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Can Consumers and Patients Be One in the Same?

March 26, 2019

In a recent post by Dr. Michael Hodgkins, AMA’s CMIO, he cited the consumerization of healthcare as one of three digital health trends that are transforming patient care. Earlier this month, Health Affairs ‘analyzes the ups and downs of expecting patients to act as consumers’. Further, the NEJM Catalyst Insights Council revealed that the majority (96%) of its members responding to a recent survey on patient engagement said that the healthcare industry has a lot to learn from consumer-facing industries.

Jennifer Sargent, Vera Whole Health

So, this past Valentine’s Day, I had the pleasure to host a day-long event at HIMSS Global Conference, sponsored by the Personal Connected Health Alliance (PCHAlliance).  The focus was consumerization in health.  I was pleased with the level of attendance and more so with the exceptional line-up of speakers and panelists curated by my colleagues at PCHAlliance.  It was a day full of fun, insights and differing points of view on the most important issues facing connected health right now.  The initial kick-off was by Jennifer Sargent who gave a talk that was a springboard for the entire day. Her presentation touched on the trends in workplace health, and the desire of employers to provide conveniences and support for employees, to help them stay on track with primary care needs — what she called ‘whole health engagement’. Jennifer also highlighted the successes Vera Whole Health has had in getting people to adhere to recommended therapies and show up for doctors’ appointments.

Panelists: Ron Hildebrandt, Chief Product Officer, Virgin Pulse, Tim Pantello, Managing Director, PwC USenior and Urvi Shah,Manager, Life Sciences and Health Care Practice, Deloitte Consulting

Panels moderated by Kaveh Safavi and Jane Sarasohn-Kahn followed.  There was a recurring theme of ‘What do we call recipients of healthcare’?  Interestingly, this debate has been going on for some time, with providers digging in their heels, insisting on ‘patients’ being the correct term.  ‘Consumers’ still generates some discomfort with many folks.  One panelist added a new twist, advocating for the term ‘customers!’.  While I understand the controversy between terms like patients (too paternalistic?) and consumers (too commercial?), I have not heard much of a groundswell for the term customers.  I’m really torn on this one.  I can’t separate the ‘new age’ me from the provider who relishes the special relationship I have with my patients.

The next panel was a standout, moderated by Sunita DesaiChex Yu presented some very interesting data on consumerization in health.  A JMP Chase Institute study of Chase customers and their out-of-pocket (OOP) healthcare spending habits illustrated the need to consider this when structuring healthcare options and payment options. Chex shared several important observations from this study, including:  high income families had the highest spending, but low income families had the highest burden of spending; people made larger healthcare payments when they had a higher ability to pay (thus people are foregoing care); and OOPs increase after tax refunds (thus people are delaying care until immediately after they get a refund). As a board member, I was pleased to hear Kristen Valdes’ perspective on how her company b.well is helping consumers aggregate and understand their health data.

Another theme of the day was the conundrum around data ownership and value.  Grace Cordovano’s panel discussed this in detail.  So many important questions were raised, but remain unresolved.  What is the best way to encourage data transparency for consumers?  How should we set values for consumer health data and create tools that allow individuals to share their information knowingly and gain some value for it? Thorny issues to be sure.  Maybe blockchain is part of the solution. I think it’s clear that the scales are currently tipped away from patients, in terms of deriving value from data, with monetization controlled firmly by longstanding commercial interests. I could also argue that if raw data means nothing, value can be derived when data is aggregated and analyzed with proprietary algorithms and made useful through interfaces designed for clinician or patient consumption.

Dr. Joe Kvedar at the Consumerization of Health event.

Now, admittedly, I am biased due to my unbridled enthusiasm for the power of patient-generated data to engage people and aid in behavior change, but I really enjoyed Drew Schiller’s afternoon keynote.  He shared several compelling stories of how folks who monitored their health data gained insights that allowed them to change behaviors and overcome barriers in the management of a chronic illness.  We’ve seen evidence of this at Partners Connected Health.  There is one small caveat: some individuals need a good chunk of external motivation to pay attention to those numeric trends served up by their wearable devices.

After that, the agenda focused more on emerging technologies. Jody Holtzman led a panel that talked about the power of robots in the context of aging, something I care deeply about and covered in my most recent book, The New Mobile Age.  This panel included a demonstration of ElliQ, a social robot, whose impact on attendees made the point that robots can be appealing and evocative. The field of social robots continues to evolve rapidly, and with each new entrant and form factor, seems to get closer and closer to the vision where these tools are a ubiquitous part of our lives.

Steve Mitchley from the Vitality Group gave a compelling talk on making prevention trendy, demonstrating it’s possible for preventive care to succeed and stick.

