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Value-based or Fee-For-Service Connected Health Reimbursement: Which Canoe Should We Put Our Feet In?

April 17, 2018

About 10 years ago, I and many others, started talking about how care delivery enabled by connected health should be an ideal strategy in the world of value-based (VB) reimbursement. To date, there have been just a few instances where this has come to pass. Most relevant is Kaiser Permanente, where > 50% of patient interactions are virtual.  Unfortunately, there are few other examples of organizations that have invested heavily in connected health and state publicly that it represents a strategy for success in a value-based world.

Image courtesy of National Telehealth Policy Resource Center

By contrast, in the past decade, there has been significant progress in payer reimbursement for telehealth as a service (fee-for-service [FFS] payments).  For example, 48 states now have Medicaid requirements for telehealth reimbursement (10 years ago it was about 25); 21 states have requirements for remote monitoring reimbursements; and 15 for store-and-forward telemedicine reimbursement.  Currently, 33 states have parity laws that mandate private payer reimbursement for telemedicine services.  This clearly reflects the growing mainstream adoption of connected health.  The ongoing work of the American Medical Association’s Digital Medicine Payment Advisory Group (DMPAG – which I have the privilege to co-chair) is also an important force in creating CPT codes which will enable even more fee-for-service payment activity.

For healthcare provider organizations experimenting with value-based payment scenarios (ACOs, bundles and various risk arrangements with local health plans), doing business in the last several years has been described as having “a foot in two canoes.”  The tools you use to optimize reimbursement in the two worlds (FFS and VB) are sometimes diametrically opposed.  As we look at the trends in connected health adoption, is it time to think in terms of FFS-driven business plans and declare which canoe we should put our feet in?

Before I disclose my opinion, it is worth looking at how value-based programs have been implemented, to see if there are any clues as to why connected health has not been the savior as I thought it would be.  I’ll try not to over-complicate this part, as there are multiple value-based models and they get pretty complicated pretty quick.

Medicare ACOs are based largely on a shared savings model.  For the population that Medicare defines as ours, providers get paid through the usual Medicare financial channels (i.e., fee-for-service billings), and try to manage various costs in such a way that we meet savings targets on a yearly basis.  Given that the basic transactional model hasn’t changed, it is probably not surprising that care delivery at the ground level has not changed that much.  If I am a doctor seeing Medicare patients, I still get paid for office visits and procedures.  It’s the job of the delivery system I work for to manage those costs and contain patient interactions so I don’t incur unnecessary costs by billing for services I perform.

With the exception of full capitation (after our experiments with this in the mid ‘90s, no provider has any stomach for this model), all value-based models are variations on this theme.  As a result, there is much hand waiving about providers getting paid for ‘outcomes and quality’ and, at the system, level we are.  But those individuals who are doing the work, day in and day out, are being paid for services rendered just like they used to.

There are many other nuances to talk about regarding value-based reimbursement strategies, but this is the fundamental reason that connected health has not become more of a critical component to success in these VB programs.  Whatever the payment model at the top of the food chain, if a provider can’t get paid for a service rendered, it is predictable that she won’t provide that service.

This realization hit me a year or two ago and I decided to put more personal energy into creating opportunities for ‘ground-level’ providers to adopt connected health. It was right after that that the AMA graciously asked if I would be willing to help with their DMPAG. It was a perfect fit for how my thinking was evolving.

I am not trying to make the case that value-based payments will go away. On the contrary, they are here to stay.  I am just as bullish on connected health as a strategy for success in the VB world as I was 10 years ago.  Our own examples of success at Partners HealthCare — such as using home monitoring to manage readmissions in patients with congestive heart failure, and to streamline management of patients with hypertension — are proof that connected health can provide value in these settings.

However, until we change how those providing care record that they provided a service and thus derive their income, we can’t expect providers to happily embrace connected health as a strategy, whatever the system-level incentives.

Another lens to view this through is the use of connected health in care delivery.  One of the fastest-growing segments is video-based, virtual visits.  This tool improves patient access but has minimal impact on efficiency of care delivery. Thus, the future of virtual visits, in the context of value-based programs, is not clear.  By  contrast, asynchronous telehealth (direct e-visits with patients and e-consults between providers) provides an opportunity for both efficiency and improved resource utilization.  As a dermatologist, if I am asked to review a short history and a couple of images generated by one of my primary care colleagues, in many cases, I can help that individual care for the patient without the patient seeing me.  The differential for what I get paid for the e-consult, versus an in-office visit, is significant and helps the organization with its top line resource management.

The case for remote monitoring is even stronger in this context.  One nurse in a call center can manage (by exception) 100 or so patients with congestive heart failure.  This is where efficiency really kicks in.

So, putting feet in the fee-for-service canoe makes sense for now. It is the only way to insure provider adoption.  However, we must keep in mind the big picture of how we fit into value-based arrangements.

What are your views?

Bring Your Own (Health Monitoring) Device: Progress and Challenges

March 12, 2018

As we see virtual visits go mainstream (witness the recent prime time TV ad from UnitedHealth Group during the Winter Olympics), adoption of remote patient monitoring is lumbering along, still in the land of early adopters.

There are several reasons for this lag (and for the corresponding growth in virtual visits).

  1. The unit of service is a visit. For now, doctors still make most of the decisions on how healthcare is delivered. They have a deeply engrained view of care delivery measured in units of visits.  For millennia, this is how we’ve been delivering care and capturing/codifying related work – in terms of visits.  Remote monitoring opens a world where the service offered isn’t a visit, but rather surveillance of a population with proactive, preventative care and management by exception.  Despite our commitments to the Patient-Centered Medical Home and value-based payment models, we have yet to get comfortable with the workflow around surveillance and management by exception.
  2. Payment is still a concern. There is progress (see my related post) on this with the unbundling of CPT code 99091 by the Centers for Medicare and Medicaid Services (CMS) and new codes expected for 2019. But uptake of 99091 has been slow because it allows for time spent on the collection and interpretation of patient generated health data at a minimum of 30 minutes of a physician’s review time, per 30 days.  It is hard to scale that in a busy practice.
  3. There are three aspects of the technology that need refining: cost, usability and EHR integration.  I intend to expand upon these items in this post.

