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Fortnightly Healthtech Update #33

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

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

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

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

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

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

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

Hearing tests by smartphone for underserved communities.

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

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

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

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

Fortnightly Healthtech Update #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 #20

I’ve tried to keep Corona-virus free in the last couple of issues. That’s pretty much impossible at this point. However, the good news – if there is any right now – is that some wearables are actually starting to be used to help fight the pandemic. Not just optimistic press releases, but actual usage. So let’s learn about that.

Providence – first in the eye of the storm in Seattle – are using Xealth to help deliver remote patient monitoring

The ever inventive Israeli’s are adapting a couple of monitoring systems I’ve not come across before for remote monitoring. EchoCare Technologies uses radar to detect falls in seniors primarily, but also measures respiration rate. Neteera uses a similar idea, but seems to capture a broader range of vital signs.

Also from Israel, Nuvo Group gets the nod from the FDA for its remote pregnancy monitoring for both baby and mom.

Unlikely saviors for desperate times, Alphabet’s Verily has helped to roll out COVID-19 testing in California.

Meanwhile, the Aussie’s have developed a biosensor for real-time tumor tracking. Details on how it works here.

New to me, Tissue Analytics, uses a phone app and machine learning to provide remote clinicians with highly detailed insights into wounds.

I’m shocked by this survey result: 91% of American’s want healthcare price transparency. Did the other 9% not understand the question? Why would anybody not want to know the price of care before treatment…? The answer, most likely, because they have a healthcare plan that costs them little or nothing beyond their monthly premium..

It’s been widely suggested that treating patients in their home would reduce the cost of care, versus a hospital visit. Intuitive really, but still needs to be proven out. Brigham and Women’s in Boston has done that to some extent. Less than 100 patients total, but demonstrating 38% lower cost per episode of care.

Plenty of discussion about the almost complete inability to do contact tracing in the US for COVID-19. Not helped by the fact that in many ways the US acts like a collection of 50 smaller countries – not unlike the dreaded EU! Not to mention the complete lack of integrated health records. But, there is at least now an outline of a policy to tackle that. Policy papers may be irrelevant at this point though, as Apple and Alphabet have announced that they will work together to enable contact tracing. But still plenty of unanswered questions about that project.

Remote monitoring in more than one sense, Biovotion has a COVID-19 related remote monitoring project in remote Australia, Murrumbidgee Local Health District to be exact. Not to be outdone, Caretaker Medical is also setting up for remote monitoring of vitals with Australia’s first virtual hospital

Masimo SafetyNet has also been extended to remote-monitoring in the home for suspected COVID cases by St Lukes in Pennsylvania.

CMS requires providers to be compliant with a bundled care protocol called SEP-1. However, there now seems to be evidence that not all elements of the bundle are necessary. Dig deeper though, and it seems SEP-1 might not be based on clinical evidence at all.

Possibly the most classless press release of recent days: MindCotine scores US$230,000 just in time to get at-risk smokers to quit before Covid gets them. Maybe the team at MindCotine just needed to invest a little more of that $230,000 in a better translator, hard to say.

Fortnightly Healthtech Update #19

One small step on the road to reasonable med prices, Illinois caps the price of insulin.

There’s a lot of ongoing speculation that the Coronavirus pandemic might finally bring us into the telemedicine era. The FDA has lifted some restrictions on remote monitoring. It’s also temporarily blessed non-HIPAA compliant audio and video. And practicing across state borders. But it’s going to take more than that to make the change stick. It’s going to take alignment of reimbursement rates, as this tweet shows. Certainly as the stock market craters, investors are excited about companies like Teledoc. A bigger opinion piece by Forbes here.