Steve Wretling, CTIO of HIMSS, led a provocative panel on the use of immersive technologies in health.  We heard from JoAnn Difede, Kyle Rand and Anthony Sossong, experts in virtual/mixed and augmented reality, on the latest evidence, consumer and healthcare trends, and the potential for immersive realities as tools for health promotion. The message across panelists was that devices have become better and more affordable, and they see VR as having real value in healthcare in the future. This group is doing some fascinating research in PTSD, overcoming social isolation/loneliness, and improving social skills. In fact, we believe this is such an important topic, we’ve already invited this panel to present at the 2019 Connected Health Conference in October.

Joy for All Companion robotic dog.

To cap the day, we staged an interview with Ted Fischer, CEO of Ageless Innovation. I had the pleasure of doing the interview and we were joined on stage by three robotic pets from Hasbro, Checkers the Cat, Socks, another cat, and Rover the dog.

Ted’s story fits in well with the panel led by Jody Holtzman.  The Joy For All Companion pets, simple but adorable/cuddly robotic pets that retail for about $100, play an important role in our efforts to combat social isolation and provide services to folks with mild cognitive impairment.  He was articulate and the pets were a boatload of fun!

Our day-long symposium focused on consumer behavior insights and the role digital health technologies can play in shaping a more pleasing and engaging experience of care. Our goal was to shed light on the drivers for change — from new insights and better decisions enabled by data science and artificial intelligence, to the science of behavior change and the urgent need to rethink health to care for an aging population.  No doubt, we have made great progress in putting the consumer at the center of their care. But we still have miles to go to achieve a future in which consumers and patients are one and the same.

What are your thoughts on how we can successfully create knowledgeable, empowered and engaged health consumers?

NOTE:  Much of the content from this event is a catalyst for our upcoming Connected Health Conference, where we will dig deeper into these critical issues. The 2019 theme is “Designing for Healthy Habits & Better Outcomes: Design. Data. Decisions.”  It is going to be our best yet.

The Emerging Trends in Connected Health from 2018

December 20, 2018

As the year comes to a close, I can’t help but reflect on where we are in the connected health adoption journey.  2018 will go down in history as a pivotal year.  It will be cited as a year when we started to see evidence of movement from early adopter to early majority, or, if you like, moving from the gradual slope of the adoption curve to the steep ‘hockey-stick’ phase of growth.  This is due to a convergence of factors from market forces and new reimbursement mechanisms to better technology.

Here are some observations:

This is the year digital health became a ‘stay-in-business’ application for the majority of providers and payers.  Everywhere I go, the dialogue is about implementing digital health in order to remain competitive.  The days of lengthy interrogations from decision makers about ROI, liability, reimbursement, and workflow seem to have faded into the past.

The Centers for Medicare and Medicaid Services (CMS) is on board! New codes have been presented over the last couple of years and they have embraced them.  These new codes are classified in such a way that they do not drag with them the geographic restrictions of legacy telehealth reimbursement.  While the impact is not yet obvious, this will make a huge difference in time.  I predict that adoption of these new codes in 2019 will be modest, but as third-party carriers follow CMS’s lead, their use will take off.  This will act as a springboard for new care models such as asynchronous, patient-initiated evisits, remote monitoring for chronic illness, and brief online inter-professional consultations between primary care providers and specialists.

With crystal ball in hand, I offer several other observations and prognostications for the year ahead:

Because of the sheer PR power that Apple possesses, this was the year that consumer devices became medical devices.  It is too early to know whether the cardiac rhythm features in the Apple Watch will make a difference, but the world was abuzz with conversation about these new capabilities.

There is also growing discussion and interest in treating the whole person — treating more than a single symptom or condition — which can lead to improved outcomes and lower the cost of care. For example, integrating primary care with mental health and substance use disorder can proactively identify patient needs and better coordinate care to address and resolve potential issues. Value-based care emphasizes collaboration between care settings; and combines community-based resources with clinical care.  These themes are part of a tendency to turn away from the coldness of technology and a renaissance of the human aspects of clinical care.

We have seen the market moving towards more consolidation, including the merger of ‘strange bedfellows…’ think CVS Health and Aetna; AthenaHealth and Veritas; Amazon and PillPack; Amazon, JP Morgan, and Berkshire Hathaway. With these consolidations, we will also finally begin to incorporate some of the learnings from consumer organizations — like engagement and personalization strategies — into our healthcare system. These developments make it hard to render predictions, as they don’t really seem to have a common theme other than consolidation. In 2019, we’ll learn more about what Amazon has in mind, what CVS/Aetna can really bring, what Walmart is up to, etc.  I, for one, am not predicting how all of this will unfold.

I’m pleased to note that more attention is being paid to social determinants of health, both within and outside of healthcare, to promote health and health equity.  We know that the conditions in which people are born, grow, live, work and age can influence health, and there are a number of emerging initiatives to address these factors.  Once again, it is difficult to say how this will shape the market and care delivery, but it is a welcome emphasis.

Similarly, the business value of diversity in our workforce is being recognized, as a diverse workforce leads to insight from multiple points of view. For example, diversity is one of the greatest drivers of innovation, creates a robust learning environment and a more inclusive culture.

