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Public Option-A Vital Step, Smartwatches Spot COVID, Fixing Lockdown Loneliness-The HSB Blog 12/1/20

Biden’s Public Option Brings Americans One Step Closer to Fixing the System

Event: Among President-elect Biden’s stated legislative goals is to improve healthcare access by lowering the Medicare eligibility age from 65 to 60 years old and allowing those below age 65 to buy-in to Medicare via a “public option”. Under Biden’s plan, eligible participants between the ages of 60-65 could maintain their existing source of coverage or purchase Medicare via the public option. While it is impossible to analyze this portion of the plan in isolation (and we will include additional analysis in later posts), we believe the Medicare public option is a net positive for healthcare access and would generally improve the quality and lower the cost of care in the U.S.

Description: Under the proposal, Biden plans to create a public health insurance option which would let individuals purchase Medicare coverage. As noted by the Committee for a Responsible Federal Budget (CFRB), since “Medicare rates are generally lower than private insurance, the public option could be cheaper than alternatives in many cases…[and] competition from the public option could reduce the cost of private insurance as well”. Biden’s proposal would make coverage available to those who lack coverage, those with Employer sponsored insurance, those who get coverage through the current ACA exchanges and in states where Medicaid was not expanded. It is estimated that

under the plan approximately 15-20 million uninsured Americans would gain coverage. Biden’s proposal would pay for coverage by increasing the amount of ACA premium subsidies and financing them by increasing the top marginal tax rate (to 39.6% from its current 37%), increasing tax rates for those making over $1M per year on capital gains (to 39.6% from the current 20%) and estate taxes (via the addition of a stepped up cost basis). While many insurers oppose the plan fearing that pressure from the public option could significantly shift coverage, according to Avalere only about “13.4M individuals currently enrolled in employer sponsored insurance [ESI]”, or approximately 9% of the total ESI market (and likely less-as discussed in implications) would buy in to the public option. Biden’s plan should not be confused with a nationalized or single-payer healthcare system, as: 1) It doesn’t require that everyone be enrolled in a single government insurance plan, 2) it does not contain limits on provider payment rates, 3) it does not eliminate the Medicaid eligibility gap, and, 4) it does not allow those in households eligible for ESI to take advantage of Federal insurance subsidies. Despite the fact that many would argue that his plan would be the beginning of a move in that direction, given the lack of traction gained by Senator’s Sanders and Warren during this election cycle, we see this as highly unlikely for the foreseeable future.

Implications: The current U.S. healthcare system is unsustainable for well known reasons of cost, quality, inefficiency and equity. While Biden’s public option will create some near term shifts in sources of coverage for payers and providers, it would provide coverage for many Americans without healthcare insurance or struggling to pay premiums, and we expect over time will actually benefit providers and payers. For example, as cited earlier, Avalere estimates that 13.4M would shift from ESI to Biden’s public option, realistically any public option will have to be bid out to the commercial insurance companies in the same way Medicare Advantage is currently run. Although some have surmised that employers may chose to drop employees to let them buy into a public option plan or that large segments will drop employer coverage to buy into Medicare, we note similar arguments were made with ACA exchange plans and never materialized (and could run afoul of discrimination laws). Moreover, given that Medicare Advantage is one of the most successful government programs ever and now accounts for almost 40% of Medicare enrollees up from 25% in 2011 we expect payers to benefit from additional application of analytics and further economies of scale in treating this cohort. In addition, despite the fact there is some dispute about MA margins, given that over 50% of MA market share is concentrated among three of the public managed care programs that would argue in favor of its profitability and attractiveness. Although Biden's plan will increase the national deficit by $800 billion in ten years according to the CRFB, additional improvements in coverage could bring additional benefits of lower costs and improved outcomes much like were seen in the early years of the ACA.

Pre-Symptomatic Detection of COVID-19 From Smartwatch Data

Event: A study shows consumer smartwatches data can be used for the pre-symptomatic detection of COVID-19. The study analyzed physiological activity data from 32 individuals infected with COVID-19, identified from a cohort of nearly 5,300 participants, and found 81% had alterations in heart rate, number of daily steps, or time asleep. Using retrospective smartwatch data, it was shown 63% of the COVID-19 cases could have been detected before symptom onset in real-time via a two-tiered warning system based on the occurrence of extreme elevations in resting heart rate relative to the individual baseline.

Description: This cohort study investigated whether smartwatches could be used to detect COVID-19 at an early, pre-symptomatic stage. Smartwatches included Fitbits, Apple watch, Garmin devices, and others. The parameters evaluated were abnormal resting heart rate (RHR), heart rate-to-steps ratio, sleep and activity alterations, heart rate signals and other symptoms. These were evaluated for association with COVID-19 and to establish an approach for the early detection of early COVID-19 onset in real-time. The study found that all the above parameters were altered by COIVD-19. Elevated heart rates occur before disease and provide utility as a general signal of respiratory illness. CuSum an online detection method with the ability to detect altered physiology in advance of symptoms, was developed to detect early stages of COVID-19 illness in advance of symptoms using a smartwatch.

Implications: As the findings suggested, activity tracking and health monitoring via consumer wearable devices can be used for large-scale, real-time detection of respiratory infections, including COVID, often pre-symptomatically. With the second surge of COVID-19 currently hitting the US, the use of smartwatches could help substantially improve widespread testing detection. In addition, the application of wearable devices to virus detection has ample potential to mitigate the spread of the pandemic as well as addressing respiratory illness overall. It allows self-monitoring, the early detection of symptoms and the ability to place suspected virus carriers in protective protocols without having to expose themselves or others to additional sources of infection.

