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2 Sided Risk Key to Pop Health, Telemedicine Access During COVID, Medtech & AI-The HSB Blog 1/5/21

Incenting or Mandating Downside Risk Is Key to Population Health

“Our Take”: To simultaneously decrease cost and improve quality of care, providers must share in downside risk. This pushes them to adopt new strategies of meeting patient needs, discouraging a volume-centered approach to treatment. Providers in alternative payment models (APMs) operating under a framework of value-based care are driven to pursue new methods of coordinating care, aiming to reach a higher level of quality with a less resource-intensive approach. Population health management tools are key in achieving this. The more targeted holistic care philosophy that population health management fuels, is what will make APMs viable for providers of all sizes. These strategies for care coordination include data integration from multiple sources, keeping physicians engaged, and educating the patient population, among others


Description: According to Lumeris, total health care spending reached $38 trillion in the United States, and the Congressional Budget Office estimated that it will increase at 5.4% annually, reaching $6 trillion in 2028, an estimated 19.7% of GDP. The Center for Medicaid and Medicare Innovation (CMMI) has created over 50 alternative payment programs, but much of the existing reimbursement structure in the United States operates on a fee-for-service (FFS) basis. The incentives providers face under FFS are toward volume in services billed, rather than toward positive health outcomes or cost efficiency. The concept of value-based care is rooted in the notion that care should be motivated by a patient’s needs, and financial incentives should reflect that. Population health management is a key set of tools for improving performance that offers cost saving potential. Providers in APMs, such as accountable care organizations (ACOs) and bundled payment arrangements, are already embracing population health techniques, because they enable focus on preventive care and consideration of physical, social, and economic conditions that affect health, according to Modern Healthcare. These two dimensions align with the value-based care ethos, prioritizing patient needs and resource management over reimbursement optimization. Modern Healthcare reports that three technological advancements drive the availability of population health management: 1) interoperability, which is the access to comprehensive patient data across health care systems; 2) predictive and prescriptive analytics, which can identify patient health risks before complications arise; and 3) patient engagement solutions, including digital tools such as virtual and remote care, that make it easier for people to participate in their own care. The COVID pandemic has laid bare the failings of the FFS system and highlighted the potential for population health to improve care at lower costs. For example, in it’s spring 2020 survey Premier Inc. identified that APM’s reported higher rates of population health management techniques than those not participating in APMs in 4 areas: 1) a head start on telehealth, allowing capacity to be kept open for those in need of inpatient care; 2) care management techniques, which kept lower acuity patients at home and the ability to monitor for suspected and confirmed COVID cases from afar; 3) partnerships with post-acute care networks which facilitated connections allowed health systems to work together to understand post-acute capacity and ensure successful care transitions from acute care hospitals; and, 4) data systems that facilitated population health by using analytic tools to make data actionable and meaningful in determining needs and creating protocols. As illustrated by the Premier survey, providers in APMs rely more on advanced population health management strategies and can improve care coordination, lower costs and are better equipped to serve the health needs of a community.

Implications: Moving to population health will be essential to help bend the cost curve in healthcare and moving to models that require two-sided risk will be critical to the adoption of population health. However, sponsors of two-sided risk arrangements must take the proper steps to ensure that clinicians have the appropriate tools to succeed in population health arrangements. For example, the Health Care Payment Learning & Action Network (HCPLAN), a public-private health care policy group, notes as part of it’s Resiliency Framework report that APMs are key to building health system resiliency to deliver coordinated, high-quality person-centered care after a crisis like the COVID-19 pandemic. In the report, HCPLAN outlines four steps to work towards more resilient APM’s including advocating for models with two-sided risk. In moving models towards two-sided risk establishing and maintaining a clear path of communication with clinicians is key. As a recent article in In Healthcare Executive entitled, “Achieving ACO Savings: A Case Study” noted, keeping primary care physicians engaged and invested in the value-based care process from a culture of mutual respect and providing constant feedback and education is essential. In a similar vein, research has shown that information was best communicated to physicians by peers or clinical leadership, rather than from administration. In addition, providers should leverage information technology to overcome challenges in care coordination by integrating multiple data sources through electronic health records (EHRs) as well as financial, and operational tools that promote the sharing of information between clinicians. Importantly, while having necessary information on hand is essential to care coordination and the success of ACOs as a report in Healthcare Business and Technology entitled, “the ‘path to success’ for ACOs requires data they can use”, emphasizing the need for “clean, usable data” that can help providers reach “deep interoperability,” something 86% of those surveyed reported they had not done. For example, of those surveyed, 68% of ACO respondents said data use and analytics helped them achieve cost savings, and 50% noted it helped them improve utilization, but “access to outside data” and data integration remained challenges for about two-thirds of respondents or more. Interestingly, breaking through data silos requires cooperation and collaboration from other providers as well as within their own staff. Finally, constant innovation and organizational commitment to keep iterating new approaches is needed as well as constant participation and oversight by senior levels management in the governance structure of any population health initiatives. As demonstrated by the vulnerabilities in care delivery exposed by the COVID pandemic, the FFS system continues to underperform and is poorly equipped to handle large scale health issues such as pandemics. The techniques employed under population health management must be more strongly incentivized (and perhaps even mandated) as to what structures providers must enact to ensure stability and viability of the healthcare system long-term. Their widespread adoption will further the feasibility of two-sided risk APMs and value-based care by providers would likely drive more rapid and sustainable change in the system.

