for it in turn? And hospital visits aren’t going to dry up anytime soon while the American Hospital Association spends $26m a year on lobbying. Unless we push really hard on the ACO model and make sure value-based care fulfills its promise. Better outcomes at lower cost.

Tangential I know, but US life expectancy actually increased for the first time in four years. But only by a month. Lower death rates from cancer and opioid overdoses are the reason.

Alphabet’s Verily playing catchup with Apple, adds FDA cleared irregular heartbeat capability. Although Verily is more focused on clinical trials than Apple is on the face of it.

Allegheny Health Network reports both good financial and clinical outcomes by adopting a faster test for sepsis that gives results in just 90 minutes. Aiming to better that, researchers in Switzerland are working on a sepsis test that can be completed in 15 minutes.

Fortnightly Healthtech Update #14

A glasses-attaching wearable to monitor eating habits – because I’m pretty sure we all lie to our calorie counting apps at least some of the time…. 

CMS loosens up the purse strings to try digital health for moms-to-be and kids with complex needs.

Some positive results for the Medicare bundled payment experiment, lower costs for hip and knee replacements with no loss of quality. The study doesn’t see any change with other bundles though (there are 48 possible bundles in total). That doesn’t surprise me – and it’s not necessarily a bad thing. By far the most popular bundle with hospitals was hips and knees. Basically, it was a very low risk way to get into the bundled payment game – a relatively simple, repeatable procedure. So, the reason why we’re not seeing savings with other bundles yet could just be a lack of volume for providers to learn from.

Not an option for those that sleep in the buff, smart pajamas for monitoring vitals and sleep patterns.

Boston/Paris based Cardiologs picks up $15m in funding for its afib diagnostics algorithm. Abstract for a clinical study here.

Ah, the tensions of the journey to value-based care….BCBSMN tries to steer patients to out-patient clinics for lower cost care. Hospitals that stand to lose out, sue.

Why aren’t patients electronically accessing their medical records? Because – IMO – there’s rarely anything to be gained by doing so….I can go to my docs portal, I can login, I can see my data, and then…so what, there’s nothing useful to do with it.

VC’s clearly think bundled payments are here to stay, sinking an extra $27m into Aver. They might be right, unless we all go down the ACO path instead. Or just pull the plug on value-based care.

More potential lawsuit woes for Apple, being sued for patent infringement by Masimo. The basis seems to be that instead of licensing the technology, Apple hired key people away. Quite a nifty strategy if you can pull it off actually.

Is digital health failing before it’s even really got started…? Maybe. The good news is a Stanford Medicine survey finds that the vast majority of docs see value in self-reported health data. The bad news…a third are looking for help on how to use AI. So that’s a big fail right there.  Docs really shouldn’t need to know how the algorithm works, unless they want to get into research.

Israel-based Clew raises a B funding round for it’s AI-based platform for predicting patient deterioration. 

Can AI reverse the ‘unsustainable’ trajectory of spine care? In a word, no. Because spine surgery rarely brings much benefit.

Interesting use of Fitbit’s to track the spread of flu.

Payers and providers are squaring up to each other on how to address surprise bills. I’m honestly not confident this will help. The problem isn’t surprise medical bills. The problem is just medical bills. I’m mindful of this case from a couple of years back, where a woman begs people not to call an ambulance because she couldn’t afford it.

Rock Health reports that digital health funding dropped a little to $7.4bn in 2019, Still the second highest funding year on record though.

Masimo to acquire some assets from NantHealth, basically a device integration play. 

The Camden Coalition has previously been seen as a great success in addressing the high cost of high utilizers. Unfortunately, that no longer seems to be true.

Enrollment in Medicare’s MSSP program is stalling as CMS tries to get ACO’s to take on actual financial risk earlier. Meanwhile, it’s reported that one of Medicare’s other ACO programs (Next Generation) saved Medicare $184m in 2018. That’s good, but bear in mind the total budget for CMS is $1.2tn….

Healthtech Fortnightly Update #10

Clinicians may have the opportunity to use wearables to help PTSD sufferers.

A good primer on bundled payments for anyone that wants to understand more about that value-based care experiment. Oh, and enrollment in Medicare’s BPCI voluntary bundled payment program dropped 16% when providers had to take on risk. A number of reasons why are offered in the article, and they’re all valid to some extent. But, this program was introduced in April 2013. So, in reality, that’s over 6 years for providers to figure out their costs, what causes readmissions etc. Clearly, that hasn’t been a priority for some.

