HLTH 2021

We’re Boston-bound!

By Sara Aldworth |

The Milliman HealthIO team is excited to sponsor HLTH 2021, the industry’s most important event for healthcare innovation.

We invite you to join us for a 10-minute Tech Talk on Monday, October 18th at 4:05 p.m. EDT. Our CTO Dave Neuman will be appearing on stage in Hall A, explaining how digital health can help us see the forest AND the trees.

Of course, you don’t have to wait until HLTH to meet us—our door is always open. Drop us a note and let’s connect. We’d love to help you solve your toughest healthcare challenges.

Want to learn more about us? Check out our HLTH Announcement Spotlight below for preview of what we do.

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Disruptive innovation in healthcare

Disruptive Innovation

A wicked problem?

Disruptive Innovation

What is disruptive innovation?

The concept of disruptive innovation has attracted significant attention since it appeared in Clayton Christensen’s influential book “The Innovator’s Dilemma.” Yet its meaning is often misunderstood or misapplied. More than a decade after the book’s publication, Christensen revisited the theory in the pages of the Harvard Business Review. He and his co-authors emphasized that disruptive innovation begins with products creating low-end or new-market footholds that relentlessly move upmarket, eventually displacing established competitors.[1] In other words, disruption starts when a company identifies and satisfies an unmet (and sometimes latent) need.

Take the automobile for example. In the late 19th century, cars were not a disruptive innovation. They were luxury items occupying the high-end of the transportation market. Most people continued using more affordable horse-drawn vehicles to travel. True industry disruption came in 1908 with the debut of the Ford Motor Company’s “Model T.” This lower-priced car changed the transportation industry by making automobiles an affordable replacement for horse-drawn transportation, creating a whole new tier of consumers.

More recently, Netflix is an example of disruptive innovation. Catering at first to a niche group of consumers with its web interface and mail-order delivery, Netflix didn’t appear to challenge Blockbuster, the industry leader in movie rentals. However, the advent of streaming technology enabled Netflix to completely re-think the business. Netflix’s ability to pivot quickly, along with the convenience, ease-of-use, and low price point of its offering, allowed it to quickly unseat Blockbuster.

Although disruption has been around for a long time, the pace has accelerated. We can look to the turnover of companies listed on the S&P 500 equity index as a measure of the change. On average, a listed company is replaced by a newcomer every two weeks. It has been estimated that over 40% of today’s Fortune 500 companies listed on the S&P 500 will no longer exist within 10 years.[2]

What leads to disruptive innovation?

Technology advancement and the digitization of information has played a large role in the disruption of industries and markets. However, it would be a mistake to attribute disruption solely to technology. There are several other factors underpinning disruptive innovation regardless of industry. An industry ripe for disruption typically exhibits one or more of the following dynamics.

Complex experiences

There are few industries as complex as healthcare. As noted by Jeffrey Braithwaite, professor of health systems research and president of the International Society for Quality in Health Care, “Healthcare is a complex adaptive system, meaning that the system’s performance and behaviour changes over time and cannot be completely understood by simply knowing about the individual components…No other industry or sector has the equivalent range and breadth—such intricate funding models, the multiple moving parts, the complicated clients with diverse needs, and so many options and interventions for any one person’s needs.”[3]

Many times, simple healthcare needs can lead consumers into a maze of appointments, practitioners, treatments, and locations. When that happens, it may lead consumers to decide it’s just not worth their time or money to deal with the healthcare system, potentially to the detriment of their health.

Against this backdrop, MinuteClinic was founded to provide convenient, high-quality access to routine healthcare needs. Located inside retail chains like CVS and Target, consumers can walk in without an appointment and receive care from a nurse practitioner or physician’s assistant. Services range from sports physicals to flu shots to the diagnosis and treatment of common illnesses such as bronchitis or strep throat. This model of care has proved to be popular. Since the inception of the first retail clinic more than 20 years ago, there are now nearly 3,000 such clinics in the United States.[4]

While MinuteClinics won’t put primary care providers out of business, the convenience of getting a flu shot while shopping may be the beginning of a disruptive innovation that leads to additional alternative care settings.

Consumer confusion

The insurance industry has a long history, dating back to ancient Babylon and enshrined in the Code of Hammurabi.[5] Despite the social benefits of risk management, the industry’s participants and regulators have often called for increased transparency in product definition, pricing, and claims processing. With contracts full of legalese and jargon, insurance products are often viewed as complex and hard-to-understand. Sometimes it seems the insurance industry is more oriented toward the business side of things than appealing to customer needs.  

Enter Lemonade, a company determined to make insurance loveable. Designed to be fast and simple–-90 seconds to get insured, three minutes to get paid–-it makes the entire customer lifecycle experience almost frictionless for consumers. Further, by donating the leftover premiums to a charity of the consumer’s choice, the company has repositioned insurance from being just a necessary risk management vehicle to one of societal good.

