Category Archives: Value Based Care

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 #21

The state of Illinois partners with OSF and Southern Illinois School of Medicine team up to monitor some COVID-19 patients at home. But before you get too excited, it’s pretty low tech.

While COVID-19 obviously makes some healthcare providers overburdened, some might struggle to survive: Almost half of primary care practices may have to close in a month due to lack of patients/revenue. Which could allow cash buyers to pick up the assets at fire sale prices, and that often drives up costs for consumers. On the other hand, here’s a viewpoint that it might ultimately send primary care docs down the direct primary care/concierge medicine path instead. For more on that, keep scrolling…

Good to see the federal government can still move apace when it feels the need: The FCC funds 6 hospital telehealth programs within days of application

Is consumer health tech more trouble than it’s worth? A high false alarm rate and lack of robust connectivity is a problem for Owlet. Being open that your device is not a medical device doesn’t matter. It might get you off the hook legally, but new parents who can splash $300 for a monitoring device are going to have high expectations. Being accurate/connected *only* most of  the time isn’t going to cut it.’s solution for measuring vital signs automatically via camera is being trialed in Montreal.

Necessity is the mother of invention: Mount Sinai in New York adapts an existing stroke solution for remote monitoring of COVID-19 patients. Also adapting existing solutions to the pandemic, the eCart algorithm for early detection of patient deterioration is being fine-tuned.

Sensium gets a COVID-19 bump monitoring quarantined travellers arriving through Heathrow airport.

Could coronavirus derail the decades-long shift to value-based care? Could it derail it…? No “could” about it, it’s nailed on that it will. Coronavirus has already derailed absolutely everything else about “normal” that I can think of, so it’s pretty much guaranteed. Exhibit A: CMS is delaying the new payment model for ET3. There’s no doubt in my mind that we’re entering a new era for US healthcare. We’re a nation where so much of healthcare spend is via employer-subsidized insurance. And suddenly so many people have lost that benefit – and their income – however much we might whine about the cost of healthcare ordinarily. And everyone downstream of that cozy employer-employee relationship is going to lose healthcare revenue too – insurers, big pharma, PBMs, providers – everyone. Something is going to change. It’s a period of destruction, but will it be creative destruction? Maybe this will be a pivotal moment for direct primary care.  Similar thoughts here.

A sharp idea straight out of the University of Washington, using machine learning to distinguish a genuine cough from noise.

Digital health funding broke all records in Q1, according to Rock Health. It’s going to be really interesting to see how much the pandemic affects the rest of the year. I expect funding will drop overall, but anything that supports healthcare-remote-anything might find itself caught up in a funding boom.

Researchers in The Netherlands determine that AliveCor may be just as effective for managing blood pressure remotely as in-the-flesh visits to a clinic. Which leads us neatly into….

A couple of developments coming out of MIT. I think this is a development of a project I first saw maybe three years ago, using wireless signals to measure vital signs for COVID-19 patients at home. And further out still, embedding sensors into clothing to measure vitals continuously.

Is AI really better than physicians at diagnosis? I have two thoughts on that. First, AI’s diagnostic skills are still improving at a much faster rate than human docs. Second, AI is – or will be – cheaper. And that, in countries that have a strong focus on total cost of care, is going to be what drives adoption.

The long read: The history of telemedicine, how it came to be, how it promised to break down socio-economic barriers, and how it seems destined to be a tool for the wealthy. Really, it’s a good read, my description doesn’t do it justice. If nothing else, it highlights the tension between those that see the practice of medicine as a public good, and those that see it more as an opportunity for profit.

Fortnightly Healthtech Update #17

Lengthy article on the evolution of mobile phones for digital phenotyping (ie. continual data collection of the individual). 

CareSignal (formerly Epharmix) gets funding from customers and others for remote patient monitoring. The beauty is, it’s a relatively low-tech solution that can be used by many diverse patient populations with different conditions. See studies on COPDdiabetes, and mental health. Often, simple really is better.