Sensor-based medication adherence firm Proteus Digital Health shows some success with hepatitis C, more clinical details here

Skilled Nursing Facilities (SNFs) fret that value-based care is going to drive them out of business unless they adopt technology. Well, they’re right to worry, because there’s likely to be a bloodbath. There are over 15,000 SNFs, many of them smaller, independent facilities. And many of them are about to get squeezed out of the market. First, Medicare is trying to bypass SNFs altogether, and discharge people directly to their homes, with home health agencies to provide rehab. That’s because it’s cheaper, all other things being equal (although comparing  readmission rates would be interesting…). In addition, in the past, patients needing further rehab have been free to choose any SNF when discharged from hospital. As Medicare tries to make hospitals accountable for reducing readmissions, hospitals need more control over the entire episode of care, end-to-end. So, they are going to develop preferred partnerships with SNFs so they can manage and improve quality. Ergo, there will be far fewer patient days in SNFs, and only the SNFs that can guarantee quality outcomes and integrate seamlessly with hospitals will survive. A good opportunity for companies likes EarlySense and Curavi Health to help out. Even so, some SNFs will go out of business, others will be gobbled up by large SNF corporations or healthcare systems. Expect that 15,000 SNFs to become 12, maybe even 10, thousand over the next few years.

The most impressive thing from the Apple Watch heart study isn’t it’s ability to detect afib. It’s the fact that they collected data from 419,000 people. In the era of AI and machine learning, that’s a game changer. Because, all other things being equal, in the era of AI and machine learning, the person with the most data wins.

The VA obviously likes what it’s seen in it’s diabetic foot pilot with Podimetrics that it’s expanding use to all clinics.

I’ve been of the opinion for many years that the best path to bring healthcare costs under control is to make it a fully transparent and competitive market for consumers. A bit like buying a car, or a fridge, or a central heating upgrade. The push for value based care – ACOs, bundled payments etc. – haven’t really got into that yet. Now the federal government is pushing harder for transparency, and predictably the hospitals are starting to squeal louder. I touched on site neutral payments in my last piece, and predictably hospitals aren’t keen on that either. Because both transparency and site neutrality will mean lower costs for you and I, and lower margins for the hospitals.

Still on the topic of site neutrality, Fresenius reports huge growth in home dialysis. Which is just as well for a couple of reasons: First, Fresenius has to go to home dialysis if it wants a business because Medicare is pushing on that for cost reasons. Second, that’s the main reason it acquired NxStage. Relatively speaking, the US has low rates of home dialysis. Because, it seems, decades ago Medicare policy drove people into dialysis centers. Apart from the cost, I have to believe that in a country like the US with large, sparsely populated rural areas, home dialysis can provide a much better quality of life for many people.

Forest Devices wins a pitch competition for a device to help EMS crews rapidly diagnose a stroke.

Some people are very upset that Google has access to patient data through a partnership through Ascension Health. Google has since clarified things a bit. Me, I’m not that concerned about it. If healthcare is going to become affordable and accessible, we need a revolution, not tinkering. And revolution never comes from within, always from the outside. So I’m all for new approaches that might dramatically improve quality and lower costs.

Humana reports $3.5bn savings from value based care in its Medicare Advantage program.

Docs still don’t like EHRs. Never have, almost certainly never will if it takes away from their patient time. But, hard to deny that having a permanent record that could be shared is better than paper and all its limitations. Nevertheless, it unfortunately seems that EHRs are a good idea badly executed.

But wait, another plus for EHRs….the UKs NHS reports good result with the early detection of in-hospital sepsis. I think this is the full study here, so it looks like an algorithm running in Cerner is the business end of that. We can only speculate how much better the results might be if fed by continuous data from patient monitoring.

More good news on sepsis, University of Colorado has developed a predictive algorithm that runs against the EHR to predict sepsis in children.

Fortnightly Healthtech Update #9

The social determinants of health (SDOH) have rightly become a strong focus in the US in the last couple of years. Insightful then that medical students are poorly trained in nutrition. SDOH is warming up sufficiently that there is an analytics startup focused on just that – called appropriately enough Socially Determined.

The traditional split between providers and payers is fading away, with UnitedHealth buying Vivify for remote patient monitoring. As it’s the Optum division doing the buying, I don’t think this has any role in the payer side of UnitedHealth. But, monitoring patients in the home is a cost containment/reduction play, as providers try to reduce hospital re-admissions. So, most likely RPM is a service that will be offered to providers, and potentially more powerful when integrated with its population health offering.