Redundant intermediaries

Once a staple of strip mall storefronts, most retail travel agencies have fallen victim to disruptive innovation. Traditionally, the travel agent acted as an intermediary, scouting prices and arranging itineraries for travelers. The advent of widespread internet access and sites like Expedia, Travelocity, and Orbitz made travel agents unnecessary middlemen. With just a few clicks, consumers compare their own flight prices and hotel accommodations, which often allows them to book with ease.

Travel agents are no longer the only source for learning about different destinations and experiences either. The proliferation of review sites and recommendations from other travelers on social media has diminished the expertise of agents. As “anywhere, anytime” technologies continue to develop, along with AI virtual assistants, the travel industry will continue to transform. This disruption will almost certainly continue to benefit the average consumer with increased convenience and lower cost travel experiences.

Limited access

There is no shortage of financial management firms in the world. Generally, many investment advisors may be most interested in working with high-net-worth clients who need a suite of services and are willing to pay the associated fees for high touch service. That strategy has left a large population of younger and/or less affluent potential investors looking for help to manage their finances easily, conveniently, and at a low cost. Robo-advisors are filling that gap.

Robo-advisors are algorithm-based automated platforms that provide financial management services. Although the use of technology to facilitate investing is not new, offering it directly to consumers is. Like other disruptive innovations, robo-advisor platforms like E Trade, TD Ameritrade, and Robinhood offer services at a fraction of the cost of traditional human advisors with increased convenience.[6] As demographics shift in the market and younger, digitally savvy workers accumulate wealth, the disruption of wealth management may be here to stay.

Who benefits from disruptive models?

Consumers are an obvious beneficiary of disruptive innovation. The easy access, convenience, and lower costs of disruptive products meet their needs in a marketplace that may have previously had no way to service them.

Perhaps less intuitively, an argument can be made that all industry participants tend to benefit from disruption. While established entities may experience some upheaval, disruption forces them to revisit their business models and refocus on their core businesses. They have new opportunities to innovate existing products, invest in their workforce, and ensure they are serving consumers.

What is the business of healthcare?

Does history repeat itself? In business, it often appears to. Many victims of disruptive innovation made the mistake of defining their business by what they produced, rather than understanding what consumers wanted. This point was made powerfully by the scholar Theodore Levitt in his classic article “Marketing Myopia”, first published in the July/August 1960 issue of the Harvard Business Review.[7]

“The railroads are in trouble today not because that need was filled by others (cars, trucks, airplanes, and even telephones) but because it was not filled by the railroads themselves. They let others take customers away from them because they assumed themselves to be in the railroad business rather than in the transportation business. The reason they defined their industry incorrectly was that they were railroad oriented instead of transportation oriented; they were product oriented instead of customer oriented...”

The healthcare industry may find itself in a similar situation. While the human body may always need clinicians who can tend to ailments and cure disease, what people really want is health. Our current healthcare system is a means to an end, and an expensive one at that. National healthcare expenditures in the U.S. grew to $3.8 trillion in 2019, or $11,582 per person, and accounted for 17.7% of gross domestic product. It is projected to continue growing at an average annual rate of 5.4% and reach $6.2 trillion by 2028.[8]

The signals for disruption are present in the market, as noted in the MinuteClinic example at the beginning of this article. Our modern healthcare systems took shape in the early twentieth century, during a time when infectious diseases were the primary cause of mortality.[9] Today, we understand that health is more than just biology. Environmental factors and social determinants play an important role in health outcomes. It has been reported that 90% of American healthcare expenditures[10] and 70% of our mortality rate[11] can be attributed to preventable chronic conditions. Yet the complexity of our healthcare system often lacks the incentives to create a consistent, consumer-focused model that meets modern needs.

Erosion of trust also appears to be an issue for the healthcare industry. In a review of historical polling data and surveys published in the New England Journal of Medicine,[12] Robert Blendon and his co-authors wrote,

We found that, as has been previously reported, public trust in the leaders of the U.S. medical profession has declined sharply over the past half century. In 1966, nearly three fourths (73%) of Americans said they had great confidence in the leaders of the medical profession. In 2012, only 34% expressed this view.

This general lack of trust may contribute to a reduction in healthy behaviors, ranging from medication adherence to following a care plan. Equally important, this lack of trust may be a barrier preventing consumer adoption of industry-led healthcare innovations.

As the healthcare industry works to improve the care delivery model while grappling with the perception of eroded trust, consumer expectations continue to evolve rapidly. Technological leaps in other industries have transformed aspects of everyday life. However, the healthcare industry lags conspicuously behind. A 2016 survey of US healthcare consumers found that over 50% of respondents would likely switch hospitals due to poor electronic communication.[13] Interacting with the healthcare system continues to be far more complex and frustrating compared to consumer experiences from any other industry (e.g., retail, banking.) Consumers have come to expect frictionless interactions. For many, the healthcare system is not servicing their needs.

How will healthcare get disrupted?

