Category Archives: Value Based Care

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.