At Partners Connected Health, we’ve been working on each of these issues, using a new ‘bring your own device’ (BYOD) infrastructure and a process that democratizes the deployment of remote patient monitoring devices. But let me back up for a moment.

For several years, we managed remote monitoring programmatically.  We had dedicated staff, a preferred solution and managed our own device inventory.  We reasoned that the best use case for remote monitoring was in the context of our value-based payer contracts and that the deliberate roll out of this care model would make the most sense.  The logic was good, but the costs of maintaining inventory were simply too high.

At one point, we did an analysis and showed that at the current rate of program effectiveness and cost, we’d need to enroll 10 times the number of eligible patients just to break even on our risk contract bonus payments.  When presented with stark data such as this, we asked ourselves, “Can we make the program 10X more effective or should we think about lowering costs”?  As we grappled with this reality, we saw other use cases for patient-generated device data emerging across our delivery system; ones that we hadn’t anticipated and that our program structure could not support.  For these reasons we felt we had to venture into the brave new world of BYOD.

After surveying the marketplace for options, we formed a partnership with Validic and changed our process in some interesting ways. This is my first progress report on our new approach.

The infrastructure we set up with Validic (and also using tools from Intersystems Healthshare platform) is called the Connected Health Integration Pathway (CHIP).  It makes it relatively easy for our patients to collaborate with their physicians around their device data.  The first step is that the doctor invites the patient to participate through a link in our patient portal.  The patient goes through a straightforward set of steps and links their consumer device account with their patient portal account (this is the step that Validic enables).  Through the Healthshare integration, the clinician is able to see patient device data in the context of their Epic record. They can communicate about the data via the patient portal or in the context of an office visit.

This approach gets us out of the inventory business, for starters.  It also enables clinicians around our system who have novel ideas about using patient-generated device data to easily set up their own programs.  Our role is more enabler/support as opposed to program oversight.  In this way, this new infrastructure should help us with the cost conundrum referred to above.

We have been doing this for a few months so we’re just beginning our learning.  Here are a few early insights.

  • The overlap between people who wish to share their data and those we wish to monitor is small.  This is really not a surprise, but it points out that we are still some ways away from true BYOD.  Most of the clinicians that are using CHIP are finding ways to distribute preferred devices as part of trials/research programs or other efforts that have budget to support device distribution. So, yes, we are out of the inventory business but we’re not really seeing BYOD.
  • Despite our efforts to simplify onboarding, the technology is still complex.  Roughly 50% of our earliest cohort of patients had trouble connecting or staying connected. While onboarding is straight forward, patients must use third-party device manufacturer apps on their mobile devices as conduits to move data from sensors to the cloud, and these apps are widely variable in their usability.  One glaring challenge is that our preferred blood pressure monitor — from an accuracy/clinical perspective — has a very challenging, non-intuitive app. Just our luck. We’re watching carefully to get a sense of whether the resources we had put into inventory management will simply re-emerge as needed tech support resources.  This part is particularly frustrating for me…We need to all work together to reach the goal of frictionless data capture or ‘wear and forget’ data uploads.
  • There are indeed many more use cases appearing that we had not thought of.  For example, some of our providers are showing lots of interest in using activity trackers to follow post-operative progress and as a proxy for general health improvement.

It is early days in our new BYOD world.  I know we’ll get there.  I can see a path to ubiquitous use of patient-generated device data through continued improvements in technology (especially ease of use), improved EHR integration and new reimbursement pathways.  It is an exciting time.

What’s your experience with BYOD?

As Healthcare Providers, Technology is Our Friend (not a misprint)

February 19, 2018

Ask medical school applicants why they wish to enter the arduous 7+ year training process that it takes to become a physician and virtually all will have the following admixed in their answer: “Because I want to help people.”  The cynics among us will snicker, thinking that’s a canned answer lacking sincerity.  I disagree.  Most medical students I meet are sincere about their professional choice and want to do good.

Luke Fildes, “The Doctor”, 1891

In fact, a painting by the artist Fildes, from the late 1800s, depicts the purity of the patient doctor relationship. The patient in the painting, a child, will most likely die. But you see the doctor, at her bedside, at the family’s home, providing whatever care, comfort and compassion he could.

Fast forward to today. If you ask individuals finishing residency training and applying for their first jobs as attending physicians about their motivations, you’ll find that their answer will likely not be about helping people.  There are many reasons for this predictable change. In the last few years, frustration with electronic medical records has risen to the top of the list.  Most doctors quickly generalize these frustrations to include other technologies in the care delivery process.  That makes it tough for those of us making the case that technology can play an important role in improving care delivery.

I was privileged to speak at TEDx BeaconStreet this past fall, and chose to talk about this dilemma.  Many of the concepts in that talk are also covered in my recent book, The New Mobile Age: How Technology Will Extend the Healthspan and Optimize the Lifespan.

As healthcare providers, we’ve lost our way when it comes to the power of caring.  For more than 20 years, we’ve known that there is a positive correlation between a caring doctor/patient relationship and improved health outcomes.  Yet, for providers, today’s healthcare model creates unhappiness and frustration, forcing us to spend time on data entry, dealing with reimbursement issues and other mundane tasks instead of focusing our attention on caring for our patients.  And as our schedules come under more and more pressure, we will spend the allotted 7-10 minutes per office visit just skimming over each patient’s health problems, like a rock skipping on top of a body of water. All this is being compounded by the fact that, as our population ages — the older we get the more healthcare we need — we will run out of healthcare providers and caregivers.