In planning and policy, a “wicked problem” is a problem that is difficult or impossible to solve. Elements that factor into a wicked problem can include incomplete knowledge, the number of stakeholders and/or opinions involved, and how the problem intersects with other problems.

From an economic standpoint, a disruption of the healthcare industry is likely. Over the last decade, the cost of healthcare per person has been increasing approximately four percent, outpacing two to three percent GDP growth.[14] This is a highly unsustainable environment.  However, the strong financial performance of payers, providers, and pharma provides limited incentive for change.

Is this the wicked problem of healthcare? If the industry itself can’t be relied on to innovate, who will provide the necessary disruption to improve the system? Here are two likely candidates.

The healthcare consumer

Changing demographics, consumer expectations, and technology are creating a new paradigm in which the current healthcare system cannot survive. The shift in thought and behavior is already evident in the difference between the Baby Boomer and Millennial generations, as shown below.

Attitudes toward healthcare: Baby Boomers versus Millennials[15],[16]

Attitudes toward healthcare: Baby Boomers versus Millennials

The Millennial mindset has already led to an increased adoption of self-management health technologies ranging from activity trackers to devices for managing chronic conditions. Similarly, empathy networks (such as PatientsLikeMe[17]), telehealth technologies, and a heightened awareness of managing stress and lifestyle make these consumers likely agents for change in the healthcare industry.

Cohorts focused on health and wellness

Industry players don’t have adequate incentives for keeping individuals healthy. Over the past several years, regulatory efforts have been made to move the needle from “sick care” to true healthcare. A few examples:

  • The HITECH Act and its Meaningful Use program incorporated financial incentives and financial penalties depending on the success care providers achieved in utilizing electronic health records. Among the program’s objectives? Improve coordination and quality of care while reducing costs and engaging patients in their own care. [18]
  • The Patient Protection and Affordable Care Act shifted the emphasis from payment for volume to payment for value.[19] Traditionally, care providers are paid a fee for each service provided, regardless of outcome. New payment models reward providers who focus on the health outcomes of their patients and the quality of care and service their patients receive—not the number of times a service is rendered.
  • The Centers for Medicare and Medicaid Services (CMS) have also introduced payment models designed to reward outcomes. Examples include, but are not limited to, bundled payments for an episode of care or the Medicare Shared Savings Program, which allows for the creation of Accountable Care Organizations that take on the financial risk, rewards, and sometimes penalties, of coordinating care for a population.[20][21]

There is still a long way to go in the shift from fee-for-service to value-based care. Other cohorts and communities who have a vested interest in an individual’s health may provide a faster path to disruption. Employers and large self-funded organizations can benefit significantly from the health of their individual employees. The increased interest in “whealth” (a portmanteau of wealth and health) management introduces life insurers and financial managers as other stakeholders who find value in the health and longevity of populations. Creative thinking from these outsiders may unleash the disruptive innovation that those within healthcare simply cannot provide.

The result of healthcare disruption.

While past performance is not a guarantee of future results, it’s almost a sure bet that the process of disruptive innovation will improve healthcare as it has for so many other industries. As new products meet consumer-driven demand, health and economic gains will spread to stakeholders and beyond.

This does not negate the role of current industry participants. In the healthcare ecosystem, hospitals, insurers, providers, and more can build off of disruptive innovation, even if they haven’t created it themselves. Established players are beginning to take ownership of innovation, in some instances creating leadership roles to help improve their product offerings.[22]

Thankfully, in the midst of disruption existing digital health services are already finding ways to deliver simplified, cost-effective care on demand. However, they can’t transform the industry alone. Smart policy, private enterprise, and continued support of entrepreneurs will be necessary for society to reap the benefits of consumer-focused healthcare in the years to come.

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Will COVID-19 help move us towards a better model of healthcare?