Some wearables are certainly getting a kick in adoption, with the Oura Ring being used to monitor the health of caregivers in a couple of San Francisco hospitals.As far as I can tell, this is a wellness device, not a medical device (ie. not FDA approved). Which probably explains why it’s on caregivers, not patients. That said, the FDA has also relaxed the regs on ventilators manufacturing. Which is fine. If the only choice you have is a possibly iffy vent, or no vent at all, which would you pick? Expect the FDA to relax plenty more rules over the next 12 months. The more interesting thing is how many those changes will stick when we make it through to the other side.

While many industries are looking for the federal government to bail them out as their revenue plummets, ACO’s are looking for help as their costs threaten to explode. Personally, I’m just as interested in seeing what help there will be for families who face bankruptcy because their healthcare insurance cover is so meager.

In news that is probably not COVID-19 related, patient monitoring company Masimo is set to acquire a ventilator company, TNI Medical. As the press release states there is no material impact for 2020, it looks like a longer term play. Masimo’s core business is measuring and monitoring patient oxygenation. Acquiring a product for ventilation is perhaps a move to close the loop between monitoring and therapeutic delivery and deliver a more complete solution.

On that note, I’ve highlighted a lack of continuous patient monitoring as an issue in Cleveland before. Therefore good to see further studies and adoption of solutions to address this need. First, Masimo reports zero deaths or injuries from opioid induced respiratory depression from a 10 year study. In the much smaller control group, sadly 3 deaths occurred. Second, Children’s Hospital of Georgia signs up for Philips’ IntelliVue Guardian to measure early warning scores more reliably, and so improve intervention when needed.

Alphabet’s DeepMind throws its weight behind COVID-19 protein structure folding. Protein folding using spare cycles from home computers has been a thing for over 10 years. That means you can do your bit to tackle COVID-19 and other diseases, sign up here.

Population health is an under-rated discipline – especially in the US where the payer/provider landscape is so fragmented. That may change with the current pandemic, aided by the increased use of consumer wearables. Researchers at Scripps have kicked off a project to do just that

Fortnightly Healthtech Update #18

This might just be the only COVID-19-free healthcare email you read this week. I wanted to keep it that way, providing a veritable oasis of calm. But that does make it a smidge shorter than usual….Personally, I am very interested to see how this pandemic might change the delivery of medicine. We’re still mostly dependent on in-person visits in the US. But that’s more about how providers get paid than it is about a lack of technology alternatives I suspect.

Phone camera based vital sign measurement from now offered with Burnalong, a fitness app. I’m hoping this isn’t the be all and end all for Most likely there’s a professional medical application lurking in here too. But working with the consumer market should give the company quick access to lots of data. And that data can be used to refine the underlying AI models to improve accuracy and accelerate product development.

US researchers working on a smart bandage to both monitor the patient and promote healing.

Somatix has an interesting approach to monitoring the elderly as unobtrusively as possible. It uses gestures and hand movements to look for signs of impending trouble. I don’t quite understand why it positions itself as an AI company and not a medtech company, but it does.

I once had a physical therapist friend tell me that women’s pelvic health was a massively under-diagnosed issue. So it’s good to see VaGenie is the winner of Boston Scientific’s Connected Health Challenge.

BioBeat gets CE mark for its wearables that measure blood pressure, cardiac output, stroke volume, oxygenation, and heart rate. This in addition to the FDA clearance granted last year for some parameters. What’s particularly noteworthy is the ability to measure blood pressure off the chest, as well as the wrist.

Lyft simultaneously finds recurring revenue and helps with the social determinants of health. This deal backs onto an existing 3 years deal. It’s great that people are being creative about solving the transportation issue for patients who need it. And presumably, in an accountable care world, providers will actually pay the $20 for the ride if they are going to save thousands in downstream healthcare costs.

A Philips survey reports that 35% of young doctors are overwhelmed by patient data, or aren’t sure how to use analytics. Sounds like we need to re-think physician education.

Researchers find that 3D printing could lead to a better type of silicone wearable.

Some are excited that the federal government has published interoperability rules that *might* allow patients better access to their data. Others are concerned that said rule is a hefty 1,244 pages long.

