Basic Tools for Disparities, Keeping Empathy in Digital Care, Costs of Inequity-The HSB Blog 1/19/21
Adopt Basic Tools to Fix Disparities While Digital Divide Persists
“Our Take'': While certain barriers to access telehealth technologies were acknowledged and are slowly being addressed during the pandemic (ex: ‘broadband access’, ‘reimbursement’, and ‘licensure’) the ‘digital divide still limits the utilization of digital technologies so the industry must look at deploying basic tools in the near term to address the divide. Although telehealth has been around for quite some time, it was not until the advent of COVID that it gained significant traction with consumers and doctors, seeing an increase in utilization of 154% compared to 2019. Despite the relative ease of deployment, convenience, and ability to limit patients’ exposure to the virus in physical facilities, there are still several patient populations that are not being reached. As a result, providers, payers, and policy officials need to continue to prioritize initiatives to make healthtech more accessible to poor, rural, and other underresourced communities. While issues such as reimbursement and licensure had been temporarily solved, permanent fixes may take time and as such, we need to look at adopting basic tools near-term to address health disparities.
Description: Prior to the pandemic there were a limited number of services CMS approved for reimbursement delivered via telehealth. However, with the onset of COVID and the declaration of a public health emergency (PHE) both CMS and State regulators waived enforcement of restrictions or added reimbursement for a significant number of procedures including originating site requirements and originating place of service requirements. As a result of the eased restrictions, providers and payers reported dramatic increases in demand in the wake of limits on access to physical facilities. For example, Blue Cross and Blue Shield of Massachusetts reported that claims for telehealth visits skyrocketed 190-fold during the pandemic, from 200 prior to onset to 38,000 at peak. Healthcare Dive reported that before the PHE was declared in March, only 15,000 traditional Medicare beneficiaries used a Medicare telehealth service each week, but between the middle of March and the middle of October, more than a third of fee-for-service Medicare recipients had used virtual care according to CMS. Nevertheless, although there has been a substantial pickup in usage, one of the most challenging hurdles to overcome with telehealth adoption is the digital barrier. Even with regulations being eased for existing telehealth services, and additional support being provided for digital tools, there remains a large population of underresourced communities that didn’t have access to smartphones, broadband, or which are simply not digitally literate. As noted in “Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic”, digital barriers are responsible for poor adoption of telehealth among older adults, racial/ethnic minority population, rural population with low socioeconomic status, and those with limited English proficiency. Similarly, a recent Kaiser Family Foundation poll found that only 7 in 10 adults 65 and older (68%) report having a computer, smartphone, or tablet with internet access versus virtually all younger adults. Moreover, while 18% of older American adults need chronic management, only 55%-60% of them own a smartphone or have access to broadband. Some of the barriers noted in a recent study by the School of Public Health at the University of Maryland are: 1) the cost of implementation; 2) patients’ inability or difficulty to view their medical record online; 3) the ability to electronically transmit medical information to a third party; 4) the ability to request an amendment to change/update their medical record, request refills for prescriptions online; 5) being able to schedule appointments online; 6) capability to pay bills online; 7) mechanisms to submit patient-generated data; and 8) a means to communicate via secure messaging with providers. The study also found lower overall adoption of telehealth was due to lack of training of both patients and health care providers in the use of healthcare information technology systems.