A photo of people taken during the Spanish flu
A photo of people taken during the Spanish flu
One hundred years ago, the world experienced a health catastrophe that has been unparalleled – the “Spanish Flu.” The loss of life during that pandemic shook the fabric of our society and delivered major learnings that fundamentally reshaped the charter and the construct of health care systems, globally. Until that time, disease had been considered a result of the natural degeneracy of the poor rather than a result of the environments they lived in. Public health had been all about isolating the elites from the “scourge” of the poor, and thus preventing the spread of disease in the society1. That pandemic did not respect such social boundaries. The biggest structural impacts of the Spanish Flu included influencing governments worldwide to embrace the concept of socialized medicine, and, more importantly, to define the role of the physician as one who not only cures illness but also suggests ways to prevent it. Public health – as we know it today – was born. Roll forward 100 years from today, and we will undoubtedly be looking back at the pain and anguish caused by COVID-19. We may also be looking for lessons from the observed changes that impacted our lives and the healthcare system as a result of the current pandemic. New and important lessons are already emerging, and they have the potential to have a strong bearing on the healthcare system as well as the nature of the interaction of the health care consumer with the system. Here are some of them:
  1. Heightened awareness of one’s own health: As with COVID-19, so also in many other health situations – in the absence of any pharmacological solution, the best course of action is often to stay healthy. By being active and eating healthy, we can strengthen/balance our immune systems and avoid many chronic health issues. The good news is that a large percentage of chronic issues are either preventable or manageable. A heightened self-awareness of health and self-management will likely become part of the daily lives of a large percentage of human beings.
  1. Engaging critically with community health: The current crisis has exposed capacity constraints in the health care system that prevent efficient and effective management of an event that impacts a large segment of the population3. It has become evident that the traditional model of “the doctor will see you now” may no longer be the best approach and that health care – including patient-physician interaction – may be better delivered in the community and in people’s homes. Digital health channels offer the health care system an opportunity to provide surveillance and prevention that helps maintain a healthier society. 
  1. Prioritizing the health of health care workers: While the people on the front lines continue to do a tremendous job of taking care of us, who is taking care of their physical and mental health? Through the use of digital health technologies, health care systems may be redesigned to balance the load on the health care worker, potentially reducing unnecessary utilization and fatigue. Digital health technologies can be a great way to prioritize clinical workload while keeping health care consumers engaged.
  1. Gathering robust longitudinal data: The cornerstone of public health is data – data that can be used to study patterns as well as potential cause and effect relationships in the health of a society. While population health data collection has been going on at the federal level since 19572, data collection and use for individual benefit or society at large continues to be limited – in large part due to the fact that an individual, on an average, spends only a few of the 5000 waking hours4 in a year with the health care system – generating a small amount of point-in-time data.

“Use of digital health and remote monitoring technologies have the potential to…enable prediction and prevention of many health issues.”

Many organizations are seeking ways to leverage digital health technologies to improve the quality – and quantity – of data available. With increased geographical mobility of the population and changing lifestyles (including a highly switched-on and digital population), ease of data collection has changed. Use of digital health and remote monitoring technologies have the potential to dramatically expand collection of robust longitudinal data, which may in turn enable prediction and prevention of many health issues. Many believe a health care revolution is approaching; made possible by the exponential growth in technology and technology platforms that have the potential to substantially lower the costs of prevention and intervention. Add to this changing consumer expectations5 of being treated anytime, anywhere, and with adequate cost transparency so that health care doesn’t disproportionately burden the society. This revolution will shift the emphasis of the industry from “sick-care” to true “health care.” Perhaps COVID-19 just accelerated our journey towards the revolution.

1 Spinney, L. (2017, September 27). How the 1918 flu pandemic revolutionized public health. Retrieved June 21, 2021, from https://www.smithsonianmag.com/history/how-1918-flu-pandemic-revolutionized-public-health-180965025/
2 Blumenthal, D., & Seervai, S. (2021, February 01). Coronavirus is Exposing deficiencies in U.S. health care. Retrieved June 21, 2021, from https://hbr.org/2020/03/coronavirus-is-exposing-deficiencies-in-u-s-health-care
3 Asch, D. A., M.D., M.B.A., Muller, R. W., MA, & Volpp, K. G., M.D., Ph.D. (2012, July 5). Automated hovering in health care – watching over the 5000 Hours: NEJM. Retrieved June 21, 2021, from https://www.nejm.org/doi/full/10.1056/NEJMp1203869
4 Topol, E. J., M.D. (2016). The patient will see you now the future of medicine is in your hands. New York, N.Y.: Basic Books.
5 Topol, E. J., M.D. (2013). The creative destruction of medicine how the digital revolution will create better health care. New York, N.Y.: Basic Books.

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The digital health revolution is here. What’s in it for providers and consumers?

Blue walkway
Blue walkway

Recent advances in digital technology have revolutionized healthcare as we know it. In 2018, the global digital health market size was valued at $95.8 billion, expected to quintuple to $509.2 billion by 20251. Increasing demand for remote monitoring devices to manage chronic ailments, a significant rise in the penetration of smartphones, and an abundance of mobile health apps are all potential drivers for the expected growth of market size.

Another contributing factor to the growth is global investment in digital health – it hit a record high of $14.6 billion in 20182, marking the sector’s eighth consecutive year in growth.

What is the value of digital health tech in patient care?

Before we answer that question, let’s first take a closer look at what encompasses digital health – it includes mobile health apps, wearables, big data, telehealth, personalized medicine, and everything in between. These technologies provide an overall picture of patient health abetting informed clinical decisions, better management of chronic conditions, early disease diagnosis, and timely intervention and prevention. Utilization of the right digital tools and strategy can improve the ability of the healthcare system to take a more consumer-centric, proactive approach to improve patient outcomes and increase operational efficiencies. It also has the potential to reduce costs all while building a system that benefits providers and consumers alike.

The provider perspective

From a provider’s standpoint, benefits include:

  • Improved diagnostic ability and quality of personalized care
  • Increased patient access
  • Reduced inefficiencies and costs

Unlike the point-in-time data acquired in a clinical setting, health data generated through smart devices and wearables provide an outlook on the patient’s overall health over a period of time, rendering the data more useful for disease detection and diagnosis and thus improved clinical decision making.