The direct primary care model continues to evolve with Clove Health claiming to be the first legally incorporated as a public benefit corporation getting to work in Florida. More on that style  of incorporation hereCitizen Health is heading down a similar path.

I touched on the ongoing battle over patient access to their own data. Apparently the federal government has started hitting providers with fines if they make it difficult for patients to get their data.

From Imperial College London, using sound to detect vital signs allows a device to penetrate layers of clothing.

Medicare builds on the mixed success of ACOs to create the Direct Contracting model for the next stage of value based care. There’s also the Primary Care First model, now due sometime next year. Also, a fresh study of Medicare ACOs finds that much of the cost variation comes from the use of out-of-network primary care docs.

More Medicare, the CJR program was controversially introduced as a hip and knee replacement bundle a few years ago. Controversially because it was a mandatory bundle introduced because providers didn’t sign up for the similar voluntary program with sufficient enthusiasm. Now CMS wants to extend it for another 3 years, and add in outpatient settings too. Which makes sense because it will drive the cost down, all other things being equal.

A new design to make better, cheaper biosensors for fluid analysis. Quite honestly, it works in ways I don’t fully comprehend, but hopefully it means something to some of you…

More healthcare reform, CMS picks 205 EMS services for the experimental ET3 model. The intent of ET3 is mostly to help people with chronic conditions get treated in their homes, avoiding the personal discomfort and stress of perpetual trips to the ED. It also should save Medicare money on avoidable ED visits too. To do that, ET3 allows EMS to get reimbursed for other services, not just transport. This potentially opens up another route to market for medtech vendors in applications like remote patient monitoring.

Wearables and machine learning start to show real promise: PhysIQ and VitalConnect study shows promise for predicting hospitalizations for heart failure patients. We’re already seeing machine learning breaking into imaging. I think continuous patient monitoring also has real potential. There’s a big need to determine baseline vital signs for individual patients, rather than just using generic values. I think machine learning might have the potential to usher in more adaptive algorithms that can help to reduce the long-running over alarming problem.

Apple leans hard into atrial fibrillation. A new collaboration with J&J makes the Apple Watch available for $49 to seniors who take part in a study. This could be a win for everybody: Seniors who avoid a potential stroke through the early detection of afib, cardiologists who get more business, and obviously Apple. Presumably J&J has some meds for managing afib in its portfolio too. And Medicare could win, since stroke care is reckoned to cost $40bn a year.

Sepsis has been a silent killer for a long time. A new study finds a stunning growth of 40% among Medicare beneficiaries who were hospitalized. Digging deeper into the economics, the same study finds the total cost of treating sepsis to be much higher than previously thought – over $23bn for inpatient care alone.

At the other end of the age scale, Children’s Hospital of Philadelphia has developed a new algorithm for detecting pediatric sepsis.

A new potential tool in the opioid crisis, a wearable to detect opioid induced respiratory depression (OIRD) in the community. Developed by Altair Medical in Scotland, I’m interested to see how this develops and works in practice. There are definitely challenges in current opioid addiction treatment that this could address. (For podcast fans, Freakonomics has a good two-parter on the crisis and current approaches). Also, equal parts tragic, genius, and sheer practicality, a number of communities are training kids to administer Narcan. Note, OIRD is still a major problem for post-surgical patients too, where hopefully the patients location and time to rescue are more predictable, so potentially more effective overall.

Simple early warning scoring is still an undervalued (and under adopted) practice for catching patient deterioration early. One hospital system in the UK dropped cardiac arrests by 75% by capturing vitals at the bedside with iPads and calculating the early warning score automatically. 

An unfortunate reminder that technology alone can’t change anything: WellSpan Health York Hospital gets cited for failure to respond to a patient in distress. It seems even thought the patients falling heart rate and oxygenation levels were noted for at least 20 minutes, nursing staff failed to intervene.

Fortnightly Healthtech Update #16

Walmart moves into radiology, opening a clinic in Calhoun Georgia with x-ray facilities. Which is a nice lead in to will big retail disrupt healthcare more than big tech?