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic

Event: On December 29th, JAMA network published a study regarding the usage of telemedicine platforms among minority populations during the COVID pandemic. As telemedicine use has increased during the pandemic, the question about whether telemedicine exacerbates or helps address disparities in the delivery of healthcare has arisen. This study of approximately 150,000 patients at a large academic medical center found that older, Asian and non-English speakers as well as Medicaid patients were less likely to use telemedicine services.

Description: Prior to the COVID pandemic, a previous JAMA study of telehealth utilization found that only 4% of respondents had used videoconferencing visits for healthcare. In addition, that study found that while approximately half reported being willing or very willing to use videoconferencing visits, those who were Black, older than 65 years old or had less education (high school or less vs advanced degrees) were less likely to be inclined to use videoconference visits. The study of telemedicine use during COVID found that patients who completed telemedicine visits were more likely to be younger, English-speaking, females with commercial insurance with a higher median household income and were less likely to be Asian. Compared with White respondents, Asian respondents were associated with fewer completed telemedicine visits whereas those of Black race and Latinx ethnicity were associated with more telemedicine visits compared to Asians.

Implications: There is a significant difference between pre-COVID usage of telemedicine platforms and usage during the early phases of the pandemic. Due to the lack of education, funding, and access amongst Black individuals, rural residents, and those of a lower income status, usage of telehealth platforms was extremely limited in comparison to higher income, educated White individuals. While use of telehealth by underserved communities did increase during COVID, with the percentage of Black patients indicating they had used telehealth equaling almost 25%, that number was still less than half of the percentage of Whites who had used telehealth (23.8% for Blacks vs. 62% for Whites). In addition, the limited usage amongst Asian populations (3.2% vs. 62%) during the pandemic is attributed to lack of access, poor patient-physician relationships, more frequent negative interactions with providers and increased racism due to fear of racism created regarding the origin of COVID. The results showing the age difference in usage is consistent with evidence that older age is associated with lower internet availability,lower use of digital health technology, and slower rates of technology adoption. Moreover, language barriers continue to be a limiting factor in both studies, despite the installation of translation options to combat the disparity. The shifts in usage show that although great efforts have been made to address disparities in the delivery of telemedicine “inequities in accessing telemedicine care are present”. As such, barriers and challenges for minority groups still need to be addressed to ensure better access and more comprehensive solutions to meeting the health needs of all populations.

Medtronic, GE, Philips, Embrace AI Amid Regulatory Limbo Around Algorithms.

Event: HealthcareDive recently reported that GE Healthcare, Medtronic, and Philips are investing heavily in artificial intelligence (AI) and machine learning (ML) technologies despite the fact that the FDA has yet to finalize a regulatory framework for machine learning-based software as a medical device (SaMD). The article noted the companies see the potential for the technologies to improve diagnosing, managing, and treating a wide variety of diseases and health conditions. The article noted that the CEO of Medtronic recently stated that the integration of medical technology with innovative robotics, sensors, and the computational power of AI could be among some of the greatest advances in medical technology unfolding right now.

Description: The article noted that 3 medtech giants are each taking a slightly different tack.Medtronic has initiated technology support such as robotics, navigation, advanced imaging, and pre-operative planning aided by AI to support its spine surgery portfolio. For example, Medtronic recently completed a tender offer for French AI spinal surgery specialist Medicrea whose platform uses predictive modeling algorithms to measure and digitally reconstruct a patient’s spine. With the acquisition, Medtronic claims it will be the first company in spinal surgery offering AI-driven planning, personalized implants, and robot-assisted delivery. Philips’ is focusing on AI-enabled informatics to help clinicians identify actionable insights and bring greater precision to radiology diagnosis (with the goal of expanding to cardiology, pathology and other areas over time). GE Healthcare’s Edison Marketplace is “working with third-party AI developers to address all the security, privacy and application programming interface (API) issues with the goal of reducing overhead and software administration issues for hospital providers. GE’s Edison Marketplace apps are meant to work within a hospital’s existing workflow using an “Open AI Orchestrator” that simplifies the selection, deployment, and usage of AI in imaging workflows at scale (akin to app stores for Smartphones).