Furthermore, some mobile health apps go a step further and provide a portal for patients and providers to have a direct line of interaction, which increases patient satisfaction and quality of care.

Per the findings of a survey3 conducted by EY, physicians polled widely agreed that digital technology will contribute to population health management, ease the burden on the healthcare system, and reduce costs. More specifically, 66% of the surveyed physicians think that technology that captures consumer data generated from mobile applications and digital sensors can reduce the burden on doctors and nurses, positively affecting the rate of physician burnout.

The consumer perspective

Wearables and mobile health apps have substantially driven the consumer side of digital health; the modern patient/consumer can use digital tech to track physical, mental, and wellness aspects of their health. Instead of an annual physician visit painting the picture of patient health, consumers now have the ability to view and manage their health every day and in the comfort of their homes.

For the first time, this is putting the power of health management in the consumers’ hands in a meaningful way. It also raises the hope and expectation that consumers will gain a deeper understanding of their health and will be engaged to make better self-care decisions.

What’s next in the digital health revolution?

Based on the growth of the digital health market and associated investment, some key questions might get answered over the next half-decade:

Will the consumer be King?

With increasing proactive engagement from consumers, will the current provider-driven system shift to consumer-centric care? Will consumers set their own health goals and preferences, driven by a better understanding of their health data? Perhaps the growth of digital health will lead to a consumerization of healthcare that hasn’t been witnessed before.

Will true integration and interoperability of data across platforms finally be achieved?

Consumer-centric healthcare and individual hunger for control over one’s own health data could lead to a stronger push for a digital infrastructure that enables data interoperability, allowing data to flow between clinicians and patients.

How will data governance evolve?

With the widespread use of data across health systems comes the growing risk to security and privacy that can compromise data integrity and ownership. Policy frameworks in a consumer-centric health system will need to strictly enforce safe and secure access of personal health data by providers and consumers to achieve the best outcomes.

“Healthcare of the future could be preventive, predictive, and participative.“

Will we finally shift to prevention?

Healthcare of the future could be preventive, predictive, and participative. With the rapid progress of digital and artificial intelligence capabilities, organizations could use predictive analytics to identify populations at high risk of developing certain preventable conditions, prioritize care, and proactively mitigate risk in a timely manner.

The power of digital health tech rings especially true during the current COVID-19 pandemic that has battered the world. The ongoing crisis has definitely pushed digital tracking, remote monitoring, and telemedicine to the forefront, finding virtual ways to substitute in-person visits. Although every aspect of life seems unsteady at the moment, forging a path to progress through trying times has always been the American way – and in that way forward, the pulse of digital health tech in everyday life will be felt stronger than ever.

1Grand View Research (2019). Digital Health Market Size, Share & Trends Analysis Report By Technology (mHealth, Digital Health Systems), By Component (Hardware, Software, Services), And Segment Forecasts, 2019 – 2025. Retrieved November 2, 2020, from https://www.grandviewresearch.com/industry-analysis/digital-health-market

2Fortune (2019). Digital Health Companies Hit a New VC Funding Record in 2018. Retrieved November 2, 2020, from https://fortune.com/2019/06/23/digital-health-companies-investment/

3Healthcare Innovation (2018). Survey: Most Docs Optimistic that Digital Tech Will Reduce Provider Burden. Retrieved November 2, 2020, from https://www.hcinnovationgroup.com/clinical-it/news/13029960/survey-most-docs-optimistic-that-digital-tech-will-reduce-provider-burden

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Managed care organizations and remote care management: a perfect match

A woman on a laptop
A woman on a laptop

Imagine the scene: you, a care coordinator working for a managed care organization (MCO), are responsible for clients that are notoriously hard to contact or connect with. Your clients are phone-averse, have difficulty with transportation, or are immunocompromised, and coming into the clinic is not the best idea amid COVID-19 restrictions. However, there are meds to be managed, metrics to be collected, and other standards by which you need to abide.

For many professionals working in the MCO world, scenarios like these are extremely common. So how can the average care team remedy these issues? To continue to offer efficient, cost-effective, and accessible care today and in the future, healthcare providers need to use technology to adapt to a structure that enables them to improve care metrics without increasing costs.

Remote Care Management (RCM) is one possible solution. RCM is care delivery that enables providers and care coordinators to use digital technologies to monitor individuals outside of conventional clinical settings. Wide availability of easy-to-use devices to measure vitals, high smartphone penetration, Bluetooth and Cloud technology, etc. make it possible for an individual to measure and record health data at home and transmit it securely to a care provider in a different location for review.