At Partners Connected Health, we saw great progress on several fronts, including the launch of a new mobile app for our PGHDConnect program, a cloud-based digital health platform that allows patients to share personal health data with their care team seamlessly and securely using their own consumer devices, via the Partners eCare Electronic Health Record (EHR). Our new telehealth initiative is gaining traction; and in collaboration with Persistent Systems, we launched Pivot Labs, a new center of excellence focused on reimagining the patient experience. Our Partners Online Second Opinion (POSO) team created a new online experience, to help patients and doctors from around the world benefit from remote consultations by national and international leaders in medicine, research, and training at Partners-affiliated hospitals.

Dr. Cynthia Breazeal at the Connected Health Conference 2018 – Photo courtesy of Christopher Huang

In October, we served as the Organizing Partner of the Connected Health Conference, in partnership with HIMSS’ Personal Connected Health Alliance. This thought leadership event will again return to Boston in 2019, and I’m pleased to continue as Program Chair for this important summit. As part of our mission to educate, inform and inspire others in the adoption of connected health strategies, I also launched a new podcast series, Well/Connected. We recently concluded our first season, and have lined up a schedule of premier visionaries and innovators for the year ahead.

With great momentum and enthusiasm, we close out the year and look forward to 2019 and what promises to be another exciting year!  I wish all of you a warm, healthy, holiday season filled with family and fun.

 

 

What does the 2018 Connected Health Conference tell us about the state of the industry?

November 2, 2018

These days, there are lots of places you can go to learn about trends in the digital health market. Over the years, the Connected Health Conference has consistently lived up to a reputation of being the place where a balanced, no-hype view of the industry is presented, giving the audience a clear roadmap of what to expect and prepare for over the next 18-24 months. As program chair, I admit to being biased, but I’d say this year was no exception.

One striking observation was how this year’s theme, “Balancing Technology and the Human Element,” served as a loom, allowing us to weave the conference together, creating a single tapestry. That tells me that we’re reaching an inflection point with the adoption of technology in healthcare, as more automation creeps in. Both consumers and providers are concerned about how technology is altering their relationship with one another. For example, as we see more concrete examples of artificial intelligence, there are corresponding fears – fear of job loss or at least a loss of job satisfaction on the provider side, and fear of a more impersonal, less human relationship with the doctor on the consumer side. This is expressing itself as a trend toward more attention given to design, and more thoughtful user experience design, for digital health products and services.

Another observation from the conference is that we’ve crossed the threshold of thinking about a digital health strategy to actually executing one. A digital health strategy has become a stay-in-business requirement for both payers and providers. This, despite the fact that reimbursement is still evolving, the technology itself is still evolving and adoption is somewhere between early adopter and early majority on the famous s-shaped adoption curve. Everyone is all in.

I believe the reason is that those individuals who are mostly healthy expect a high-quality digital experience when they consume any service — and why should healthcare be any different? Both providers and payers covet this demographic, so are marching forward with a digital strategy as a way to capture as many of these folks as possible and to keep up with their competition.

My interview with Aetna EVP and CMO Harold Paz (Photo by Christopher Huang)

I had the pleasure of interviewing Dr. Harold Paz, Chief Medical Officer at Aetna, during the conference and his comments largely confirmed these trends. This, of course, is all music to my ears. But, it’s worth mentioning because, as you may recall, we went through about a decade when healthcare executives looked at digital health with a good deal of healthy skepticism, and suddenly it seems like no one is skeptical anymore.

One of the more fun sessions was a debate between colleagues Andrew Watson and Ateev Merhotra (moderated by Partners HealthCare Chief Digital Health Officer, Alistair Erskine) on the value of telehealth. Both debaters did a good job. Andrew (taking the position that telehealth is cost-effective) spoke from experience and as a telehealth visionary, but I daresay Ateev had more hard data to back up his position that cost-effectiveness evidence is lacking. At the end of the debate, the audience was firmly in Andrew’s camp, confirming that we’ve crossed that threshold from skepticism to execution.

FCC Chairman Ajit Pai delivering his Thursday morning Keynote (Photo by Christopher Huang)

The technology is coming along. This was in evidence everywhere: from Federal Communications Commission Chairman Ajit Pai’s keynote about initiatives to get broadband to all citizens (I am particularly enthusiastic about 5g), to a panel I had the honor of moderating on the state of IoT in healthcare (the state is quite healthy, to steal a pun), to the parade of exciting startups in our annual “HealthTech Standout Competition.” See also the reference to better design above. With so many people working on better ways to integrate wearables, more compelling, engaging software, and better security without added complexity, the future of digital health is bright from a technology perspective.

Another striking observation was that the companies that exhibited at the conference are maturing their offerings. This comes across to some as ‘nothing new on the exhibit floor,’ but I see it differently. There are enough mature products and services. and enough of a sense of the market in 2018, that we have a mature exhibit floor. Those exhibiting are refining products, preparing them for scale and getting ready for the bump in activity that will come with new reimbursement codes imminent in the next couple of years.