Implications: Over the last year, telehealth use has skyrocketed. Barriers such as reimbursement have been identified and at least temporarily rescinded thus facilitating increased access of patients to the digital healthcare system. However, there are steps that still need to be taken to close the gap in healthcare disparities. According to a recent article in the NEJM, a number of additional steps are needed including: 1) developing solutions to mitigate barriers to digital literacy and resources needed for engagement in video-visits; 2) removing health system-created barriers to accessing video visits; and, 3) advocating policies and infrastructure that facilitate equitable telemedicine access. Along those lines, providers such as UCSF General Internal Medicine Primary Care Practice and San Francisco General Hospital academic practices have started an outreach program for all patients 65 years old and older. Under the program, staff members contact patients with scheduled visits by phone and walk them through setting up video platform application and practice connecting to the video. While, introductions such as this step-by-step guide are useful in enabling patients to access digital tools, access to broadband to close the digital divide needs to be addressed. It is not just the rural parts of the country that experience inaccessibility to broadband, certain groups or parts of even major cities still don’t have access to wifi or smartphones. As noted in a recent JAMA article, “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine”, over 40% of Medicare beneficiaries lacked access to a computer with high-speed internet access at home, and a similar amount lacked a smartphone with a wireless data plan. In order to make it available, healthcare institutions, providers and government must work together. An option could be stakeholders partnering together and providing hotspots every few miles so people can access it, Another option might be providing various broadband internet options at subsidized rates of low-cost to encourage communities to adapt to digitalization. While increasing broadband access is a necessary step and will likely take time, there are other immediate steps that the healthcare system can take to improve access. One strategy deployed by NYC Health+Hospitals Corporation during the pandemic was to make available city-wide telephone hotlines that connected providers for same-day-appointments with patients for opioid addiction treatment, leading to continued access and increased access for a lifesaving medication-assisted treatment. However, for actions such as this to work, telephone call appointments and even check ins need to be reimbursed at the more commensurate rate with video-visits. Despite certain security and privacy concerns, a strong argument can be made that, particularly in underserved areas and for lower income populations, audio-only telephone visits and even the ability to provide asynchronous communication would broaden access, is more convenient and has lower technological and locational barriers than audio-visual calls. While CMS began providing reimbursement for audio-only telephone services in March, and they have been broadly used during the pandemic, the American Medical Association, along with other physician groups, urged CMS to continue allowing the audio-only services in recent comments on proposed rule changes, and to make the change permanent which we would agree with. No doubt there are challenges to implementing strategies to mitigate disparities, and though there have been temporary fixes, knowing telehealth is here to stay, measures in favor of broadening access to digital services and enhancing convenience need to be made permanent.
Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic; COVID-19 Reveals Telehealth Barriers, Solutions; Are There Health Disparities in COVID-19 Telehealth Access, Use?
At the Height of Digital Wellness, Are We Missing the Human Touch?
Event: On January 14th, an article in MedCityNews highlighted that human interaction must remain an instrumental part of the healthcare experience. The article noted that if we are not careful about how we implement the move towards digital care healthcare risks losing empathy. Although the COVID-19 pandemic rapidly accelerated the healthcare industry toward digitization, human touch, and face-to-face interactions remain necessary and risk becoming “a thing of the past,” if we are not careful. While many providers have turned to digital communication and data management, e-visits, and telehealth to continue serving patients in a time of lockdowns and social-distancing mandates, going forward in a post-pandemic world will require a delicate balance.
Description: Touch and human interaction are vital to learning secret information about the body, reliably guiding providers a problem's root cause (often referred to as the “laying on of hands” by the physician). Multiple studies have championed the power of touch and empathy in medicine showing that: 1) compassion can reduce pain after surgery; 2) improve survival rates; and, 3) boost the immune system. Additional studies have demonstrated that patients have significantly better outcomes when their physicians score high on empathy, as it increases both patient satisfaction and compliance, while the simple act of holding a patient's hand can be beneficial as human touch can lower cortisol levels caused by stress. While firms are scrambling to provide more efficient and higher quality care by streamlining delivery systems via secure, accessible and reliable technologies, healthcare industry participants are struggling to find the right role for doctor-patient interaction. Although providers, payers, and patients are beginning to embrace digital innovation, the article highlights that human touch continues to be fundamental to one's health experience as it forges personal connections, decodes human emotion, and promotes trust and healing.
Implications: Health technology has become extremely advanced and intuitive but cannot replace human interaction because patients will always value and seek human touch. This is because: 1) they remain wary of AI and other nuanced technology, preferring to seek care from other human beings rather than computers; 2) have emotional needs when dealing with potentially life-altering diagnoses and unforeseen outcomes, that are best delivered by a living, breathing, and feeling individual; and, 3) believe that physical examinations are reassuring and restorative. While there is no single solution that can help preserve touch in health care, as we move towards digitization at a rapid pace, it is crucial to pay attention to the positive aspects of technology. For example, technology allows providers to reach more patients, reduces administrative burden, and expands access to treatment both through efficiency and remote care. Even though technology can often place a barrier between patient and provider, providers must explore the new avenues that technology can be applied to enhance empathy and build rapport. Although medicine will never progress without technology, human interaction remains an integral part of the healthcare experience and it should not be left in the past as it remains unique in its power to comfort, heal, diagnose and treat patients.