While RCM can bring several benefits to MCOs, the most significant ones might be:

  • Active patient tracking
  • Improved metrics
  • Increased access to care

Active patient tracking: With remote care management, not only can care team staff have a near-constant connection to members and patients under their care, but they can also have more direct access to members’ data. Such access helps care providers stay “in the loop”—monitoring data, metrics, and the regularity of measurements. This, in turn, also gives them the necessary inputs to provide additional education, support, and feedback.

“…healthcare providers need to use technology to adapt to a structure that enables them to improve care metrics without increasing costs."

Improved metrics: RCM can also help improve performance and quality metrics by encouraging patient adherence to the care regimen. RCM tools usually have built-in reminder capabilities. RCM not only allows for a connection between provider and member, but also between members and their respective health data, which plays a role in members feeling empowered and engaged in managing their health.

Improved access to care: Another benefit of remote care management is increased access to care. Geographic separation and distances become much less of an issue for members and patients who live in remote, rural areas. Care providers are able to manage higher caseloads due to the reduced need for home visits, thus improving utilization of their resources. As well, hurdles to deploy such care models have been mitigated with changes. For example, in 2019, the Centers for Medicare and Medicaid Services (CMS) expanded the reimbursement code for remote care,1 allowing for more services to be covered.

With these potential benefits, remote care management can work well for MCOs when looking to improve member care experiences and enabling healthcare providers to engage in more cost-effective business models.


1mHealthIntelligence (November 5, 2019). CMS Finalizes New Reimbursement Rules for Remote Patient Monitoring. Retrieved March 12, 2021, from https://mhealthintelligence.com/news/cms-finalizes-new-reimbursement-rules-for-remote-patient-monitoring.

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Health technology for the heartland

A hospital sign on a rural street
A hospital sign on a rural street
Remote care management (RCM) can be instrumental to closing the gap in accessing healthcare that exists in rural communities. When options such as in-home healthcare can cost an average more than $4,000 a month for services1, many of which don’t even encourage the improvement of personal health outcomes, it is imperative to find alternatives that work for providers and patients alike. Attempting to provide care in rural communities can often pose many different challenges. First and foremost is the disparity in primary care physician (PCP) to patient ratio between urban and rural areas. Limited provider availability can mean that patients wait months to receive care. Patients with chronic conditions, who rely on regular care, are particularly affected – they may have to miss work for the first available appointment and require flexibility for long wait times or rescheduling. At the same time, depending on where they are seeking services, some patients must travel long distances for care, sometimes resulting in a drive of two hours or more.2 In the case of specialists, drives for these patients can be even longer.

“With RCM, the time spent away from the doctor can now be used as an opportunity to measure and track vitals, medications, and wellness. "

For those successfully managing chronic conditions, visits are generally uneventful and consist of checking and charting vitals – something that RCM can easily provide3. Through RCM, health vitals such as blood pressure, weight, blood glucose, heart rate, and oxygen levels can be easily measured by patients in the convenience of their home using devices that are designed for this purpose. These devices have become sophisticated enough to automatically transfer the measurements to patients’ phones and other smart devices, which then allow the data to be shared with their care provider (PCP, other healthcare professional, caregiver, or family member). Many digital health applications also keep a log of the vitals for patients and their care providers to see trends over time as well as the ability to set up alerts so that if any vital goes above a patient-specific threshold, the care provider is alerted and can take immediate action if needed.

With RCM, the time spent away from the doctor can now be used as an opportunity to measure and track vitals, medications, and wellness. For users in rural communities, this can go a long way towards eliminating the hassle of face-to-face check-ins with their healthcare provider. By integrating RCM with the care provided in rural communities, the access to care increases, the emphasis of care shifts to maintaining wellness, and the gap that once existed closes as patients have ownership over their care and personal health.

1Cost of Care Survey, 2019. Genworth. Retrieved on November 15, 2020, from https://www.genworth.com/aging-and-you/finances/cost-of-care.html

2Syed, S. T., Gerber, B. S., & Sharp, L. K. (October 2013). Traveling Towards Disease: Transportation Barriers to Health Care Access. U.S. National Library of Medicine, National Institutes of Health.  Retrieved on October 10, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/

3Turner-Lee, N. ( Summer 2019). Can Emerging Technologies Buffer the Cost of In-Home Care in Rural America? Generations: Journal of the American Society on Aging. Retrieved on December 8, 2020, from www.jstor.org/stable/26760121

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Combating healthcare costs in the digital age: A quick guide for self-insured employers

A man typing into a calculator
A man typing into a calculator

More than half of all Americans receive health insurance through their employers.1 In 2016, about 40% of private sector establishments reported they self-insured at least one of their health plans.2 A self-insured employer is one that, instead of paying a predetermined premium to an insurance carrier, pays for healthcare claims out-of-pocket and assumes the financial risk of its employees.

There are several benefits of self-funded health plans: customization for the workforce instead of a “one-size-fits-all” model, improved cash flow due to absence of prepayment for coverage, and no health insurance premium taxes. Self-funding makes it imperative for such employers to meet the healthcare requirements of their employees in a preemptive, cost-effective fashion, while also creating systems to bolster healthy behavior and outcomes.