What time is left to care, you ask?

Enter technology, in particular artificial intelligence (AI).  I was inspired a year ago when I read an article in the Harvard Business Review (February 2017) by Megan Beck and Barry Libert.  The title, ‘The Rise of AI Makes Emotional Intelligence More Important,’ gives you a hint at why.  They wrote about how the rise of AI makes emotional intelligence more important.  Most knowledge workers do a few things repeatedly – gather data, analyze, formulate a plan and execute that plan.  I immediately saw a parallel to the world of doctoring:  gather data = medical history and physical exam; analyze = devise a differential diagnosis; formulate = create a care plan; and execute that plan.  Beck and Libert point out that with the minimally sophisticated AI we have today, computers can do most of this work more effectively than people.  Yet, we pay little attention to the human side of care delivery that relies on those emotional intelligence traits that only humans and not machines possess — including caring, judgment and attention to quality. Likewise, I think care providers are underutilizing technology and continually trying to prove that our patients are better off if these routine tasks are done by humans.

Our traditional model of one-to-one care delivery is simply not an option, considering that, by 2020, for the first time in history, we’ll have more people over 65 than under 5.  That trend is projected to continue such that, by 2050, twice as many people will be over 65 as under 5.

The stark reality is, soon we won’t have enough healthcare providers to sufficiently care for our citizens.

We must adopt the use of technology to create one-to-many care delivery models, rather than the more traditional one-to-one model that is already overburdened. This is critical to bridging the gap between the growing number of patients and the diminishing number of care providers. I call this kind of delivery model connected health.

Healthcare professionals need to look for opportunities to outsource routine tasks to machines, not be afraid to do so, and appreciate the value of caring and human connection, judgment and attention to quality. We must develop these technologies to enhance and support the human interaction between a healthcare provider and patient.  If we do this, I believe we would improve care and satisfaction levels of both providers and patients.

Other service providers have done this.  Companies like Uber, Amazon and even the banking industry have integrated their digital and in-person experiences. In the case of Uber, for example, the service is delivered in person by a human, but the surrounding experience is made incredibly more pleasurable, convenient and efficient for the consumer and the driver by the use of technology.

We all need to work together to get this right — to use technology to create one-to-many care models that recognize the value of human bonding in the care process. Most healthcare providers went into the field because of their desire to care for patients.  The paradox is that, in order to free up time to do this, we must embrace technology and outsource routine tasks.

Moving from one-to-one care delivery to one-to-many will allow healthcare providers need to get back to caring for our patients.  Technology is our friend in this transition.

Apple’s Health Records App: A Ripple or a Roar?

January 29, 2018

To quote Yogi Berra, “It’s déjà vu all over again.” Or so it seems.

Apple’s Health Records App

Last week, Apple made a big announcement that headlines and excited many in our industry. They have enlisted two of the largest medical records companies, Epic Systems and Cerner, as well as Athenahealth, and a number of respected healthcare institutions, including Johns Hopkins Medicine, Cedars-Sinai, Penn Medicine and UC San Diego Health. And, according to their press release, they have built their newly updated Health Records app based on FHIR (Fast Healthcare Interoperability Resources), which is the interoperability standard for transferring electronic medical records.

This is all good very good news. I might add that Apple has build an undeniable reputation on their ability to create beautifully designed and highly intuitive software and highly integrated hardware. I dare say, no one does it better.

But I can’t help but recall similar attempts to create health data repositories for patients on their mobile devices. In 2012, Google shut down Google Health after just three years due to “lack of widespread adoption.” Microsoft HealthVault has also seen its share of challenges since it launched in 2007. Of course, Apple entered the health market in 2014 with its Apple HealthKit which, to date, has not been the game-changer it was originally expected to be. A few weeks after the HealthKit launch, I actually catalogued my wish list for Apple HealthKit, and several themes from that 2014 post are still very relevant.

While I applaud Apple and their partners for this latest attempt to put personal health data into the hands of consumers, we should keep a few important caveats in mind. Why haven’t these tech giants — and others — been successful? Why won’t this latest announcement from Apple revolutionize healthcare? I have a few theories.

First, access to medical records is just not that compelling for the average consumer. Think about it. How many times do you wake up in the morning and feel the urge to check your medical records? Don’t get me wrong. It should be an imperative to have easy access to important personal health data, that you can simply and securely share with your healthcare providers, or access in an emergency. I have long been a vocal proponent to giving individuals access to their personal health data.

But that leads me to my second point. Access to personal health records will not magically improve clinical outcomes, or even motivate individuals to better manage their health and wellness. As we now know from our work at Partners Connected Health, it takes a sustained, highly personalized experience, seamlessly imbedded into our daily lives, in order to change behavior that can lead to better outcomes. Knowing my blood pressure results from my last doctor’s appointment six months ago will not motivate me to take a walk after dinner.  We must not think that access to health records will automatically lead  to improved health outcomes.

My third caveat is that, while this is a very worthwhile advance for Apple users, but what about those committed to devices that run on an Android operating system? According to data from Gartner, in QI 2017, 86% of smartphones sold worldwide ran on Android. If we are going to make personal health records available to consumers, we must make it device agnostic in order to create real change.

I suggest that we more closely examine how Apple’s new Health Records feature is actually different from past attempts.  It will likely be much easier to set up than Google Health or HealthVault and anything on a mobile platform is immediately more accessible. Apple also has their wonderful consumer design capabilities to bring to the party.  Undoubtedly, they will talk about those instances where an individual whose home is in Massachusetts breaks a leg skiing in the Rockies and is able to present her health record to folks in the Denver emergency room.  This is progress.  There are just so many other problems that providing access to medical records don’t solve.  Medical record data is not that compelling from a consumer perspective.   If they bring something to the table that inspires consumers to care (and Apple knows how to do this), that could be transformational.

