Tag Archives: #valuebasedcare

Digital Health, Healthcare, Healthcare Reform, Medtech, Value Based Care

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 COPD, diabetes, 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 here. Citizen 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.

Digital Health, Healthcare, Healthcare Reform, Value Based Care

Fortnightly Healthtech Update #14

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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….

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.