In order to successfully navigate these challenges, employers should consider a combination of disease management programs, proactive health management tools, and on-site or employer-sponsored health clinics to address the health needs of their employees in a holistic manner.

The elephant in the room is chronic disease: we know that employees diagnosed with chronic disease can be costly to employers—not only are there direct healthcare costs due to medications and frequent doctor visits, there are also indirect expenses associated with absenteeism and loss in productivity. Per the Centers for Disease Control and Prevention (CDC), six in 10 Americans3 live with at least one chronic disease like heart disease, stroke, diabetes, or cancer. Therefore, chronic disease management should be an important facet of any undertaking by self-insured employers to manage their healthcare costs.

The core elements of disease management should include vitals tracking, medication adherence, and management of nutrition and physical activity.

Vitals such as pulse, blood pressure, temperature, and blood oxygen saturation represent the body’s basic functions, help assess the physical health of a person, and provide clues to disease prognosis. Changes in vital signs prior to clinical deterioration are well documented4 and, therefore, regular vitals tracking becomes a compelling activity to enable early detection of preventable outcomes, which is key to timely intervention.

Monitoring medication intake is also critical when it comes to disease management. To offer some perspective, in the United States 3.8 billion prescriptions are written annually; approximately one in five prescriptions5 are never filled and, of those filled, about 50% are incorrectly taken (i.e., incorrect dosage, frequency, or timing). These are staggering numbers that emphasize the need for a trusted method to manage medication adherence.

Benefits of diet and nutrition management and regular physical activity are well known and widely researched.6 Adults who make a conscious effort to manage nutrition and get regular physical activity can reduce the risk of many chronic conditions.

Employers have at their disposal several strategies to encourage and motivate their populations to do some or all of the above. One such approach is to adopt a digital health monitoring program that enables employees to establish health goals and keep a check on their vitals, medication, and wellness-related activities via smart medical devices.

Today, one in five Americans7 uses a smartwatch or fitness tracker; the increasing adoption of digital technology paves the way for employers to also integrate wellness initiatives into these health programs (e.g., weight loss goals via healthy eating programs, or exercise routines and tips and tricks to stay fit), thus taking a holistic approach toward disease management. With the employees’ consent, data obtained from such programs can be shared with care providers, who can access a health profile outside episodic visits and become equipped to better manage chronic issues in collaboration with the employees, thus improving health outcomes.

Not limiting their programs to disease management, employers should also promote proactive health management strategies and tools to motivate healthy employees to remain healthy. The same concept of vitals and wellness tracking can be extended to the healthy population as well (i.e., those not diagnosed with any chronic condition) with the goal of prevention and early disease detection. Data obtained through monitoring of vitals over a period of time can reveal trends that employees and their care providers can jointly use for health management. This type of proactive management empowers employees with awareness around their health and helps them stay alert to changes, thereby enabling early detection and timely intervention by the medical team if necessary.

“The core elements of disease management should include vitals tracking, medication adherence, and management of nutrition and physical activity.”

If employers are to institute a preventive digital health and wellness program that takes a holistic approach toward health management, it is critical to do so in collaboration with an onsite or similar employer-sponsored clinic. A qualified, employer-approved health professional at a convenient location who can work with employees to keep a pulse on their health and take actions to effectively prevent or manage adverse health outcomes creates a recipe for successfully helping employees take control of their own health and build lifelong healthy habits.

Employers that want to successfully reduce healthcare costs for themselves and their employees, while also implementing tactics to improve the health of the workforce, should commit to the idea that health and wellness management is an essential business strategy. They have to consider a combination of well thought-out programs, monitoring tools, and touchpoints to achieve the outcomes needed to create an environment where they are not only empowering employees to build healthy habits, but also playing a central role in developing a more resilient and sustainable health system for the future.

1USA Facts (March 23, 2020). How do most Americans get their health insurance? Retrieved March 12, 2021, from https://usafacts.org/articles/how-most-americans-get-their-health-insurance-medicare-employers/.

2Employee Benefit Research Institute (August 1, 2019). Self-Insured Health Plans: Recent Trends by Firm Size, 1996-2018. EBRI Issue Brief. Retrieved March 12, 2021, from https://www.ebri.org/publications/research-publications/issue-briefs/content/self-insured-health-plans-recent-trends-by-firm-size-1996-2018.

3See the CDC website at https://www.cdc.gov/chronicdisease/index.htm.

4Churpek, M. et al. (May 1, 2017). The value of vital sign trends for detecting clinical deterioration on the wards. PubMed Central. Retrieved March 12, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834231/.

5CDC (November 17, 2017). CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management — Innovations and Opportunities. Morbidity and Mortality Weekly Report (MMWR). Retrieved March 12, 2021, from https://www.cdc.gov/mmwr/volumes/66/wr/mm6645a2.htm.

