Big Tech & Retail Disruptors Continue to Run Into Same Challenges in Healthcare-The HSB Blog 3/22/21

Our Take: While non-traditional tech and retail disrupters in healthcare, like IBM, Walmart, Amazon, J.P. Morgan and Berkshire Hathaway (through the Haven joint venture), and Google, all had different goals in changing the face of healthcare, they have all had difficulty gaining significant traction the marketplace for similar reasons. These reasons include: reasons include starting too ambitiously with a poorly defined strategy; lacking distinct goals; failing to align their interests with patients and providers and, under or over-marketing their healthcare product.

Description: Non-traditional, tech, and retail giants like IBM, Walmart, the Haven J.V. partners, and Google either recently or historically have all entered the consumer-facing portions of healthcare for different reasons. IBM built up and eventually branded its AI healthcare unit as Watson Health to use AI to improve health outcomes in Cancer and other diseases; Walmart planned to leverage its existing brand and retail store base to build 4,000 primary-care clinics initially focusing on underserved communities; Amazon, J.P. Morgan, and Berkshire Hathaway through the Haven joint venture attempted to reimagine the delivery of employer-based healthcare; while Google created Google Health back in early 2011 as a repository of health records and data (known as a personal health record) to allow patients to have access to all of their health records in one place. While all of these were worthwhile goals, many of them were too ambitious and poorly defined. For example, IBM focused Watson on curing cancer, as noted by Ariell Trzcinski, an analyst at Forrester, “these {were} really ambitious goals. One of the things we see with organizations that have been more successful in applying AI in healthcare is that they start small”. Similarly, one observer commenting on the collapse of Haven noted, “a boulder-sized problem as big as healthcare cannot be solved with an equally sized sledgehammer solution. It is best done in moderation with a chisel, and over time”. In addition, often these goals are very broad and lack a specific achievable goal. Walmart’s goal was to be “America’s neighborhood health destination” with a strategy that included a timeline of opening 125 clinics by the end of 2021, 1,000 clinics by 2024, and 4,000 by 2029, according to Business Insider. Along the same lines, IBM referred to Watson as a Cancer moonshot while Haven’s goal was “reimaging employer-sponsored care”. While we are not privy to internal projections which likely contain more explicit financial goals, the goals in these statements, though laudable, are not very specific in terms of treatment of distinct medical conditions or costs. In addition to overly ambitious and broadly defined goals, these initiatives often fail to align their interests and incentives with those of patients and payers. For example, according to Adam Bosworth the original leader of Google Health, Google never really pushed to see what people would want, they basically offered a place to store data. [People] want to be healthy but they need more than that. Connecting these efforts to the interests of payers is equally important, as noted by current co-founder and CEO of Health Rosetta and former Microsoft executive Dave Chase, “as much as we’d like to think it isn’t the case, the fundamental driver of most (not all) behavior in healthcare is the reimbursement scheme”. Likewise with Haven as one observer noted, despite the presence of many large organizations in healthcare, “healthcare is always a local delivery and local financed industry...the challenge is always aligning interests and goals.” Finally, not surprisingly given the importance of healthcare as a vertical for these disruptors, these efforts often fall prey to over-hyped marketing strategy. According to STAT+, IBM “announced a flurry of partnerships before it had the resources, the scientific evidence, and in some cases the technology to support them.” Similarly while Haven’s marketing team touted their goal of providing “simplified, transparent healthcare at a reasonable cost”, Haven’s partners never clearly outlined what their contributions to the partnership would be or what their commercial expectations were.” In the same vein, Google Health was poorly marketed and lacked support at the highest levels of the company to succeed.

Implications: For non-traditional entrants like retail and tech entering healthcare and gaining market share in the consumer-facing aspects of the industry is difficult, time-consuming, and fraught with risk. The varied nature of healthcare data, the intricate nature of data privacy and security rules such as HIPAA and CCPA, and the often complicated relationships between patients, providers, and payers can make navigating the space difficult at best. While the technology is often steeped in a culture of “move fast and break things”, healthcare is infamously associated with Hippocrates and his oath to “do no harm”. As a result, achieving change in healthcare can be methodical, require broad consensus, and involve cross-collaboration support from broad swaths of an organization or parts of the industry. In the words of the former worldwide head of healthcare at Microsoft, “health is hard, it takes a lot of time, money and partners to transform an industry”. As a result, we recommend disruptors approach the market tactically with very specific, defined, and realistic goals to cure one problem. Innovators need to realize that success will breed success and drive internal demand from customers which can dramatically shorten the sales cycle. Moreover, while groundbreaking technology is wonderful, realize the limitations of the technology itself. For if the technology does not align with the customer’s problems or allow them to impact something under their control it likely will not succeed. In the words of Amit Kaushal, professor of bioengineering at Stanford, “having technology that works is necessary, but it’s not sufficient to ensure you’re going to alter clinical outcomes”. Lastly, disruptors must also identify their market strategy and be careful not to oversell their health products without inflating the capabilities recognizing that healthcare may be a very different market from where they are coming from. As noted by STAT+ “IBM failed to fully comprehend the differences between its traditional tech business lines and the complex world of health care."