Will history repeat itself? Will the promise of making personal health records just an app away fizzle or, at best, create a ripple rather than a roar? Time will tell.

What do you think? Is this déjà vu or do you think this will help to improve the quality of care?


From Bathroom to Bedroom: Insights from CES 2018

January 24, 2018

CES is always a bit of a phenomena and I, like many others, carefully follow the news and trends in consumer health technology being showcased in Vegas. I am especially interested in how some of the newest technologies might impact our work, and seeing how connected health tools are evolving. This is the first year in many that I haven’t attended CES, but have relied on ample news coverage from major media outlets, as well as trusted sources such as Jane Sarasohn-Kahn’s HealthPopuli blog.

At first blush, I was struck by the fact that a number of the trends and technologies at CES were featured in my new book, The New Mobile Age:  How Technology Will Extend the Healthspan and Optimize the Lifespan. We wrote extensively about things like social robots, artificial intelligence, vocal biomarkers and facial decoding that will analyze emotion, anticipate health problems, improve quality of life and enable better relationships with healthcare providers. As was evident at CES, these types of health tech innovations will create a better and more responsive healthcare system for everyone — and help keep older adults vital, productive and indepentent. It has also been interesting, and quite rewarding, to see how the concepts and offerings we wrote about 2+ years ago in The Internet of Healthy Things are coming into the marketplace as well.

But let’s explore some of the consumer health technologies to watch in 2018:

Moen Smart Shower

Just how far can tech invade your personal life before you say enough?
From the perspective of the popular press, the highlights from CES this year were on embedded voice activation in everything, different variations on robots and new technologies taking over the bathroom.  Both Kohler (smart mirror and voice activated toilet) and Moen (smart shower, controlled by voice activation) made headlines.  Each year, CES has a controversial theme and this is as good an example as any.  Is the bathroom, the one room that we don’t really want to be monitored?  While the smart toilet has been a phenomenon in Japan for years, it has been slow to take off in the U.S.  Queue up the privacy advocates on that one.

Modius Headband

Wearables have not gone away
Chapter 1 of The Internet of Healthy Things looked into the not-to-distant future and introduced Sam, my omniscient personal virtual health assistant. Sam was able to not only predict the right health care behaviors for me, but could cajole me into achieving them due to a mix of rich data inputs and a deep understanding of behavior change psychology.  Sam was collecting and analyzing my data from vital sign and sleep monitoring, geo-location and other IOT technologies.  Since the book was released just two years ago, we’ve seen all aspects of this scenario get closer to reality.  Wearables has not softened as a category and, with new entrants, keeps getting more interesting.

One new wearable device that caught some attention this year is Modius.  It arrives in a headband form factor and stimulates the part of the brain that is involved in appetite suppression.  You wear it 60 minutes a day and it allegedly alters your hunger.  It is connected to your smartphone, of course, and the company plans to utilize community as a strategy to promote adherence.

Robots for elder care is becoming a category
In The New Mobile Age, we pay a good deal of attention to robots, especially in the context of caregiving.  This category is broad — for example, we can even think of the now-ubiquitous Amazon Echo as a social robot.  But social robots are becoming much more interesting than that.  Japan leads the way in the use of these tools, and represent a harbinger of what we’ll be experiencing in the rest of the developed world in the coming years.  The reason is pretty obvious: 27% of the population in Japan is over 65, as compared with 13% in the U.S.  Robots represent one very important tool to move caregiving from one-to-one (our current model) to one-to-many.  What kinds of tasks can robots handle as our older citizens need more attention?  We have to thread the needle between a dystopian future — where our elders are cut off from human contact and deal only with machines — versus today’s model that stretches families and caregivers to the breaking point, who are often caring for both children and parents, frequently separated by great geographic distance.

ElliQ Tabletop Robot

We highlight Catalia Health’s Mabu and Ohmnilabs’ Omnhi in the book, as well as Hasbro’s Joy for All Companion Pets which has been well-received in assisted living and long-term care faclities to stem loneliness and, in some cases, reduce anxiety, especially among dementia patients. But two entrants from CES are also worth mentioning.  One is ElliQ, an AI-driven table top robot that is meant to be part elder companion and part connectivity with family members via traditional communications channels.  The company’s website suggests that ElliQ’s value will be in the user interface, making it easy for the user to access all of these tools through a combination of voice prompts and vocal responses to verbal reminders from the robot.  Another interesting entrant is Somnox, which presents initially as a pillow that you can cuddle with in bed, but reacts to your breathing patterns and allegedly helps you get a better night sleep. While the company does not emphasize the robot as a companion, you can’t help but wonder if it is part of a tool kit to deal with isolation, which we know is prevalent in the elderly and has great negative consequences on the healthspan.

Jibo Robot

I’ll also use this opportunity to reference my friend Jane’s post (linked above) and her thoughts that sleep technologies were a big theme this year at CES.  To round out the category, I’d be remiss if I didn’t mention Jibo, which is the robot that has probably gotten the most press.  The fact that there are so many emerging robots is really exciting.  There are lots of challenges in the space right now – cost, business model, improvements in AI. But we need this category to succeed if we are going to conquer the biggest challenge we raise in The New Mobile Age – bringing the healthspan into focus with the lifespan.

CES is part crystal ball, part circus.  Companies showcase a bit of their R & D and everyone’s goal is to appear to be on the cutting edge.  Over the last decade or so, there have been more and more companies showcasing at the intersection of health and technology.  This category keeps getting larger and more interesting.  That is very encouraging to me because if we’re going to solve the immense challenges detailed in The Internet of Healthy Things and The New Mobile Age, this category has to succeed.

I wonder what the theme will be next year? I’ve got a few ideas….