Profusa’s Lumee tiny oxygen sensor gains a CE mark. Intended for conditions such as peripheral artery disease, the device operates for 28 days, clinical study here.

Apple highlights it’s healthcare presence in its earnings release, claiming 100% of F500 companies in the healthcare sector use Apple. Which sounds impressive, but when you think about it, that’s a small number. You might even be able to count those companies on the fingers of one hand. 

Medicare’s bundled payment isn’t perfect, it rewards doctor’s who take lower risk patients. Really would be nice if it worked the other way around perhaps.

The legal fight over price transparency continues. Meaningful transparent hospital pricing would lead to meaningful competition among hospitals. Competition among hospitals would lead to lower prices. Hence, the AHA is obliged to fight it on behalf of its members. But the American Academy of Family Physicians is not.

On the theme of overpaying, Medicare paid $7.8bn for insulin. If it paid the same prices as another federal government department (the VA) it would only have paid $3.4bn. That is just one of many examples of Medicare overpaying because of a lack of political will.

Verily partners up with Santen for vague eye are projects.

Continuous vital sign monitoring in hospitals is becoming a thing at glacial pace. (See Isansys in the last post). This study compares the performance of devices from EarlySenseSensiumVitalConnect, and Masimo. In summary, all are accurate for heart rate, some better than others for respiratory rate.

The lack of continuous monitoring still hits the broader headlines occasionally. In this case,  Cleveland area hospitals are highlighted for their tardy adoption following the tragic loss of a patient in 2016. 

Also continuous monitoring, continuous monitoring of urine for the early detection of kidney problems from Serenno Medical.

Virta Health – treating diabetes the old school way with diet – has been running a pilot with the VA for a year.

Scientists in Korea have developed a biosensor test for the early detection of Alzheimer’s.

An opinion piece from a Professor at Stanford University School of Medicine, outlining how a simple market segmentation would improve healthcare delivery. In practice, I think market forces are already doing this to some extent. The reasonably wealthy/reasonably healthy are starting to adopt concierge medicine, or direct primary care. But, I can’t figure out how direct primary care is going to work for the chronically ill. The direct primary care model often touts unlimited primary care access as a benefit. But, unlimited access to a primary care doc is just like having unlimited paid time off. It only works if you don’t take the “unlimited” literally. And that won’t apply to many chronically ill people with multiple comorbidities of course. And if that mild criticism wasn’t enough for you, Molly Osberg well and truly shreds direct primary care – the comments are definitely worth a read too.

Oh, and Iora Health, one of the pioneers for direct primary care, just closed $126m in funding.

Apple finds itself squaring up to Epic and assorted hospitals in the fight to allow patients to easily access and share their healthcare data. Epic and friends voice concerns about patient privacy. But, dig deeper. Allowing Apple access to health records is a long-term threat to Epic’s dominant position in the EMR business. And, as noted above (on price transparency), hospitals aren’t keen on competition either. Preventing people from easily moving their data from one provider to another is just one more way to lock in a patient’s revenue stream. Which is really unfortunate. Because, if consumers had better access to quality data, better access to pricing, and could easily move their health records from one provider to another, hospitals that delivered greater value to consumers would ultimately thrive. And those that did not would either raise their game or wither and die. Everybody wins – except sucky hospitals.

Also in the EMR connectivity game, Innovaccer raises $70m to create longitudinal patient records to support the transition to value-based care. I imagine it will find “patient privacy concerns” to be a challenge too. 

Caretaker Medical of finger-cuff blood pressure fame, adds ECG via a partnership with VivaLNK. Ditto VitalConnect, partnering with CorVitals to add arrhythmia detection.

Researchers in New South Wales come up with a superior algorithm for early detection of sepsis.

Machine learning is steadily making inroads into the diagnostic space. PhysIQ adds a patent to estimate cardiopulmonary function from wearables.

Challenging assumptions or a little Christmas humor…Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial.

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.