Goodbye, Haven: The Benefits Industry Reacts; 10 Reasons why Google Health Failed; Inside the Fall of Watson Health: How IBM’s Audacious Plan to ‘Change the Face of Health Care’ with AI Fell Apart; Walmart is Slowing its Ambitious Push Into Healthcare, Employees and Leaked Documents Reveal (subscription required for last two articles)

MedPAC Recommends More Telehealth Study, Concerned About Fraud and Waste

Event: An article from mHealthIntelligence describes the stance taken by the Medicare Payment Advisory Committee (MedPAC) relating to the future of telehealth coverage after the COVID pandemic. In the report, MedPAC did not endorse any final decisions concerning telehealth rules that were suspended during the public health emergency (PHE), instead suggesting that many temporary measures be extended so that they could be studied further.

Description: On March 15th, MedPAC submitted its March 2021 Report to the Congress: Medicare Payment Policy to Congress that contains the Commission's recommendations on the future of telehealth coverage by Medicare. The report recommends that the telehealth coverage expansions that were put in place during the COVID PHE be extended for 1-2 years so that additional data can be collected to evaluate the impact of telehealth on healthcare costs and quality. During the pandemic limits on a number of telehealth rules including those limiting originating site requirements, cross-state licensure, and others were suspended or not enforced so that services that could not be safely delivered in person could be delivered. Importantly, the report recommended “Medicare should return to paying the fee schedule’s facility rate for telehealth services and collect data on the cost of providing these services” after the PHE ends, essentially returning to covering telehealth services at a lower rate than in person visits. In addition the commission suggested extending coverage for telehealth services regardless of originating site, (telehealth is often used to overcome distance for patients who cannot reach their provider easily), and recommended allowing clinicians to be allowed to bill for audio-only services (which were not covered prior to the PHE). In defending it’s recommendations MedPAC stated it prefers the continuation of this evidence-gathering period, over a permanent extension of all of the over 140 added telehealth services by the Centers for Medicare and Medicaid Services (CMS). It also recommended that providers no longer be allowed to waive cost-sharing for telehealth services.

Implications: As noted by mHealth Intelligence, many will be disappointed that MedPAC did not embrace the alternative for permanent extension for the majority of the approximately 140 coding changes that it mentions. Many industry participants had hoped, and anticipated that the massive uptake in telehealth usage during the pandemic would lead to a shift in policy. While it is important to note that MedPAC's recommendations are not binding and it has no official role over CMS, the Commission's recommendations often carry much weight. In addition, if Congress and CMS do not act, once the PHE ends, certain limitations on telehealth services like those limiting originating site of services will go back into effect. Moreover, although the Commission is right to focus on the potential for fraud and abuse in telehealth, as demonstrated by success of telehealth during the pandemic, those concerns may be outweighed by the benefits that can be brought to patients, particularly the underserved. Though some have pointed to the recommendation for further evidence gathering and study noting disappointment, we believe the Commission’s recommendations indicate that some, but not all, of the regulation changes to telehealth services covered during the public health emergency will eventually be made permanent, but there are no guarantees. As we pointed out earlier, the Commission appears to be focusing only on direct costs and does not appear to be taking into account other indirect cost and the opportunity costs of lost improvements in care. While many of these are difficult to measure, they should be taken into consideration as we seek to broaden access with new, more innovative tools.

MedPAC Recommends Limiting Post-COVID-19 Telehealth Coverage, More Study & MedPAC March 2021 Report to the Congress: Medicare Payment Policy

Using Telehealth to Keep People with Developmental Disabilities at Home

Event: Recently, Healthcare IT News reported on a plan that Partners Health Plan of New York has implemented to use telemedicine to decrease ED visits for its members. According to the report, Partners is a managed care organization that is dedicated to helping people with intellectual and developmental disabilities (IDD). It noted that those with IDD may experience trauma associated with hospitals, often can have difficulty dealing with change and may face discrimination or difficulties communicating. As a result, all of these issues can lead to people with IDD having negative experiences in medical settings.