My Holiday Wish List for Connected Health

December 18, 2017

Year-end may be a time to reflect back on the past twelve months, acknowledge achievements and raise a glass to all we are thankful for. I certainly agree there is great value in doing so. However, you may not be too surprised to learn that I prefer to take what we’ve learned and look ahead, to anticipate the future and set our sights on the next milestones for connected health.

In that spirit, I’ve identified six key initiatives that will not only advance connected health and better enable patient-centered health and wellness, but will change healthcare delivery, reimbursement and help individuals remain vital, engaged and independent throughout the lifespan. It’s an ambitious list, but based on the progress made in 2017 and the significant milestones already achieved, I am very optimistic for the future of connected health.

So as we close out a very successful and exciting year, I’d like to share with you my holiday wish list for the coming year, and invite you to add your ideas, your vision for the future. And, I wish you a happy, healthy and joyous holiday season!


The Tone of Your Voice Holds the Secret to Moving Connected Health to the Next Level

December 11, 2017

Lately, I’ve been thinking quite a bit about what I consider to be an urgent priority — moving from the antiquated, one-to-one model to efficient, time- and place-independent care delivery. I’d like to opine about the topic here, but first need to present three bits of context to set up this post.

Think about your interaction with a doctor.  The process is as old as Galen and Hippocrates. You tell the doctor what is bothering you.  She asks a series of questions.  She gathers information from the physical exam.  Not only the obvious things, like heart and lung sounds, but how you look (comfortable or in distress), your mood, the strength of your voice when you talk, the sound of your cough (if you have one) and your mental state.  Armed with this data, she draws a diagnostic conclusion and (presuming no further testing is needed), recommends a therapy and offers a prognosis.  For the better part of the last quarter century, I’ve been exploring how best to carry out this process with participants separated in space and sometimes in time.  The main reason for this is noted in the next two bits of context, below.

There are two big problems with healthcare delivery as it works today. The first is that, in the US, at least, we spend too much money on care.  The details here are familiar to most…20% of GDP…bankrupting the nation, etc.  The second is that we stubbornly insist that the only way to deliver care is the one-to-one model laid out above.  The fact is, we’re running out of young people to provide care to our older citizens. This is compounded by the additional fact that, as we age, we need more care.  By 2050, 16% of the world’s population will be over 65, double the amount under 5.  More detail is laid out in my latest book, The New Mobile Age: How Technology Will Extend the Healthspan and Optimize the Lifespan.  We need to move to one-to-many models of care delivery.

Efficiency is a must, and one-to-one care is very inefficient. Essentially, every other service you consume — from banking, shopping and booking a vacation to hailing a taxi — is now provided in an online or mobile format.  It’s not just easier for you to consume it that way, but it’s more efficient for both you and the service provider.

If you can accept my premise that we need to move to efficient, time- and place-independent care delivery, the next logical step would be to ask how are we doing in this quest so far?

We’ve employed three strategies and, other than niche applications, they are all inadequate to get the full job done.  The most loved by today’s clinicians is video interactions. With the exception of mental health and neurological applications, video visits have a very limited repertoire.  We stumble over basic symptoms like sore throat and earache because a video interaction lacks critical information that a conversation alone can’t provide.  The second strategy is to take the interaction into an asynchronous environment, analogous to email.  This is time- and place-independent, so it has the potential to be efficient, but lacks even more nuance than a video conversation.  This modality is also limited in scope to a narrow set of follow up visits.  In some cases, patients can upload additional data such as blood sugar readings, weight or blood pressures, and that increases the utility somewhat.

The third modality is remote monitoring, where patients capture vital signs and sometimes answer questions about how they feel.  The data is automatically uploaded to give a provider a snapshot of that person’s health.  This approach has shown early success with chronic conditions like congestive heart failure and hypertension.  It is efficient and if the system is set up properly, it allows for one-to-many care delivery.

As a Telehealth advocate, I am compelled to remind you that each of these approaches has shown success and gained a small following.  We celebrate our successes.  But overall, the fraction of care delivered virtually is still vanishingly small and each of these methods has more exceptions than rules.

Remote monitoring is the right start to achieving the vision noted above.  It is efficient and allows for one-to-many care delivery.  But currently, all we can collect is vital signs, which represent a really small fraction of the information a doctor collects about you during an office visit.  So while we can collect a pretty good medical history asynchronously (we now have software that uses branching logic so it can be very precise) and we can collect vital signs, for years I’ve been on the lookout for technologies that can fill in some of the other gaps in data collected during the physical exam.  To that end, I want to highlight three companies whose products are giving us the first bit of focus on what that future might look like.  Two of them (Sonde Health and Beyond Verbal) are mentioned in The New Mobile Age, and the third, Res App, is one I just became familiar with.  It is exciting to see this new category developing, but because they are all early stage, we need to apply a good bit of enthusiasm and vision to imagine how they’ll fit in.

Res App has a mobile phone app that uses software to analyze the sound of your cough and predict what respiratory illness you have. This is not as far-fetched as it sounds.  I remember salty, seasoned clinicians who could do this when I was a medical student. They’d listen to a patient with a cough, and predict accurately whether they had pneumonia, asthma, heart failure, etc.  Res App, Australian by birth, says they can do this and have completed a good bit of clinical research on the product in their mother country. They are in the process of doing their US-based trials.  Stay tuned.  If it works as advertised, we can increase the value of that video visit (or the asynchronous data exchange) by a whole step function.  Imagine the doctor chatting with you on video and a reading pops up on her screen that says, ‘According to the analysis of this cough, the patient has a 90% chance of having community-acquired pneumonia and it is likely to be sensitive to a course of X antibiotic.’  Throw in drone delivery of medication on top of e-prescribing and we really could provide quality care to this individual in the confines of their home, avoiding the high cost part of the healthcare system.