What Is the Healthcare Cost of Racial Health Disparities, Inequity?
Event: On January 13th, Patient EngagementHIT reported that the social determinants of health in Texas have resulted in $2.7 billion in excess medical spending, and another $5 billion in lost productivity. That represents a 60 percent increase in excess medical spending and 72 percent in lost productivity due to health disparities since 2016. The article noted how healthcare costs could have been avoided during COVID if racial health disparities had been more adequately addressed prior to the pandemic.
Description: In Texas, Black and Hispanic children are more likely to grow up in neighborhoods of poverty and their families are more likely to lack health insurance, causing large disparities in health status, disease prevalence, and premature death. According to Episcopal Health Foundation, Texas is incurring $2.7 billion in excess medical care spending annually as well as $5 billion in lost productivity. In addition, this lack of care leads to 452,000 life years lost due to premature deaths valued at $22.6 billion. It is likely that these figures will increase by 22% as the Texas population grows and becomes more diverse, increasing racial healthcare disparities. According to the article, if Black and Hispanic populations in Texas were hospitalized for COVID at the same rates as non-Hispanic Whites, there would have been 24,000 fewer COVID hospitalizations in Texas through September 2020. The article adds that if Black and Hispanic populations had the same mortality rates as their non-Hispanic counterparts, there would have been 5,000 fewer deaths as of the end of September 2020, reducing the death toll by 30%. These outcomes are largely attributed to institutional inequality and the fact that Black and Hispanics are more likely to work frontline or essential workers and are at a higher risk for severe illness should they contract coronavirus due to pre-existing chronic illness as well as lack of health insurance.
Implications: If the issue with racial healthcare disparities and higher costs persists, Texas may see up to $3.4 billion in excess medical spending, $6.1 billion in lost productivity, and 551,000 life years lost. Although Texas is being highlighted, racial healthcare disparities occur all over the world and need to be addressed. The global pandemic has laid bare healthcare disparities that are claiming the lives of many minorities due to lack of access and availability of healthcare resources. The study highlights Medicaid expansion as a gateway to closing racial health disparities exposed by COVID, which could help increase patient access to care through telemedicine. However, policymakers still need to focus on key factors such as housing access and quality, food security, air quality, educational attainment, employment, and institutional racism as part of their efforts to close gaps in care due to race. If stakeholders do not make these factors priorities, this will continue to be an issue and many more lives will be claimed as a result.
Doctor on Demand Partners with Texas Health Plan for Virtual Primary Care HMO
Event: A recent article in Healthcare Dive noted that Community Health Choice, a Texas-based health insurance not-for-profit organization, is partnering with telehealth vendor Doctor on Demand to set up an HMO plan for virtual primary care. The plan is launching on the Texas ACA marketplace and will offer patients a primary care physician and virtual visits with urgent care and behavioral health.
Description: Community Health Choice has significant Medicaid offerings in Texas, a state that has not expanded Medicare eligibility under the ACA. Deemed the “Virtual Bronze” plan, this HMO plan is targeting uninsured people who are not eligible for Medicaid, filling a gap in coverage for more than 760,000 residents who are also ineligible for premium subsidies. This new partnership is consistent with the other steps Doctor on Demand has taken to capitalize on demand for virtual health services during the pandemic. It became the first telehealth vendor to enter the Medicare Part B market in May, and entered into a contract with the state of Massachusetts to provide free virtual visits for people who are on Medicaid or uninsured during the pandemic in April.