Also on the exhibit floor, the Innovation Zone showcased corporate and academic innovation centers, accelerators, incubators, and portfolio companies. This was the place for entrepreneurial healthcare providers, market-leading tech and medical device companies, pharma and biotech leaders, startups driving healthcare consumerization and organizations fueling the innovation economy to meet, network and create opportunities. This kind of collaboration would have been unheard of just a few years ago.

AMA’s Digital Health Playbook

Yet another sign of maturity is the American Medical Association‘s (AMA) involvement. Just five years ago, digital health was barely a blip on their radar. Now, in addition to a very successful strategy to improve reimbursement, they are offering physicians tools to help them adapt to the new digital world. One example is the AMA’s new Digital Health Implementation Playbook, which they launched at the conference. When the AMA gets behind something, it is going mainstream. Another indicator of the mainstreaming of digital health was the strong showing of providers in attendance. In fact, the number of healthcare providers that attended CHC18 more than doubled from last year’s event. To help put that number in perspective, there were 41 speakers on the program from Partners HealthCare-affiliated hospitals, including Massachusetts General Hospital and Brigham and Women’s Hospital, and many more in the audience.

Another theme that was clearly in evidence was the attendee enthusiasm for digital health. Across the board, people had fun and learned. More than one person commented to me that the Connected Health Conference is the one event they attend every year because they get an update on the industry and everyone they want to meet is in attendance.

Our closing panel of rockstar women having fun in the green room after their presentation (From L to R: Kyra Bobinet, Rose Sheehan Aenor Sawyer, Patti Maes, Aimee van Wyndsberghe)

We also received kudos for the number of women speakers featured throughout the program, as well as patients participating in several panel sessions. This is a testament to the high caliber of women executives, entrepreneurs, and providers who are helping to lead the charge toward the future of technology-enabled health and wellness. At our closing session, we had a blockbuster panel of women, discussing the future of care delivery, noting that how well we succeed in taking advantage of technology to solve the challenges of healthcare will depend, in part, on its symbiotic integration into human-centered care. It was a dynamic and inspiring discussion to end the conference.

Partners Connected Health is excited to partner again next year with HIMSS and the Personal Connected Health Alliance, and we’re looking forward to another exciting event. The Connected Health Conference will be back in Boston, October 16-18, 2019, so mark your calendar!

Is talking to software the next big step in healthcare delivery?

September 11, 2018

Provider to Patient Ratios by 2020

In my latest book, The New Mobile Age, we spend some time talking about the growing demand for care (we’re getting older and older people need more care) as compared to the flat supply of healthcare providers.  The outlook is bleak – we’re running out of young people to take care of old people. It is a global problem.

I can only think of one solution — to introduce more automation into the care delivery process. I’ve written about the need to adopt the use of technology to create one-to-many care delivery models in several recent blog posts looking at technology and the provider, voice technology, and connected health for our aging population.  It was also the subject of a recent TEDx Talk.

In this context, I’ve become very interested in chatbot technology and am wondering if it’s ready for prime time. Could we create a near-term future where your first interaction with the healthcare system is via an automated chatbot?  Are today’s chatbots up to the challenge?  Are we able to seamlessly escalate to a human being, if necessary, so you don’t feel trapped in chatbot hell?  Will individuals feel cared for and will we be able to spread our healthcare provider resources across larger populations of patients?

To achieve this, an individual’s conversation with a chatbot has to approach feeling human.  This is not a new concept.  In 1950, Alan Turing developed a test where a human being interacted with a computer and, in order to pass the test, the computer needed to seem human to the person.  Over the years, computers have gotten better and better. Alexa and Siri are ubiquitous now, but do they pass the test? Only in a very narrow way.

James Vlahos

James Vlahos is a journalist who writes about this topic and, in fact, created a ‘DadBot’ to immortalize his father’s life story before he passed away. You can read more about this in a very poignant story James wrote for Wired last year. He will be a keynote speaker at the Connected Health Conference on October 18 and I’m excited to hear what he has to say.  In February, he wrote another intriguing article for the magazine, about Amazon’s Alexa prize, which offered a significant sum of money to create a bot that could carry on a conversation for 20 minutes.  There was no winner, but I highly recommend reading the article, which illustrates the subtle ways our minds work and that, so far, no computer is able to think in such a nuanced, sophisticated way.

But, the functionality required in bots used for frontline healthcare interactions may not need to be as sophisticated as Amazon was shooting for. Several years ago, we collaborated with a computer scientist at Northeastern University (Tim Bickmore) to investigate whether a software bot could motivate people to be more physically active.  We called her ‘Karen the virtual coach’ and she had both visual (a cartoon-like persona) and auditory (an early speech-to-voice engine) components.  The paper is worth reading, but the bottom line is that we showed that folks who interacted with Karen three times per week were significantly more likely to achieve their exercise goals than those who did not. Interestingly enough, we found that participants either loved or hated Karen. At the end of the study, a few participants asked for her phone number as they contemplated inviting her on a date!