Similarly, Israel-based Beyond Verbal has shown — in collaboration the investigators at the Mayo Clinic no less — that the tone of your voice changes in a predictable way when you have coronary heart disease.  Same scenario as above, but substitute heart disease for pneumonia.  And then there is Sonde, whose algorithms are at work detecting mental illness, once again from the tone of recorded voice.  As William Gibson said, “The future is here. It is just not evenly distributed.”

We are a ways away from realizing this vision.  All of these companies (and others) are still working out kinks, dealing with ambient noise and other challenges.  But the fact that they have all shown these interesting findings is pretty exciting.   It seems predictable that companies like this will eventually undergo some consolidation and that, with one smartphone app, we’ll be able to collect all kinds of powerful data.  Combine that with the ability to compile a patient’s branched-logic history and the vital signs we routinely collect and we can start to envision a world where we really can deliver most of our medical care in a time- and place-independent, efficient matter.

Of course, it will never be 100% and it shouldn’t be.  But if we get to a point where we reserve visits to the doctor’s office for really complex stuff, we will certainly be headed in the right direction.

Medicare Reimbursement for Remote Monitoring Should Drive Adoption (What a long, strange trip it’s been….)

November 16, 2017

The Centers for Medicare & Medicaid Services (CMS) released the 2018 Physician Fee Schedule about two weeks ago and there is at least one nugget in there that should speed the adoption of remote patient monitoring.  In fact, the news is even better, but I’m getting ahead of myself.  First, let’s examine the broader context of what adoption of remote monitoring will mean for healthcare delivery and the amazing story of how we got here.

Why it matters

By 2050, 16% of the world’s population will be over 65, more than double the number under five years old.  Inevitably, older people require more healthcare resources and caregiving.  The math is too stark to ignore:  we’re running out of young people to care for our elders if we continue to offer only one-to-one, face-to-face care as an option.  If you want to learn more about this conundrum, it is covered in some detail in my new book, The New Mobile Age: How Technology Will Extend the Healthspan and Optimize the Lifespan.

Remote monitoring is critical to move us from one-to-one models of care delivery to one-to-many.  Other services have done this, and we need to catch up. At Partners Connected Health, in collaboration with colleagues in our delivery system, we have shown, more than once, that home monitoring of patients with congestive heart failure leads to lower hospitalization rates and improved mortality.  Others have shown this too.  In this type of remote monitoring system, the nurse to patient ratio is about 1:100. That’s what I mean by one-to-many.

Yet, to date, most telehealth has been delivered via videoconferencing between patients and doctors.  These interactions have improved access, but still rely on that one-to-one model.  Stated another way, video communication breaks the ‘place’ barrier but remote monitoring is both time and place independent — a challenge for healthcare providers who are used to thinking that healthcare should be rendered in the doctor’s office.

A survey, published by the American Medical Association (AMA) in 2016,  succinctly outlined the barriers to digital health adoption among physicians:

* Need for evidence
* Reimbursement
* Liability coverage
* Workflow/EMR integration

These insights have driven AMA’s digital health strategy since.  For the last year, I’ve had the privilege of working with them on several aspects of this, including co-chairing their Digital Medicine Payment Advisory Group (DMPAG), which has focused on reimbursement for digital medicine, including remote monitoring.

The specific news

In 2004, I took my kids to the Lemony Snicket movie, “A Series of Unfortunate Events”. The story on Medicare reimbursement for remote monitoring is just the opposite: many dedicated people working, sometimes in coordination and sometimes not, at the right place and right time in history, culminating in a series of fortunate events.

Here are the specifics of what we learned when the 2018 Physician Fee Schedule was released on November 3:

CMS has decided to unbundle and activate CPT code 99091 (collection and interpretation of physiologic data).  CMS has stated that this is an interim step until the Agency considers new CPT codes and valuation recommendations. 

CMS stated in the rule that the Agency “look[s] forward to forthcoming coding changes through the CPT process that [they] anticipate will better describe the role of remote patient monitoring in contemporary practice and potentially mitigate the need for the additional billing requirements associated with these [99091] services.”

This is an amazing announcement since, for decades, Medicare had turned a deaf ear to most forms of telehealth and any discussion of remote monitoring was relegated to the depths of despair.

How we got here

When providers perform a task related to your care, they document the work using a common procedure coding system which includes a number of codesets such as the one maintained by the Current Procedural Terminology (CPT) Editorial Panel.  In most cases, these codes are used to electronically bill your insurer, who then pays the provider according to a contracted fee schedule.  The CPT Editorial Panel has been around for decades and though the members, comprised of a cross-section of healthcare stakeholders including insurers, are appointed by the AMA Board of Trustees, the Panel’s decision-making is independent of the AMA.

The code change application process can occur in a relatively rapid period of time—a matter of months from the date the application is submitted to the date it is considered by the CPT Editorial Panel. However, the Medicare program’s process for considering recommendations for valuation and coverage (through the rulemaking process) can be lengthy because such decisions are made on an annual basis.  Hence, the Medicare process takes years and a code can be derailed at any point.  Medicare can choose not to pay for a code and they can also choose to ‘bundle’ the code, if the work related to that code is already covered in their reimbursement of other services.

The classic example is the code that reimburses doctors for telephone calls with a patient. Insurers don’t pay because Medicare decided that telephone follow up is included in reimbursement for an office visit.  It is important to note that commercial payers can utilize the codes as soon as they are publicly posted by the CPT Editorial Panel and are not required to follow the Medicare process for valuation and coverage.

The importance of the new fee schedule is this: although CPT code 99091 has existed for years, it was bundled.  By simply unbundling this code, CMS opened the door for remote monitoring reimbursement.  And, because the code exists, it already has an assigned monetary value, so as of January 2018, providers can start to provide remote patient monitoring services and actually receive reimbursement.

