Digital Health, Healthcare

Fortnightly Healthtech Update #13

As the diabetic population continues to grow, medtech vendors are looking for alternatives to the unpleasant finger stick to measure glucose levels. Continuous Glucose Monitoring (CGM) wearables are a commercial reality, while researchers have explored using tears as a reliable glucose measure. Now, researchers in India have a plan to use saliva.  Talking of diabetes, incidence is lowest among caucasians in the US.

Patient monitoring of a different kind: Roosevelt General Hospital in Portales, New Mexico tells patients to monitor bank accounts after malware infection. 

A possible speed bump for Apple, a New York doc claims patent infringement for the afib algorithm.

Payers are gearing up to address the social determinants of health, with programs from the University of Pittsburgh Medical Center, BCBSRI, and Cigna. Meanwhile, UPMC are implementing remote blood pressure monitoring using Vivify Health for new moms after they are discharged. The aim is to improve care quality by catching hypertension early, and reduce costs  by managing follow-up appointments more appropriately. 

Last time I noted how the “healthcare system” fails mothers. Apparently if’s failing kids too, with fewer hospitals able to treat pediatric inpatients. But at least the US isn’t unique in that, with the UK facing a lack of pediatric ICU beds.

In Pennsylvania, the Rural Health Model spins up to see if Medicare can incentivize better access to care for rural communities.

Creative accounting of a good kind, payer and provider split the investment in a social worker to try and keep frequent flyers out of the ED.

A doctor’s disarmingly honest account of how a hospital stay often turns out to be very bad for your health. It’s a long read, so you might prefer the podcast instead. 

From the National University of Singapore, an RFID enabled biosensor less than 1mm wide.

Mobile telestroke program cuts door to needle time for stroke patients by 30 minutes. It’s mostly underpinned by simple process changes, enabling critical treatment steps to run in parallel instead of sequentially. 

Apple was recently granted 35 patents, the most healthcare related being a mattress for measuring vitals signs, and exercise intensity via a PPG sensor.

Many of the ancestry/genealogy companies have two revenue streams. Charging individuals for testing their DNA is the obvious one. But, less well known, a second revenue stream comes from selling the individuals anonymized data to big pharma. 23andMe is doubling down there, inviting individuals to add their medical history to the 23andMe database. As the article notes, that could be a hugely powerful dataset – but should it be owned by a private, for-profit company?

On that note, some concern about Facebook encouraging users to share their health data so that they can get recommendations for preventative care. I think there will always be concerns here. Many tech companies change their terms of service frequently, which is always a concern. On the other hand, if it helps people take care of their health better than the traditional “healthcare system” does, it’s worth thinking about.

Related to that, a Rock Health survey finds that only 10% of consumers would be willing to share their data with a tech company (free download). But, before you read too much into that, here’s the exact question that was asked in the survey: “Please indicate which of the following individuals or organizations you would be willing to share your health information with…”. 

So I’ve done primary research for a living. With every data set that I ever collected, I’d always look at the data afterwards and think “Doh, I wished I’d asked <fill in the blank> instead”. In this case, I’m thinking a more insightful question might be “Would you share your health information with a tech company if it saved you $500 a year in your out of pocket healthcare costs?” I think you’d get a very different answer from 10% would be willing to share. Different again if you suggested $100, and different again for $1,000. A more informative approach perhaps. Everything has its value, everything has its price.

Also in the very same Rock Health research survey…Apparently, consumers are significantly less likely to share their data with their own doctor than they were two years ago. Why…? I would guess because consumers can’t see any demonstrable value in doing so. Because sharing data with any entity – a doctor or a tech company – only makes sense if it leads to lower costs and/or better quality care. If it doesn’t, you’re just wasting your time.

A wearable to help identify swallowing disorders.

Progressive, but not clear to me how this would work in practice without consumption on-site: Massachusetts Looks to Open New Drug-Monitoring Centers.

Coincidentally in Massachusetts, Lowell Hospital is working with Frontive to leverage Amazon’s Alexa to try and improve post-discharge orthopedic care.

Apparently house calls by doctors have been decreasing for years. Partly – if this article is to be believed – because the reimbursement was so low. But, for homebound people, there’s real value there. This is something that Accountable Care Organizations should be willing and able to revive. If that home visit – by a doctor, an NP, or a paramedic – can keep someone healthy at home, there has to be a payoff there for an ACO. 

Digital Health, Healthcare, Healthcare Reform, Value Based Care

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.

Digital Health, Healthcare, Healthcare Reform, Value Based Care

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 healthcare, Google 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….