Our study was published in 2012, and in the last few years, a whole burgeoning industry of chatbots for health has sprung up.  It is still early going and, in my experience, none of these is quite ready for prime time.  Following is a brief review of several prominent companies working in this space.  I’m sure I missed some, so if your favorite health chatbot did not make the list, leave a comment or send me an email so I can be educated.

Conversa Health focuses on three areas: care management to deliver efficient chronic care management, decrease remissions and optimize pre- and post-surgical care; marketing/patient experience to increase patient acquisition, improve patient satisfaction, patient retention, and generate incremental patient visits; and improving patient responses.

XebraPro

XebraPro is a decision support tool for physicians, not to be confused with Xebra, which is a medical imaging software platform.  XebraPro, from Physician Cognition, has two versions, one for differential diagnosis and one called XebraED, an education tool. Unlike Conversa and some of the others, XebraPro is a tool to improve physician accuracy and efficiency.

Buoy, an online a symptom checker,  guides you through a series of questions and then recommends a course of action.  Their business model steers patients to a provider organization.  Using their site or app does not feel exactly like having a ‘chat’ but rather filling out a questionnaire.

Medumo focuses on care navigation and instructional support to help patients.  The primary delivery mechanism is text messaging or email, and the primary value proposition to the provider is getting patients to their appointments. Patients who don’t keep appointments generate a significant administrative burden and Medumo has set out to solve for that.  Mostly their communication is outbound to the patient, so it does not feel like a chat, per se.

Babylon Chatbot Interface

Babylon believes it is possible to put an accessible and affordable health service in the hands of every person on earth, using a combination of artificial intelligence and natural language processing.  They made instant headlines by winning a contract with the National Health Service of Great Britain. Their interface is very similar to Buoy, guiding an individual through a series of branched logic about their symptoms to a recommended course of action.

Lark combines artificial intelligence with behavior change design to create a scalable, personalized care management platform. Lark claims to be clinically validated to deliver positive health outcomes across each major chronic disease state, with its main virtual coaching platforms used for diabetes and hypertension.  The interface is a bit wooden in my experience, and there’s no attempt to disguise this to be anything but a dialogue with a software bot.  The bot asks questions and you choose various answers.  It seems overly simplistic to me.

Memora is an automated discharge chatbot that can also manage follow up paperwork, enabling a care team can focus on the patient instead of the details of discharge planning. Their virtual assistant is named Felix, and the idea is for Felix to have an identity.  The goal is threefold: to increase a care team’s capacity; rapidly identify high-risk patients, and deliver a world-class patient experience. It also streamlines time in front of a screen for the patient, promises 24/7 responsive team members, and an immediate start.

Tess by X2AI

X2AI seems like the most up-to-date version of AI of all of the technologies I have reviewed so far. With the goal of supplementing human therapists, researchers are instructed to teach empathy to artificially intelligent messaging tools. Their assistant is called Tess and she can schedule an appointment with a therapist, have a dialogue with a patient or connect the patient to one of the on-call therapists around the clock, for a small fee of $5 a month. Another useful feature is the nightly text encouragement from a therapist and suggestions that accompany each text. The goal of X2AI is to create a patient experience that includes interactions with Tess and some with people, with the software seamlessly triaging the interactions.

There is so much rapidly-moving innovation in this space — from companies with vastly different personas and consumer/patient interactivity — that we have to keep close tabs on it. From XebraPro, a diagnostic aid for the physician, to Buoy and Babylon, symptom checkers, to X2AI, a virtual mental health counselor.  They all share one thing in common, which is a backbone of artificial intelligence.

At some point, the first part of any healthcare journey will be interacting with software like this. In some cases, that’s all that will be required. In others, the interaction will move to a telemedicine solution with a provider and, in still other cases, the interaction will move to a face-to-face experience with a provider.

How far into the future is this?

Reimbursement Update: It’s raining new codes!

August 21, 2018

Reader alert: reimbursement codes are not exciting but are critical in advancing connected health… and, after all, we all want to advance connected health. Read on!

It is just shy of two years since the American Medical Association (AMA) asked me to co-chair their Digital Medicine Payment Advisory Group (DMPAG).  At the time, I was waking up to the idea that, for us to speed adoption of connected health in the provider community, we need more billing codes. This may sound obvious to all of you, but I was a late-comer to this party. My reasoning was that value-based reimbursement is growing and value-based contracts are very telehealth friendly, so why should I waste my time on bolstering the fee-for-service reimbursement system?