This breakthrough is not happenstance.  It is the result of two phenomena.  One is the dogged pursuit of a handful of individuals who see the mounting challenges of caring for an aging population, and who are passionate that we have to get there for the sake of better patient care.  These folks have been lobbying the government for years, and despite countless setbacks, have continued the quest.  The second phenomena was the appointment of a new CMS chief, the consequence of a new administration in Washington.  Whatever you think of our current administration, it is a fact that they are more telehealth friendly than any in history.

Now, getting back to the work of the AMA’s DMPAG, we recently put forward three code change applications to the CPT Editorial Panel, including two related to remote monitoring.  This too was not a random event.  The AMA wisely populated this advisory group with half digital health experts/practitioners and half CPT/RUC experts.  We’ve worked well together and the AMA deserves enormous credit for their wisdom and support.

So it was with great thought and preparation – and no guarantee of success – that we presented these proposed new codes in September and the CPT Editorial Panel, which acts independent of the AMA, approved them so our success was not guaranteed.  We felt a sense of victory, but also vulnerability, as we don’t have particular influence over the RUC valuation and even less over whether CMS will reimburse for the new codes. At the time, I reminded our DMPAG team that the apt sports analogy for this success was a first down rather than a touchdown.

This changed significantly with the November 3 announcement and the specific wording that CMS looks forward to new codes from the CPT process.

The wheels could still fall off the wagon. We can’t let up in our quest.

It must also be pointed out that there are other adoption barriers clearly identified in the 2016 AMA survey.  Reimbursement, however, is a big one.  With reimbursement comes enthusiasm from EMR vendors to improve workflows and processes.  As the CPT Editorial Panel only approves codes that have sufficient evidence, and though some will say there is never enough evidence, the case for remote monitoring is a strong one.  And, as we improve workflows, that should also help mitigate liability concerns.

The future is bright for remote monitoring, all of a sudden.  But it has taken us years of work and ‘a series of fortunate events’ to get there.  I’ve been privileged to be part of an amazing team that the AMA gathered, and fortunate to benefit from the hard work of others  to move thinking on this topic at CMS.

Our patients of all ages will benefit and, importantly, we can achieve a one-to-many delivery model in time to care for the oncoming ‘silver tsunami’ of our aging population.






A Front Row Seat for the Future of Technology-Enabled Health and Wellness

September 28, 2017

The 2017 Connected Health Conference (CHC) is right around the corner, after months of planning, organizing and confirming a terrific lineup of speakers and events. I am delighted that we’ll be gathered at the Seaport World Trade Center in Boston October 25-27.  It is a must-attend event if you are in any way interested in the growing field of digital health.

If you are a veteran of the Partners Connected Health Symposium and missed the news that we merged our event with the Personal Connected Health Alliance’s Conference, let me bring you up to speed.

At last year’s Symposium, we announced the merger, to establish “the singular leadership event focused on the future of technology-enabled health and wellness. ” It’s very clear now that merging the events was a wise decision. We have received very positive feedback from throughout the market, and are attracting an impressive group of sponsors, including: Intel,  Verizon, Philips, IBM and Teva Pharmaceuticals, AARP, Amazon Web Services, Medtronic, Johnson & Johnson, Qualcomm Life, Fitbit, AMA, Validic, TMC Innovation Institute and Conversa Health, with more still signing on.

And, the list of exhibitors is long as well, and we’re very excited to see this growing marketplace. On the exhibit floor, the new Innovation Lounge is bringing together provider, industry and institutional innovation centers and novel collaborations. It is a unique and dynamic area that expands the possibilities and showcases key partnerships that are driving innovation.

I have personally been developing the program with the help of our CHC Advisors and programming team, hand picking the speakers and carefully designing each session to be inspiring, provocative and informative.  Our goal is to bring people together for an experience that gives them a clear view of where the industry is headed.

It is a jam-packed agenda that will deliver forward-looking initiatives, real-world examples, insider perspectives and actionable ideas.  This year’s theme “The Connected Life Journey” brings in cutting-edge developments in aging, chronic care management, consumer and physician adoption, as well as policy, research and the investment community.

To kick off the conference, I have the privilege of delivering the opening keynote on Thursday morning, where I’ll share with you some of the insights, innovations and next steps from my new book that will be hot off the presses, The New Mobile Age: How Technology Can Extend the Healthspan and Optimize the Lifespan. We’ll look at how digital technologies are enabling people to remain vital, engaged and independent through their later years.

But with so much great content and the special events taking place at CHC17, you won’t be able to sit in on every session, so I’ve been thinking about those I’d consider ‘can’t miss’ to share with you.

Our keynote lineup is truly world-class, but I always enjoy hearing from:

Chunka Mui, an expert at fostering innovation.

Adrienne Boissy from Cleveland Clinic, who will share her thoughts on relationship-driven strategies to improve the patient experience.

My friend and colleague, Calum MaCrae, from Brigham and Women’s Hospital in Boston, who will share his vision and progress in building a most exciting future healthcare delivery model.

I’ve always looked to other industries and examples that can be applied to connected health, and one that I often cite is The Truth Initiative. Eric Asche will share their strategy for successfully changing behavior around smoking.

Their experience has wide applicability in our quest to better manage the 70% of healthcare costs that are lifestyle related.

It’s very difficult to just pick a few, but here are some breakout sessions you should also check out:


We’ve also added a new track focusing on Health System innovation, where you’ll hear from the Healthcare Transformation Lab at Massachusetts General Hospital, PULSE@MassChallenge, Healthbox and many more health system leaders.

And at the closing plenary session, Envisioning the Connected Life Journey, I have the privilege of sharing the stage with some insightful and truly visionary colleagues, including Charlotte Yeh from AARP and Rudy Tanzi, a renowned researcher who co-discovered the first Alzheimer’s disease genes and directs the Alzheimer’s Genome Project.