Implications: While the emergence of big datasets, combined with innovation in robotics, sensors, computational power, and AI, could put the medtech industry on the verge of some of the greatest advances in medical technology, the regulatory environment remains clouded. As noted, there is little regulatory clarity regarding “adaptive AI” where machine learning algorithms continuously learn on their own and don’t need human modification to incorporate learning [please see our 10/27/20 blog article “FDA Patient Engagement Advisory Committee (PEAC) Meeting on Adaptive AI and ML” Link Here . Currently the FDA has only approved devices using “locked” algorithms and while “unlocked” learning algorithms have been allowed in consumer self-diagnosis apps, diagnostic efficacy seems to worsen over time, potentially complicating longer-term approval of adaptive AI products. In addition, although the FDA appears to be considering a total product lifecycle-based regulatory framework for continuously learning AI, this could have ramifications for ongoing informed consent with patients. AI and continuous learning algorithms have tremendous potential but progress will be limited until a clearer regulatory pathway is established.

U.S. Healthcare Fintech Lendeavor Rebrands to “Provide”; Raises $34 Million Through Series A & B Investment Rounds

Event: Recently healthcare finance startup Provide (formerly Lendeavor) raised $34 million. Founded in 2013, Provide helps healthcare practices open business bank accounts and get insurance. According to the company, their mission is to offer a fully integrated suite of financial products that makes starting and running a healthcare practice easier – giving providers more time to care for their patients.

Description: Provide earns the trust of healthcare entrepreneurs by solving their most challenging financial problem: getting the funding to start their practices. The company has built software to streamline the loan application process by essentially eliminating data entry in the application process and relying on optical character recognition (OCR) to get data directly from tax returns and other documents. The company claims that this can cut the approval time for transactions from 30 days with traditional banks to 2-3 days for those that use their product. Since 2016 the company has originated $800 million for more than 1,000 practices, 80% of which are dentists (the company also markets to veterinarians and doctors). Provide also arranges insurance coverage providers needed to run their practices. The company makes money through the fees it earns by bringing business to its banking partners.

Implications: Provide allows healthcare practices and entrepreneurs to financially get on their feet. By raising $34 million, Provide could open a new market for under-financed or under-resourced healthcare companies that need extra support to run. This could help smaller health companies with niche business models be more accessible to the public. By being more responsive and flexible Provide can help practices better navigate the uncertainties of today’s uncertain economic environment. For example, when a number of its dental clients had to shut down during the pandemic, Provide was able to offer customers deferred payments as well as a $200 million subsidized refinancing facility to help their practice partners remain afloat. Also, by removing some of the stresses associated with financing operations, providers can dedicate more time to care for their patients.

5 Digital Health Trends That are Here to Stay

Event: On December 29th, an article from Entrepreneur magazine highlighted five digital health trends that stemmed from the pandemic that are here to stay in 2021. As the article noted, “the [COVID] crisis, with all its overwhelming tragedy, also ushered in tremendous intellectual energy and freedom. ...Healthcare organizations, technologists, and government agencies proved for the first time that speed, innovation, and safety were indeed possible in healthcare”

Description: According to the article there were 5 trends in healthcare due to the pandemic which will be difficult if not impossible to reverse. These are: 1) The “consumerization of healthcare” encompassing everything from home delivery of prescription medication to sleek wearable electronics that can monitor an array of patient vital signs, 2) “telehealth”, which opened up a range of communication options between patients and doctors from video visits to phone calls to texting, 3) “virtual reality,” as a powerful tool for the medical community to train future doctors and surgeons, 4) “interoperability among vendors,” which by necessity broke down information silos between healthcare systems to work with each other and makes it easier for patients and providers to exchange and manage information, and, 5) “cloud infrastructure”, specifically cloud storage, which facilitates the storage and exchange of the large amounts of healthcare data generated daily both within and among organizations.

Implications: The article highlights that technology was a slow-growing trend hampered by regulations, security issues, and privacy concerns, but once the pandemic made in-person visits problematic, all trends highlighted above exploded in popularity. HIPAA requirements were waived, and social distancing measures urged patients to seek remote access to healthcare by downloading apps and using virtual communication modes. Technology is becoming more affordable and more commonly adopted in the healthcare setting. It has also boosted convenience, improved access to care, and reduced hospitalization rates for issues that can be addressed remotely. Organizations should ensure that their strategic goals and mission are aligned with improved patient care, day-to-day workflow solutions for physicians, and maintaining regard to privacy and security regulations. As we move into 2021, physicians and patients also need to be open to telehealth technology, as it is here to stay.


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