The insight I gained from this collaboration was beautifully articulated by the AMA’s CEO, Dr. James Madara, during an interview I did with him on my new podcast, Well/Connected (click here to listen to Jim talk about this directly). Jim said that no matter what reimbursement system you choose, providers need to have a way to quantify their work product and codes allow them to do that. Indeed this has helped me understand why adoption of remote monitoring for care of chronically ill patients has lagged. Until very recently, we had no mechanism for providers to document the level of work required to take care of patients in the context of remote monitoring.

2017 was the first year of DMPAG activity and, early on, we decided to move two new types of codes through the process, one for physician-to-physician online consultation and another set for remote monitoring.  I detailed this journey in a post in November 2017.

In that post, I had referenced the Lemony Snicket movie, “A Series of Unfortunate Events,” noting that Medicare reimbursement for remote monitoring was just the opposite: it was the culmination of aseries of fortunate events. Back in November, these new reimbursement codes had been moved forward to the point where they were sitting with The Centers for Medicare & Medicaid Services (CMS) committee that proposes a value for them (known as the RUC process). It’s old news now, but as of January 1, 2018, CMS also unbundled an old code – CPT 99091 – that allows a practitioner to bill for the evaluation of remote monitoring data.

I don’t have specific data on utilization of that code, but anecdotally, it has not been a big hit. It requires a doctor (or nurse practitioner) to review data for 30 minutes/month in order to submit the code.  In our experience, unless a patient is very sick and complex, no one provider devotes 30 minutes of time/month reviewing remote monitoring data.  This code was as step in the right direction but predictably not a big winner.

About a month ago, CMS came out with their guidance on what new codes they propose to include in the code structure starting in 2019.  Some of what they published was predictable, moving forward with the codes we submitted last fall, and some was unpredictable, with the addition of new codes. But as far as I can tell, all of it is positive!  CMS is now collecting comments on these proposed new codes and, once again in November, will release what is to be included in the 2019 code set.

So, I warned you.  I tried to think of a way to make this topic interesting, but there’s just no way around it, CPT codes are necessarily dry and technical. The exciting part, however, is the receptivity of CMS, under current leadership, to move connected health forward.

New and Exciting Proposed Reimbursement Codes!

Two of the new codes are different from CPT medical billing codes. So, without getting too deep into the weeds, following is a very brief explanation of these two new codes, known as HCPCS codes (Healthcare Common Procedure Coding System). If you want to learn more about the difference between CPT and HCPCS codes, follow this link.

New Proposed Code #1: Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code GVCI1)

This is to replace a code (99441) which covered a brief telephone check-in with the patient between office visits to determine if the patient needed to come in sooner or make another adjustment.  This is a new area for reimbursement and CMS is looking for lots of early stage guidance. It’s not clear what the fate of this code will be, but the fact that they proposed it is encouraging.

New Proposed Code #2: Remote Evaluation of Pre-Recorded Patient Information (HCPCS code GRAS1)

This is to cover remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with verbal follow-up with the patient within 24 business hours.  This would seem to be a dream come true for my dermatologic colleagues (and others who evaluate images as part of their clinical decision making).  This is also early stage, but CMS suggested a value(0.8 RVU) for this code, leading me to believe they are serious about it.

Also of note is that the interprofessional Internet Consultation codes (CPT codes 994X6, 994X0, 99446, 99447, 99448 and 99449) were recently valued by the RUC, and CMS is seeking comment on some of the details.

Finally, there is good news for the home health industry, as CMS is proposing reimbursement of remote monitoring services in that sector as well.

Admittedly, all of this is a very superficial review, and for those of you interested in the details, start with the CMS announcement and work your way through it.

And even if you’re not interested in the fine print details of reimbursement, for telehealth adoption, the future looks quite bright, considering that, when CMS pays for services, it is common for other carriers to follow suit. It’s a reality I have come to appreciate – even in a value-based care delivery system, providers need to quantify their work and billing codes for connected health are a necessity.

And what does all this mean for connected health? In the next few years, as these reimbursement trends continue, we could finally begin to see the needed acceleration of telehealth adoption. And that is a very exciting proposition!

 

 

 

Aging and Technology: An Intimate Discussion with Thought Leaders

June 27, 2018

We all want to live a long and healthy life…

This was my opening statement at an event we co-hosted earlier this month.  We did so in collaboration with our friends at the d.health Summit, after learning that they were bringing their yearly thought-provoking gathering on all things aging to Boston. When Ray Dorsey first brought me into the fold as a member of their advisory board, he said to me, “The ‘d’ is for disrupt, not digital,” which, in my opinion, best describes why this is a must-attend conference for anyone in or interested in the field.

So we wanted to do something collaborative with them; to welcome Ray, Anna Stevenson and company, and show our support in hopes that they’ll bring the d.health Summit back to Boston in future years. For our part, we collaborated with Ray and his team, as well as the Personal Connected Health Alliance (PCHAlliance), to host a two-hour preconference event on June 5, the eve of the Summit.  We called it Aging and Technology: An Intimate Discussion with Thought Leaders. Included in the mix, besides yours truly, were friends Bruce Leff from Johns Hopkins, Charlotte Yeh from AARP, award-winning journalist Laura Landro and Ray himself.  Three of us gave brief talks (Bruce, Charlotte and me) followed by a panel discussion including Laura, moderated by Ray.