There will be many exhibit floor activities – an important and welcome addition to the Connected Health Symposium, which will add a new dimension for learning and insight.  We have carved out exclusive times for roaming the exhibit floor and for networking, so that attendees and exhibitors will have ample time to interact, without competing with the program.

We still have about four weeks to go until the Connected Health Conference. I hope you are as excited as I am to convene in Boston, share ideas, learn together and move the market forward.

I’m pleased to offer cHealth Blog readers a special $100 discount on your Conference registration. Simply visit the Connected Health Conference website, and register using discount code CHC17100.

Come join us.  It’s the place to be!

The Next Fountain of Youth? Rethinking Connected Health for Our Aging Population

August 23, 2017

Last month I shared an update on my upcoming book, The New Mobile Age, and am excited to share a bit more about this work.  We continue to hit our editorial milestones for an end of October launch at the Connected Health Conference, and as I’m reading the manuscript for the final time before sending it to the printer, I’m re-learning some important lessons–and enjoying the content! I’ve been honored to gather input from a long list of esteemed colleagues and wanted to share a few ideas I believe are critical in our thinking about the healthspan.   Below is a sneak peek at two fundamental concepts we discuss in-depth in the book.


First some context.  We’ve added 25 years to our lifespan in the last century through various public health innovations, but we haven’t provided tools to help us use those additional years in the most productive, fulfilling way. Instead, we’ve put folks in that demographic (those in the latter 25 years of their life) into a category of ‘old.’  They retire, are perceived as no longer adding value or, even worse, become a burden to their ‘sandwich generation’ adult children.  We must turn aging from being a dreaded inevitability into something to be celebrated. My friend Jody Holtzman, who is quoted in the book, coined the term “Longevity Economy,” and defines it as the 100-plus million people in the United States over age 50 who account for $7.1 trillion in annual economic activity.  He quite accurately notes that only in the eyes of the U.S. government would this population be viewed as a burden. Rather, we need to refocus on this group of older adults as an opportunity!


Now that we’ve extended the lifespan, our first priority should be to enhance the healthspan, by giving people the tools needed to improve their health and inspire them to maintain healthy lifestyle choices.  If we do this right, we will turn this growing cohort of older adults from being seen as a burden to one that is remaining vital, connected and adding value.  And of course, connected health is a big part of the solution.  There are multiple dimensions at play, and I can’t cover it all here, but I want to touch on two areas that became clear to me while researching the book.

The first group of insights comes from another respected friend and colleague who is helping society rethink aging, Charlotte Yeh.  Charlotte has written the Foreword for this book and has taught me several things in the process.  Once I learned of her perspective, I became tuned in to several reproducible findings in patients in my own clinical practice.

We’re used to thinking of predictors of longevity in a very scientific, dry way–measures such as exposure to tobacco, high blood pressure, blood cholesterol level and the like.  Of course, these are valid and important, but Charlotte opened my eyes to a different set of important measures.  One is a sense of purpose.  There is a lot of research on this and we cover it in the book, but anecdotally, as I’ve spoken with my own patients, I’ve seen this come to life.  People who have some purposeful activity they pursue in retirement are healthier.  The second is social connections.  Again, there is a remarkable body of evidence on this, and it turns out that isolation eats away at an individual and has the same effect on health as multiple packs of cigarettes a day!  Finally, physical activity.  This can range from taking the stairs or walking each day to going to the gym or even remaining a competitive athlete.


None of these measures are unique to aging, but to strip away the traditional, clinical science and break it down into these three simple predictors was liberating for me.  Of course, the bonus is that connected health can play a role in all three, whether it is participating in the gig economy to drive purpose, being active on social media or FaceTime to keep up social connections, or tracking your steps on a Fitbit. All of these challenges are made easier by modern technology.


The second important insight driving new, increasing opportunities for personal health technologies has to do with managing chronic illness.  As much as we’d all like to stay healthy all our lives and die peacefully at a ripe old age, the fact is we all suffer from system wear and tear and require more illness management as time goes on.  We are at the breakpoint as a society, to provide the resources needed to do this.  Very soon, we won’t have enough healthcare providers and caregivers to tend to the aging population if we only rely on one-to-one care delivery models. We spend a lot of time in The New Mobile Age talking about how to use technology to create one-to-many care delivery models.  Particularly exciting is the work of some of the early stage companies, paving the way for these new models of care, including:, a platform that features an interactive avatar to engage people in their homes—or in the hospital—to promote medication adherence, detect cognitive changes early on and keep an eye on patients who are prone to falls.

Rendever, an MIT spin-off offering a virtual reality (VR) experience for nursing home patients, as way to connect to the outside world.


OhmniLabs, a startup with a telepresence robot for elder care that enables an older person to stay in touch with his or her family or healthcare provider in real time.

Sonde Health, another MIT spin-off that uses voice-based technology to analyze health and the user’s emotional state in real life, real time.

Hasbro’s Joy for All Companion Pet, a dog or cat interactive companion pet with built-in sensors and speakers. For ages five and up, it is used for Alzheimer’s patients and as a tool to relieve loneliness, a prime example of intergenerational thinking.


Catalia Health’s Mabu, a kitchen counter robot designed to improve medication adherence that makes eye contact and tracks the emotional state of the user.

Affectiva, a leader in “emotion AI,” the new science of training computers to read and understand human emotion.

Omada Health, which offers a digital curriculum based in part on the National Institutes of Health (NIH) groundbreaking National Diabetes Prevention Program (National DPP).

Iora Health, a “whole new operating system for healthcare” that is focusing on the needs of Medicare patients.

Each of these companies has an innovative approach to helping address the challenges of keeping older adults engaged, vital and independent, and opportunities to provide technology-enabled care for this rapidly growing population.

I’ve enjoyed putting this book together and look forward to sharing it with you, to continue the discussion, gain your feedback and, together, advance our learning and care delivery in this New Mobile Age.