Flow Depression Headset to Tackle UK’s ‘Lockdown Loneliness’

Event: A recent article in Mobihealthnews examined the positive health outcomes resulting from the new rollout of the Flow headset and therapy app treatment. Individuals in the UK and EU have been using it to tackle depression and ‘lockdown loneliness.’ Recent user analysis shows that 81% of patients using the Flow headset and therapy app reported feeling better after just three weeks.

Description: The Flow depression headset aims to alleviate the burden of loneliness caused by lockdown by improving accessibility to treatment delivered to patients within 48 hours. Patients who use Flow and the behavioral therapy app wear a brain stimulation headset that improves areas known to impact depression, emotion regulation and sleep quality while increasing social support with the app. The therapy program provides an interactive chatbot therapist and a constant companion that offers personalized behavioral therapy in areas proven to reduce symptoms of depression. A study in Plos One indicated that loneliness is a significant public health issue with 70% of people with depression feeling isolated and with worse quality sleep due to the pandemic.

Implications: The COVID-19 pandemic has resulted in lockdown measures limiting social contact, which adversely affected mental health outcomes. Providing patients with access to therapeutic applications such as Flow will help tackle common conditions like depression and improve emotion regulation, sleep quality, and increase social support. Rates of loneliness during the initial phase of the lockdown were high, and findings have shown that supportive interventions can reduce loneliness that leads to depression and other mental health symptoms. Flow appears to be a promising solution for patients and clinicians because it's tailored to individual needs; it is controlled in real-time and can monitor a patient's condition and progression of treatment thus far.

AliveCor Gets FDA Nod for Suite of Cardiac Focused AI Algorithms

Event: On November 23rd, Mobihealthnews reported that AliveCor received FDA clearance for a new suite of algorithms called Kardia AI V2 that interpret ECG data to detect cardiovascular illness. The company also recently announced a $65 million Series E funding round to support its research.

Description: The algorithms are designed to capture sinus rhythms with premature ventricular contractions, supraventricular ectopy, and with wide QRS. They work using AliveCor’s KardiaMobile and KardiaMobile 6L devices, which are at-home consumer health management devices that can take 30-second electrocardiograms (ECGs) and are linked to a smartphone app. AliveCor stated the new algorithms will reduce the number of unclassified readings and have improved sensitivity and specificity relative to the company’s atrial fibrillation and other algorithms. There will also be new visualization features on the app, once these algorithms are implemented that will allow users to see their heartbeat average, PVC identification (extra heartbeats that disrupt your regular heart rhythm causing your heart to feel like its fluttering) and tachogram (for detecting heart rate variability analysts).

Implications: FDA clearance allows AliveCor to move forward with product development using their new AI technology and implement it in their current devices. Heart disease is the leading cause of death in the United States, according to the CDC. Tech companies have taken the opportunity to participate in the fight against heart disease using innovative new approaches the medical community would otherwise not implement on its own. The marketing for AliveCor’s new algorithm suggests it can improve cardiac care and telehealth services by bringing advanced preventive measures into the home thus lowering costs and improving quality.

Smartwatches Could Monitor Coronavirus Vaccine Safety

Event: On November 19th, Lifewire reported that the U.S. Centers for Disease Control (CDC) plans to use smart watches to monitor the safety of coronavirus vaccines if they are distributed in the U.S. Using V-SAFE, a smartphone based health checker researchers will be able to check in on vaccine recipients for health problems. Although this is an efficient way of monitoring patients, adherence to privacy and HIPAA regulations may be an issue as well as long-term patient compliance.

Description: With the roll out of the COVID-19 vaccine, health officials are concerned about the safety and how they will monitor the vaccine recipients. Although the results of two vaccine trials are expected to be more than 90% effective, health officials want to continue to monitor the safety of these patients along with millions of others who will receive the vaccine in the upcoming months. The CDC plans to have those who are vaccinated use V-SAFE, a smartphone based health checker that will use phone numbers from the registration process to send text messages and web surveys from the CDC to check in with recipients for any health problems resulting from the disease. Daily texts and emails will be sent within the first week followed by weekly messages thereafter for the following six weeks. Some privacy advocates have also raised concerns regarding the security of the data generated by the smartwatches in this program due to the lack of some safeguards found in contact tracing solutions. According to data privacy and protection advisor, while medical data is usually regulated under HIPAA, since participants will be using commercially available devices for this project, HIPAA may not be applicable. In addition, healthcare officials have raised questions about getting people to participate long term without feeling coerced into wearing the device in order to receive the vaccine.

Implications: While imperfect, the continued monitoring of patients via smartwatch after receiving the vaccine can aid in tracking adverse effects that may not become apparent during clinical trials. With the device, experts have the ability to see side effects or adverse events and can quickly in real-time or near-real time decide if it is a true safety concern. When needed they can make vaccine recommendations for improvements. Although data privacy could be an issue, many experts feel this can be addressed as long as patients are fully consented and informed about the distribution of the data and how it is being shared. Perhaps of greater concern is the tendency for individuals to stop wearing their smartwatches after a period of time. As such, healthcare professionals need to reiterate the importance of consistently wearing the watch so patients can see how it will benefit their well-being and the wellbeing of others in such studies.


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