Description: Patients with IDD can “go downhill with hospital admission.” While IDD has not been among the fields to provide advanced technical support to patients, Partners had begun rolling out telehealth programs aimed at helping this demographic even before COVID. Partners was working with StationMD prior to other healthcare providers opening the telehealth platform for IDD patients. The telehealth program Partners implemented showed both hospital admissions and emergency room visits decline since 2018. Following the pandemic, their telehealth program reported 91.6% of calls were treated via telehealth itself and only 8.4% transferred to the emergency department. The pilot program for Partners and StationMD included providing residential staff members with stethoscopes, pulse oximeters, blood pressure monitors as well as equipping doctors with a detailed history of patients historical claims data. As a result, by the time the pandemic hit, the system was already in place. Given the success that Partners has had rolling out telehealth to its IDD population it looks forward to implementing urinary tract infection management as a continuum of at-home service.

Implications: As noted in the article, 1 in 4 adult patients have IDD and approximately 50% of adults with IDD are frequent visitors to the emergency department. Their reported satisfaction to the ED is very low as they often face some sort of discrimination or challenges in an ED. While telehealth skyrocketed in popularity during the pandemic, concerns arose that telehealth could worsen the digital divide especially for people with disabilities since providing telehealth visits to patients with IDD was very new to providers. This new initiative by Partners Health Plan which sought to broaden the use of telehealth to people with IDD, while taking into account their unique needs and working closely with local providers, appears to have been a success. Not only has it allowed patients with IDD to have a positive experience it has also allowed them to experience it from the comfort of their own homes. Telehealth care for IDD patients indicates the use of such applications can support their particular communication needs which enables simple behavioral interventions and provides support in treatment. By creating multi-modal telehealth applications that are adapted to the health needs and capabilities of these patients, innovative care delivery teams like Partners are broadening the scope of care that can be delivered to people with IDD at home thereby improving outcomes and reducing costs. This approach, along with the development of AI based tools has the potential to revolutionize the care for patients with intellectual/developmental disabilities.

Telehealth as a Tool to Keep People with Disabilities out of the Hospital

Trialing an Edible Camera to Improve Detection of Colon Cancer

Event: (3/11) A recent article in MobiHealthNews highlighted Medtronic's new Pillcam Colon 2 technology. The NHS in England will perform a trial to check for colon cancer signs among participants given the edible miniature camera.

Description: A recent study by Oxford University noted that thousands of patients might have untreated bowel cancer as a result of diagnostic testing that was deferred during the COVID pandemic. Between April 2020 and October 2020, over 3,500 fewer patients than expected were diagnosed with bowel cancer in England. The Pillcam Colon 2 technology seeks to provide a quick, safe, and convenient approach to patients who have to monitor or test for colon cancer signs. The pill is a vitamin-sized capsule that is taken orally, does not require sedation, anesthesia, or radiation. Once swallowed, the camera-enabled capsule will take images as it passes through the bowel. The images will then be transmitted to a recording device that the patient wears. After the camera has passed through the body, it can be flushed away. The NHS plans to trial the pill by giving it to 11,000 participants in more than 40 areas in England to look for signs of colon cancer. The endoscopy team at University College London Hospitals NHS Foundation Trust, NHS in Scotland, and other international health clinics are already using Pillcam technology.

Implications: The new and innovative Pillcam technology has the potential to replace the traditional endoscopy where patients are required to undergo in-person procedures to have a tube inserted. The Pillcam technology will provide a diagnosis within hours, speed up checks, and detect cancers at an earlier stage where they are easier to treat. Clinicians can remotely monitor their patients and provide the help and support they need in real-time. Since bowel cancer is more likely to be curable if detected at its early stages, this technology can make a clear impact on identifying and treating patients with bowel cancer. Innovations like the Pillcam Colon 2 technology can help the tens of thousands living with underlying symptoms and undiagnosed cancer due to routine screenings that have been delayed or skipped during COVID. This technology, and others like it, can provide a quick and efficient diagnosis to patients from the comfort of their own homes.

NHS Trials Edible Capsule Cameras to Detect Colon Cancer