I enjoyed the event and gained many insights, so much so that I thought memorializing it in a post would enable others to learn too.

I was up first, and my talk covered themes from my new book,The New Mobile Age: How Technology will Extend the Healthspan and Optimize the Lifespan,as well as some insights I’ve already gained since we published it about six months ago.  I debuted my new stage buddy, the robotic cat (one of the Joy For All Companion Pets from Hasbro), which my daughters named Checkers. I covered many themes but, in an effort to be succinct:

  • We all want to live a long healthy life: ‘long’ as in longevity and we’ve done well there, adding 25 years to the lifespan in the past century; ‘healthy’ is where we have uneven results, that is the healthspan.
  • From a societal perspective, we need to better engage older individuals, providing them with opportunities to maintain a sense of purpose, social connections and increased physical activity. Technology can help with all of these.
  • For individuals, the decisions we make that lead to a shortened healthspan are a combination of data and emotions. Technology can help us with the data part of the equation.
  • Care-giving is in need of an overhaul, going from our current one-to-one model to a one-to-many model. Technology (robotics, artificial intelligence and other digital and emerging technologies) is critical.  I brought Checkers onstage to point out that, if we use technologies such as companion pets wisely, we can begin to attack this challenge.

Bruce Leff, a geriatrician and Director of the Center for Transformative Geriatric Research at Johns Hopkins,is a pioneer in bringing the hospital into the home. He has overseen research and implementation in this area for years and opened his presentation by telling a story about house calls when, as a medical student, he noticed how the relationship changes when a provider visits a patient in their home. You are a guest and behave differently and deliver more personalized care.

Bruce further asserted that the future of hospitals is specialized, acute care. (I agree, but we keep on building buildings. When will the tide turn?) Following that, he suggested that a supply chain for services in the home needs to be developed, as home-based care will become part of the US healthcare system, likely within the next 25 years, and hospitals will eventually turn into large ICUs.

Charlotte Yeh, Chief Medical Officer for AARP Services, is always inspiring.  Her message is that we must re-think what getting old really means. People over 50 are happier, better at problem solving, pattern recognition, empathy and have twice the success rate in entrepreneurship. Wisdom is a real thing. And if that wasn’t enough, she pointed out that the 50-plus community contributes more than $7.6 trillion dollars to the economy. Charlotte built a compelling case as to why we should stop thinking about older adults as a burden, and instead see them as an asset.

She also emphasized how important a sense of purpose, positive attitude and connectedness is, and provided some meaningful statistics:

  • Older individuals with a sense of purpose have 40% lower health care costs
  • Older adults who feel isolated cost Medicare $6.7 million additional dollars
  • And, a positive view of aging helps you live 7.5 years longer

She concluded with her rallying cry: Instead of aging in place we should be thriving in motion!

We also had a terrific panel discussion. Ray asked penetrating questions.  To kick off the conversation, Laura Landro, who had just published an important article in a special report on health in The Wall Street Journal, talked about trends in care delivery, noting that the hospital as we know it is becoming a thing of the past. Things like micro hospitals and ambulatory surgery are where it’s at today.

Charlotte added that there needs to be a shift from the medical model of care to a personal model of care — in healthcare healthis the ultimate outcome.  For the consumer, living wellis the ultimate outcome, but our current provider structure has failed to acknowledge the shift.

Ray asked the group to address those factors standing in the way of greater adoption of connected health technology. I made the first volley, stating that we haven’t done our best at thinking about what the individual wants and needs, or how to design technologies to appeal to the patient. For example, products to help the ‘sandwich generation’ — designed for adult children of aging parents — can be a turnoff for the parent or feel intrusive. Charlotte rightly pointed out that we also need to understand what a technology is solving for. For example, feelings of isolation are very different then feelings of loneliness and are solved via very different tools.

Responding to the question about how to close the intergenerational gap, Charlotte suggested we start in the workplace, hiring older adults, which has been shown to improve productivity. I noted there is also a digital divide, which creates design challenges. For example, people with two or more chronic conditions tend to use less technology, yet they could potentially benefit the most.

Ray posed a final question: If you could make one change to help aging Americans, what would you do?

Bruce suggested that we liberate payment from the doctor visit, which could go a long way to opening up new opportunities.

Charlotte responded by suggesting we change how we measure success. Rather than looking at data on mortality, morbidity, hospital readmissions and the like, she would measure life satisfaction.

If I had to identify one change to help aging Americans, it would be to accelerate value-based payments. In this way, we change what we measure and change what we pay.

And, finally, Laura urged that we work on patient engagement, and finding ways to figure out those who are in most need and then pay for services that will help them take better care of themselves.

