Despite the snow last week in Boston, the calendar tells me we’re now in Q2. It’s been a busy year already: the first wave of conferences is behind us, we’ve heard some interesting news from Apple, and we’ve seen Uncle Sam show some love to diabetes prevention and bundled-payment programs. And that’s on top of all the usual clamor. Here is a quick grab bag of a few topics drawn from my own conversations and notes over the last few weeks.
Mental health: Can we align patient needs with market opportunities?
An encouraging recent trend has been the rising popularity of mental healthcare apps. Startups have moved beyond one-dimensional mood tracking, bundling up cognitive behavioral therapy (CBT), coaching programs, telepsychiatry, smart tracking features, and more into consumer-styled apps for the modern patient. In the short term, it hints at an uptick in market appetite and investments. Over the longer term it signals a shift in industry discourse that will be critical to breaking down stigma and integrating the behavioral with the physical.
What’s not so glowing is the state of how these new tools are (or aren’t) making it to the hands of patients who need them. Today’s usual market channels are mostly limited to employer and payer programs, and to a lesser extent one-off delivery system partnerships, typically with your big academic medical center or IDN. These are necessary but not sufficient. By their own design, they cannot reach entire swaths of the population who need help. The self-insured millennial masses, adolescents and college students, and the LGBT community are but a few examples of groups with dysfunctional access to care.
And how many more people have access but don’t seek care due to stigma, cost, or sheer lethargy, which also happens to be a common symptom of depression? We’re fighting with one hand tied behind our back if all we can do is perpetuate models where the tools a person has access to depends entirely on traditional channels – payer, employer, doctor.
In a recent review of the digital health landscape, Joe Kvedar wrote about MoodGym, an Australian cognitive behavioral therapy (CBT) program that’s free for anyone to access through a public website. Is there a way to balance this direct-to-consumer (DTC) approach with a revenue strategy for the company? What about an integration strategy for the patient and their record?
I’d like to see the numerous mental health companies out there – HealthRhythms, Valera, Lantern, Iodine – think more about how technology might provide a way to help people who don’t want to go through a doctor or insurance company. How can we help those who can’t afford care, or have fallen off the behavioral health carousel of specialists, referrals, and networks and have given up seeking help?
This is a topic we mustn’t ignore, because digital health is uniquely suited to help these folks out.
Next wave of patient engagement, minus a business model
It’s undeniable that patient engagement has hit a wall. Looking beyond investments, regulations, and market activity, it just seems like the collective mojo of the space has plateaued for the time being. Do you feel it too?
I suspect we’re just at an inflection point. The failures of those remote monitoring studies still sting. Telehealth suppliers seem intent on trying to replace the traditional delivery system rather than integrate into it. Between the failure of Meaningful Use 2 and the uncertainty of MU3, our faith in the status quo’s EHR-driven approach has started eroding. As John Moore puts it plainly: Kill the Portal.
So – what’s next?
Several industry leaders have been tinkering with the notion of a patient-controlled data platform, or a data ownership engine, or a patient-driven health information economy. In other words: patients receive secure access to a meta-layer of data pulled out of disparate EHRs and facilities and even patient-owned devices through HIEs or APIs or other means. Leonard Kish and Eric Topol describe the resulting resource as an “External Wisdom of the Body.”
Developers can build specific apps on top of this layer, and patients sign up for them as they choose.
Does this sound familiar? It should – we’ve been talking about different configurations of this exact model for a decade, going back to a little company called Microsoft rolling out HealthVault. Sure, it’s nice to see the technology getting an overhaul. But it’s also important to remember, while we’re at this inflection point, that the business case and go-to-market strategy for these patient data models have simply never worked.
Who’s going to pay for this? Who is the intended audience, Medicare patients or employer-sponsored consumers or anyone who wants to create an account? Are we going to carve out small groups of patient users at a few employers and a few VA clinics around the country and declare this a success? Or are the experts and leaders going to put some teeth into legislation, strike the right partnerships across policy, payers, vendors, and providers, and figure this out as a complete system overhaul?
I know—easier said than done.
Promising models like Healthbank may show technological functionality in bubbles like Sweden or Singapore, but it’s beyond my understanding as to how such a model can attain U.S. market success. I worry that some of our brightest minds are stuck on the gadgetry of building the next thing – cutting-edge consent mechanisms, leveraging blockchain encryption models, etc. – without focusing on (or worse, willfully ignoring) the underlying challenge: a real world business model that can work in fractionated market that’s still crippled by information blocking and profiteering.
Bundles of fun with CJR
I have long thought of Medicare’s new bundled payment program for comprehensive joint replacement (CJR – hip and knee replacements) as a solid example of a specific health tech market mechanism for value-based care to take root. Huh? Put it this way: Instead of entrepreneurs vaguely pointing to ACOs as a landing pad for their technology, CJR offers a very real, very discrete use case with specific steps, technology layers, tech-tied incentives, timelines, and patient-centric measures to sink their teeth into (if you’re looking for a digestible overview, this is one of the best I’ve found.)
Cliffs Notes: This program was set into place just recently, on April 1 – Medicare chose about 800 hospitals in 67 different geographic markets and began paying them one lump sum for all inpatient and downstream care around hip/knee replacement surgeries.
The incentive/penalty scheme is driven by measures of cost and quality. The first year of the program carries no penalties or downside risk, so some hospitals are shrugging off figuring out a strategy until 2017. For others, patient volume is low enough for these procedures that they may just ignore the program or farm those patients out to other facilities.
In theory, the communities that implement this program successfully will start using data-driven methods for resource allocation, implementing downstream care management and coordination, collection, and use of patient-reported outcomes measures through mobile tech, and the other fun stuff we’ve all been waiting for.
I’m interested in how all of this is going to play out. It’s easier to understand immediate impact and progress with a discrete scenario like this compared with checking our wristwatches as large ACO programs continue tying their shoelaces. The usual lobbyists will keep on trying to delay the CJR program, saying it adds too much to hospitals’ already-full plates.
Three or four technology vendors I’ve spoken with disagree – locating and aligning the data, and then rolling out the proper tools and training is fairly simple, especially for such a straightforward use case. Relatively it’s a smaller financial opportunity for health tech, but it’s here right now and hospitals need help.
More importantly – if this begins clicking and generating savings, it is pretty likely that CMS expands the program quickly, either by expanding the number of hospitals under the CJR program in subsequent years, or adding on other DRG codes for things like COPD, or some cardiovascular procedures. Will hospitals step up to the plate and take a swing, or will they wait for the umpire to call the pitch?
Exciting times. As the saying goes, the more things change, the more they stay the same. As always, please share your comments, corrections, insights, or other thoughts below.