There’s some rough and tumble in the primary care end of the business right now. There are a number of different business models, each focused on one of the big problems for patients: Timely access to a primary care doc. On one hand, there is the growth of concierge medicine and direct primary care (DPC). It’s hard to put a solid number on that apparently, but it’s there. At the other, budget end of the spectrum, are retail clinics – roughly 6,000 or so of them if Consumer Reports is to be believed. The third approach is telehealth services, such as Teledoc and MDLIVE . And that competitive dynamic has led Walgreen’s to pull back somewhat on in-store clinics. As the article notes, direct-to-consumer (D2C) telehealth has emerged as a serious competitor. And retail clinics have seen explosive growth too, growing 8% in numbers in 2018. Expect a bit of a cull and some M&A in each of concierge medicine, telehealth, and retail clinics before each finds its competitive niche.

This is pretty cool, MedRhythms is getting into trials with hospitals to improve stroke rehab. I first saw this company a couple of years ago when they were part of the Philips Healthworks incubator. Like most moments of pure genius, it’s beguiling in its simplicity, using music to help rewire the brain.

Also a simple idea with potential, a pacifier that analyzes a newborn’s saliva.

I mused last time on the potential liability that will follow the adoption of AI in healthcare. It seems Memorial Sloan Kettering are thinking about it too, but don’t have any more clarity. But then again, AI can help avoid malpractice lawsuits. None of this is going to put the brake on AI funding thought, with Viz.ai scoring $50m from Google Ventures, among others.

Google is lined up to acquire Fitbit for $7.35 a share. That’s a premium on recent trading, but a long way from the circa $50 a share post IPO. Fitbit has been trying to pivot from fitness to healthcare for a couple of years. Makes sense as fitness trackers are a dime a dozen now. Becoming a true medical device though needs a big step up in accuracy, dependability, and reliability. It’s one thing to get pretty good data from most of the people, most of the time. It’s something else entirely to get great data from all of the people, all of the time. Contrast Fitbit’s woes with Apple growing its wearable revenue by 54%. Scroll a little further down in that Apple article though, and you’ll find Withings also trying to expand from consumer devices to professional healthcare. Respectfully, I have to disagree with the CEO of Withings who says “Data is the key to improving nearly every aspect of our healthcare system.” I’ve had this discussion with many people. Data is not the answer. The key to improving healthcare is to pay providers to do what we want them to do – namely deliver better outcomes at lower cost. If we get the financial incentives right, everything else will follow – including the use of insights from data. But unless we change the financial incentives to reward the outcomes we want, all the data in the world isn’t going to change anything.

Many different viewpoints on what the Google/Fitbit deal means btw, including accelerating the pivot to healthcareGoogle can’t do hardware, and it’s all about the data.

A new paper-based approach to detecting sepsis – and I don’t mean paper-based records, I mean a sensor made from paper that won an award.

Medicare refines the reimbursement policy on  remote patient monitoring, actually making it more likely to be adopted. This is goodness, major cost and suffering savings here if care models can fall into line and support RPM for chronic care. And that is, after all, dependent on providers being clear on how to make money from it. Something which has been missing from the reimbursement guidelines thus far. Re earlier point on data only being truly useful when the financial incentives are there.

New to me, KnowFalls has a video monitoring solution as an alternative to sitters to help prevent patient falls. As it acknowledges, it’s not the first company to go down this path, but it claims to be more cost effective. Personally, I’m not sure these solutions will ever be widely adopted. For one thing, patient privacy rights in Europe can make video monitoring difficult. Also, many of the elderly patients being monitored will unfortunately be suffering from dementia. The idea of some bodiless voice talking to patients with cognitive difficulties just feels like it could be a very disturbing experience. 

The CEO of Medically Home makes a financial case for treating chronically ill patients at home. What leapt out at me here is that in the US we spend $800bn annually on brick-and-motor hospitals (I haven’t double checked that, and it’s not sourced). Problem is, while we continue to build rooms for hospital beds, hospital CFOs will want to fill them. Isn’t the accountable care organization (ACO) the best way out of this cycle..? Define outcomes standards for managing, say, heart failure. Then it’s up to the ACO to find the most cost effective way to meet those standards for each patient. With of course downside risk if they go over budget.That is something Medicare is pushing for with site neutral payments, but legal obstacles are rightly or wrongly slowing that down.

Here’s Rock Health’s latest report on digital health consumer adoption, the key highlight for me is how patients are willing to share their health data, but few providers are geared up to work with that.

Interesting move for AliveCor as it tries to fend off Apple, starting a partnership with Huami.

Amazon continues to fill out its employee health offering, with the acquisition of Health Navigator.

To wrap up, interesting insight into the impending crisis that is the declining health of millenials. Which is odd, because the preconception I had is that millennials are super focused on being  healthy. Note, this is US millennials, not sure if it applies to other countries too. Either way, it’s not good reading….

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…