We wrapped up the event with a networking reception and the hopes that Ray and his team will bring the d.health Summit back to Boston again next year. We are also looking forward to continuing the discussion — Partners Connected Health, PCHAlliance and the d.health Summit — as part of the 2018 Connected Health Conference taking place in October.

The importance of this topic can’t be overstated.  As we enter the era where our over-65 population outstrips our youth in numbers, we need to completely rethink the older demographic and how we can leverage this amazing asset as a society.

 

Privacy Trade-Offs: Where do we draw the line in healthcare?

May 10, 2018

Everybody has something they consider private.  I think of it not as an absolute but as a sliding scale.  We all have stories about (typically young) people who share everything online in a very open way, seeming to not care about potential ramifications. But, I suspect even they have information they’d rather not share.  There are others who eschew any online presence entirely because they feel all of their information should be private.  Importantly, there is no right or wrong here; it is a personal matter.

And, there’s the old adage, pay attention to what people do, not what they say (bear with me on what this has to do with privacy — and connected health).  How many times have you heard that?  The root of this pronouncement lies in the fact that our brains color perception in so many complex ways that we report information that is often at odds with reality. Logic would dictate then that accurate, independent measurement that reflects reality is a better source of truth than asking any individual for their opinion.  Hey, isn’t that what wearables, mobile phones and sensors do?  Yes, they do!  Thus, if I want an accurate, quantitative representation of your life so I can help guide you to a healthier future, I want access to all of that ‘digital dust’ that you leave behind every day without thinking about it… GPS data from your phone, mobile purchasing habits, step counts, number and frequency of outbound messages, etc.  If I could get access to all of that information and create a unique persona of you, I’d have a better chance of guiding you to a healthier state than if I just asked you for answers to a handful of questions. The challenge lies in how an individual defines what parts or pieces of that data should be considered his/her ‘private information.’

The recent Cambridge Analytica debacle was a wakeup call for me.  Until then, I had the attitude that if people were so concerned about privacy, they must have something to hide.  Now I see what having your private information lying around like ‘loose change’ can do.  It IS a real challenge.  What are we to do?  Rely on inadequate, self-reported data to make decisions that guide an individual to improve health or convince them to share data that they may consider private.

Walgreens Balanced Rewards App Dashboard

There are four examples I know of where companies are flirting with this dilemma in the marketplace.  United Healthcare, for a couple of years now, has been giving people up to $4/day if they meet certain activity goals – as measured by a wearable.  Walgreens, via its Balanced Rewards program, offers customers in-store savings if they meet certain activity targets. Oscar Insurance and Humana, via their partnership with Vitality, have similar programs.  Thus, a small subset of consumers is getting used to trading private information for a financial, health-related reward.

I wonder if the recent noise about Facebook and Cambridge Analytica is changing consumer ideas regarding these programs.  Will enrollment enthusiasm cool?

Then there is the inevitable conversation as to whether health data is really different.  There are numerous data breaches today, credit card hacks is just one example, yet people continue to shop online, bank online, book travel online. The risk, and the convenience, is worth it to most people.  The biggest fear that sets health data apart is the fear that an insurer will deny coverage based on these data.  The Affordable Care Act, by prohibiting plans from denying coverage of preexisting conditions, should have eased these fears.  Our current political uncertainty undoubtedly raises anxiety.

I am not aware of any insurer who is collecting wearables data and then using this information to increase an individual’s cost of care.  With these early experiments, insurers are focused on rewarding individuals for healthy behavior.  Could we see a future where companies funding the cost of care use creative benefit design to shift more costs to individuals demonstrating poor health behaviors?  I think so.  It would show up as a higher baseline premium, while maintaining rewards for those achieving healthy behaviors (i.e., the consumer showing poor choices would not feel punished).

In The Internet Of Healthy Things, we talked about a number of these issues, including a vivid description in chapter 1 of a future where I trade lots of personal information that enables a personal health coach to guide me to healthier behaviors, in exchange for a premium reduction.

There has been a lot of talk recently about Facebook’s business model.  Some have suggested they offer a subscription service which allows users complete privacy. The company has rejected this notion, probably because selling targeted ads is far more lucrative than any subscription model they can envision.  By way of analogy to the healthcare insurance world, a future where you remain largely anonymous to your insurer is likely to be very costly to you.  Although insurers are not selling ads, they will get similar value out of knowing about you so they can target programs to you that have the best chance of improving your health.

I firmly believe that it is critical — in support of lowering healthcare costs and improving health outcomes and provider productivity — that we begin to synthesize these passively generated health data and use them to drive individual health recommendations.  Data breaches like the Cambridge Analytica example are scary and will set back public opinion on this topic.

The industry is taking notice.  The recent OpenMedReady framework developed by Qualcomm, Philips and others is one example.  Maybe if we work together we can thread the needle and get this one right.

Do you have suggestions on how we can leverage personal health data to drive better outcomes but assuage anxieties around privacy invasion?