Digital Health, Healthcare, Healthcare Reform, Quality Improvement, Value Based Care

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 physIQ, Current 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.

Analytics, Digital Health, Healthcare

Fortnightly Healthtech Update #7

Current Health (formerly Snap40) partners to add axillary temp and spirometry to the parameters it measures.

Detecting antibiotic levels in real-time.

Bioformis ups its game with FDA clearance for BioVitals to help manage chronic conditions.

MC10 partners with University of Rochester to collect real-world evidence for how people live with Parkinson’s. Reminds me a bit of this collaboration between IBM and Pfizer.

Interesting perspective that I hadn’t considered before: Dated US regulatory policies are endangering the US lead in healthcare technology.

Direct primary care (DPC) might help achieve half of the quadruple aim, clinician satisfaction and patient satisfaction. But lower healthcare costs overall, and higher quality overall, I’m not so sure. It’s also typically positioned as an up-sell to people who already have health insurance. But just thinking out loud, maybe there’s another angle. If you can’t afford a traditional insurance plan, would a low cost primary-care-only option with a strong focus on preventative care be better than nothing…?

Sounds like a lawsuit waiting to happen, Rensselaer County launches online emergency room for Medicaid patients. I’m sure the intent is good, to prevent unnecessary ER visits. But, pitching an app called “ER Anywhere” to a patient population might just be asking for trouble.

I expect to see more of this from large employers tired of rising healthcare premiums: Walmart to use Embold Health’s analytics to herd it’s employees to high quality providers.

Can a simplified cardiac risk score also predict strokes?

In case anyone was still in doubt, new research published in JAMA suggests 25% of all healthcare spending could be waste (free registration required). And that doesn’t include administration. Candidly, a primary care doc once told me the rule of thumb in primary care is 3 admins for every medical practitioner. Their practice at the time had a 5 to 1 ratio! I’m inclined to think that admin overhead is a direct result of the complexity of the payer/reimbursement model. And they say that government managed healthcare would be inefficient…

Best practice for in-hospital rapid response teams (RRT) include having a dedicated RRT, and the ability for anyone to trigger the RRT without fear of reprisal.

The only thing that surprises me about this is that patients still have to pay some of the cost: Devoted health to use Apple Watch with Medicare Advantage patients. I would be shocked if most payers/providers aren’t paying for wearables like this in a few years – and financially encouraging patients to use them. If they’re not, it probably means the push for value-based care has failed.

The ECRI Institute releases its top 10 technology hazards for 2020. Not for the first time, the problem of over-alarming makes the list.

In Pennsylvania a patient tragically expired in the ER after being left unattended. A potential market opportunity for wearables perhaps. But unfortunately, hard to make a business case for it that is going to make a hospital CFO jump for joy.

Funding for digital health startups has cooled a tad, but still an estimated $1.3bn in Q3 according to Rock Health.

Digital Health, Healthcare, Healthcare Reform

Fortnightly healthtech update #6

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Digital Health, Healthcare, Uncategorized

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.

Analytics, Digital Health, Healthcare, Healthcare Reform

Fortnightly Healthtech Update #4

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Digital Health, Healthcare, Healthcare Reform

Fortnightly Healthtech Update #3

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

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

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

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

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

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

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

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

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

cardiology, Digital Health, Healthcare

iRhythm: 12 words that change everything

iRhythm reported its Q2 results just over a week ago. With a 50% year-on-year growth, and a 76% gross margin things are looking really rather peachy. But there is a potential pothole or two in the road ahead. That’s why these 12 words in the press release are more important than the raw numbers:

“…our CPT code change application was accepted by the AMA for review…”

To be more specific, iRhythm is looking to change the CPT code for its devices from a category III code to a category I. Category III codes are used for experimental tests and treatments. As such, they are usually fleeting, temporary, short-lived. And as Kerrisdale Capital noted, that can create a real vulnerability for companies – like iRhythm – that depend on them. Nailing a category I code means you’ve cleared a big, big hurdle. Category I codes are what medical devices want to be when they are all grown up.

So, the AMA’s review is good and necessary for iRhythm. But, it doesn’t mean the company is home and dry yet. Under the current CPT codes (0295T-0298T, if you really must know…) the total Medicare reimbursement for using the Zio XT is about $90 a patient. They key question is this: Will the AMA review keep the reimbursement the same, increase it, or decrease it? Because that’s going to make a big difference to both adoption by cardiologists, and margins for iRhythm. And the answer to that question is, I suspect, down to lobbyists and lawyers as much as anybody else…

A quick disclaimer…Don’t take this as investment advice, because that’s not what it is, that’s not what I do.