Implications: As noted by Doctor on Demand’s head of growth and strategy David Deane, during the pandemic, patients have been deferring non-urgent care and preventive care, delaying appointments or missing annual check-ups as they seek to avoid potential exposure to COVID in healthcare facilities. Through virtual primary care plans such as this, patients can experience the “environment of having a primary care physician” without having to expose themselves to potential harm while maintaining routine and preventive care. In addition, by providing less expensive access to primary care, virtual primary care can provide an underutilized service to an underserved population. The pandemic has opened up space in the primary care market for telehealth services to fill. Other states can expect to see plans similar to this one from Community Health Choice and Doctor on Demand popping up on marketplaces soon.
Trustworthy AI Has the Ability to Transform Healthcare
Event: On January 12th, an article in Mobihealthnews reported that a problem remains among clinicians, staff, and patients with trusting recommendations derived from artificial intelligence (AI) since they cannot see or understand what the software is doing or how the model performs calculations on the data and arrives at its conclusions. The article highlighted that according to Pat Baird,senior regulatory specialist at Philips, AI needs to build trust on three levels: 1) technical trust; 2) regulatory trust; and 3) human trust..
Description: According to Mr. Baird, technical trust asks if the algorithm does what it is designed to do, regulatory trust determines if the software stands up to different agencies' [and user] expectations and requirements, and, human (interaction) trust faces the user and decides whether or not people will like it and trust it. All of these levels are important, but success is dependent on who the stakeholder is and who the user is. All applications have to be customized to fit the needs of the users. Another way to build trust in AI aside from the three levels of trust is to make the applications better by improving the data, such as making data interoperable and linkable.
Implications: Creating trust in AI has the power to transform healthcare for clinicians and patients alike. It can help free up clinicians by facilitating care and enabling computers to recommend protocols for clinicians to follow. The article highlights that part of the human-interaction trust comes from considering the differences among user populations. Often, there is an underrepresentation of intended populations due to incomplete data for which AI technology should be trained to provide unbiased outcomes. Careful attention must be given to drive positive outcomes. Using data to program technology will allow for fluidity and technological opportunities to transform healthcare delivery for many patients. Moreover, it is imperative to understand clinician preferences with regard to using artificial intelligence applications because clinicians want to know and understand how and if it will work for them and their patients. Importantly, clinicians also want to ensure they will get paid for using AI as well as ensure they won’t be held liable for decisions made or strongly influenced by AI enabled products.
Aspen RxHealth Raises $23M Series B Funding Round Led by Bessemer Venture Partners
Event: Aspen RxHealth, a Tampa-based platform that connects pharmacists with patients in need of enhanced medication services, has raised $23 million. Aspen RxHealth matches clinical pharmacists with patients based on social and clinical factors. This enriches the patient-pharmacist experience and helps them achieve better medication compliance while reducing costs.
Description: Aspen RxHealth matches its community of 5,000 pharmacists to patients using algorithms based on specific demographics and clinical attributes. This allows pharmacists to focus on meeting the needs of their patients while Aspen RxHealth manages the administrative tasks related to delivery of care. AspenRxHealth's services include medication therapy management, quality measure initiatives, medication reconciliation, high-value segments (HIV, cancer, specialty drugs), and more. With an easy-to-use clinical workflow and user experience, the Aspen RxHealth application simplifies the task of documenting patient encounters. Accessible from a mobile phone or tablet, the application is powered by an advanced clinical decision support engine which identifies the most relevant patient care interventions.
Implications: Aspen RxHealth will help improve the efficiency, quality, cost, and convenience of care. First, Aspen RxHealth helps pharmacists and doctors apply and channel their expertise most efficiently. As the market has seen a continuous oversupply of pharmacists, Aspen RxHealth helps realign pharmacists, instead of overburdened doctors, to effectively help patients. As a result, doctors can use that time and energy to help other patients in need. Second, Aspen RxHealth can improve the quality of care by utilizing the expertise of trained and passionate pharmacists. Pharmacists will be able to advise patients on medicine complications, side effects, combinations, and substitutes. Lastly, Aspen RxHealth is easy to use and convenient for patients. The platform matches patients to pharmacists based on their location and social and clinical factors. With an easy-to-use clinical workflow and crisp user experience, the Aspen RxHealth application simplifies the otherwise arduous task of documenting patient encounters for doctors and makes communication easier for patients. During the pandemic, this user-friendly platform allows patients to easily communicate with pharmacists in the comfort of their own home.