OK, so I didn’t quite live up to my promise, but it’s a great story that points to the future: Italian hospital 3D prints values it needed for the ICU.

Fortnightly Healthtech Update #5

How to make use of pulse-transit-time in wearables.

Researchers at Stanford have developed a bodyNET sensor that could potentially measure vitals. More details here, subscription required. Or, if that’s not your thing, how about bio-compatible magnetic skin.

A study in China looks at the use of photoplethysmography technology to reliably detect atrial fibrillation.

We are less than one month away from a major change in how Medicare reimburses skilled nursing facilities. The aim is to get patients the care they need while removing the incentive to provide excessive amounts of therapy. But as Avalere’s Fred Bentley explains, it’s not really value-based care, because volume will still be a big driver of SNF profitability. MedPAC insists value-based care is coming to post-acute though.

Increased signs of action to tackle social determinants of health.

Honestly not sure what to make of this partnership between Verily (Alphabet, née Google) and iRhythm to develop solutions for atrial fibrillation. iRhythm already has afib detection, that’s what it does. So, maybe this is about reaching a bigger market and going direct to consumer at some point? Because right now, iRhythm needs a doctors order…and the Apple Watch does not, neither does AliveCor. So that would be a bit of a strategic shift. Or is the clue in the word “solutions”…? More to come.

In iRhythm-related news, BardyDX extends it’s own ambulatory cardiac monitor to 14 days. This potentially offers better diagnostic yield, since longer monitoring improves the odds of detecting infrequent cardiac events. It does not, iirc, open it up to an additional set of CPT codes (aka an adjacent market segment).

Vim gets some big name financial backers to provide better integration between payers and providers for value-based care.

Another Israeli project, including Ichilov Hospital, AnyVision, and BioBeat aims to improve monitoring of patients on the general floor.

New to me Health Recovery Solutions jumps into the remote patient monitoring fray.

I wrote about Deepmind’s work on renal failure detection recently, but Intermountain is using SymphonyRM to develop personalized treatment plans for kidney failure

Modern Healthcare’s list of 25 innovators in healthcare. Innovations include avoiding unnecessary ED visits, personalized medicine, price transparency, addressing the social determinants of health, and much more…

Judge blocks former CVS exec from joining Amazon’s PillPack. Admittedly, this is about enforcing a non-compete agreement. But, I can’t help feeling that if one of your top competitive strategies is wielding lawsuits, that’s never a good look. If you were innovating fast enough, whatever your former employee might have in their head would become irrelevant pretty darn quick.

The law of unintended consequences: The post-acute care savings reaped by Medicare value-based payment programs might be at the cost of family caregivers. On the other hand, Medicare’s bundled payment programs do not seem to have worsened the outcomes for frail seniors. Is that a win? I guess it depends if you’re a family caregiver…

GE is developing a sensor to analyse sweat.

Where Apple goes, Android is sure to follow – only much later…..a collaborative effort to let Android users access their medical records.

PeraHealth adds more FDA cleared capabilities to it’s patient deterioration solution.

CMS proffers both carrot and stick to convince providers to accept downside risk. Seema Verma says all the right words about price transparency and competition – albeit with the obligatory S-word thrown in. By which I mean socialist, obviously. How did it became socialist to want high quality, affordable healthcare for all citizens of one of the richest countries on earth? If that’s how it is, I think I can live with that. Anyway, actions speak louder than words so I’ll reserve judgement on what Seema Verma delivers. I just hope value-based care isn’t going to go the same way as commercial nuclear fusion – forever right around the corner.

Covenant Health introduces a remote sitter program for monitoring at-risk patients.

Research into another new type of wearable using graphene sensitized with semiconducting quantum dots.

Mercy Virtual invests in Myia to monitor heart failure patients at home.

Wondering where America’s National Institute for Health is putting it’s money on mhealth apps? You can find out right here.