6WHO (March 4, 2002). Diet, nutrition and the prevention of chronic diseases: Report of a joint WHO/FAO expert consultation. Retrieved March 12, 2021, from https://www.who.int/dietphysicalactivity/publications/trs916/summary/en/.

7Pew Research Center (January 9, 2020). About one-in-five Americans use a smart watch or fitness tracker. Retrieved March 12, 2021, from https://www.pewresearch.org/fact-tank/2020/01/09/about-one-in-five-americans-use-a-smart-watch-or-fitness-tracker/#:~:text=About%20one%2Din%2Dfive%20Americans,smart%20watch%20or%20fitness%20tracker&text=As%202020%20begins%20%E2%80%93%20and%20health,June%2

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AI and predictive analytics are transforming healthcare. Here’s how.

Artificial intelligence (AI) has slowly yet surely pervaded our daily lives; we delegate mundane, thoughtless tasks to automated systems, attempting to purge some of the busy work and free up physical time and mental space to either be more productive at work or indulge in a little more play. We use Alexa, Siri, or other smart assistants on our personal devices to help check off our shopping lists, update reminders, and make home security safer.  AI algorithms are becoming increasingly sophisticated and more ubiquitous all to do what human beings can do today – except faster, cheaper, and better. From programming to cleaning our floors with smart vacuums to a not-so-distant future of self-driving cars chauffeuring us to personalized co-working spaces, the progress of AI is everywhere and likely here to stay.

Not so surprisingly, AI has found its way into healthcare and is making noticeable inroads in several areas. When it comes to general health and wellness, AI in combination with the Internet of Things (IoT) empowers us, the consumers, to take charge of our health and pay attention to our vitals, fitness, and diet. Smart medical devices and/or wearables have the ability to continuously track health conditions. There are many examples of AI-based healthcare solutions. Google has DeepMind Health, which combines machine learning systems and neuroscience to build algorithms that imitate the human brain. IBM’s Watson for Health, a form of AI, can store far more health and treatment information and review it exponentially faster than any human being.

In 2016, a partnership between Barrow Neurological Institute and IBM Watson made a groundbreaking discovery that was possible by Watson’s review of thousands of pieces of research to identify new genes linked to ALS (amyotrophic lateral sclerosis (ALS).1

As an example of a more tactical application of machine learning, Milliman developed a model2 to predict an individual’s likelihood of being diagnosed with opioid use disorder, thus enabling healthcare organizations to engage in a more timely manner with at-risk individuals. In 2018, researchers from the U.S., Germany, and France trained a deep learning AI platform to identify skin cancer with greater accuracy than human beings. The result was that the AI platform found 95% of the melanomas, outperforming most dermatologists at 86.6%.3

The potential benefits of integrating AI into our healthcare ecosystem and devices are numerous, including automation of tasks, analyses of patient data, and delivery of better healthcare. Analyses of massive amounts of data can lead to patient insights and predictive analytics, facilitating healthcare interventions to occur at more appropriate times and potentially avoiding expensive medical situations for patients, payers, and providers. Simply put, AI and predictive analytics have the potential to create better outcomes for the healthcare community as a whole. 

However, there are some challenges that AI faces in terms of adoption and widespread use in healthcare.

The top concern raised by far is the handling and privacy of patient data. Even though technology companies, device manufacturers, and other stakeholders are increasingly investing in state-of-the-art technology to address this concern, protecting patient data remains a high priority.

Another challenge is to form meaningful and marketable insights. That is, while the technology exists to capture and analyze large amounts of data, the inferences themselves may not make sense without the right format, context, and key metrics for the right audience to take actionable steps.

“…AI and predictive analytics have the potential to create better outcomes for the healthcare community as a whole.”

Finally, there is a notion that AI may eventually replace care providers, when in reality, AI technology and health professionals will work hand-in-hand to create the best possible patient outcomes.  This in large part is due to the fact that predictive analytics and the use of AI in healthcare are relatively new and yet to gain the trust of professionals in the medical community and consumers. Despite these potential pitfalls, public and private sector investment in healthcare AI has been remarkable. According to a February 2019 Forbes article, PricewaterhouseCoopers says more than a third of provider executives were investing in AI, machine learning, and predictive analytics in 2018. And some estimates predict total healthcare AI investment will reach $6.6 billion by 2021. Accenture predicts AI can help address 20% of unmet clinical need. Another analysis predicts that top AI applications could result in annual savings of $150 billion across the healthcare industry by 2026.4 With the potential to pare back healthcare expenditures and create better outcomes for participants in the healthcare community, the future of AI in healthcare is looking bright.

1IBM Watson Health (December 14, 2016). Barrow Identifies New Genes Responsible for ALS using IBM Watson Health. Press release. Retrieved on November 13, 2020, from https://www.prnewswire.com/news-releases/barrow-identifies-new-genes-responsible-for-als-using-ibm-watson-health-300378211.html.

2Boschert, J. et.al. (January 2020). More accurately assessing opioid risk in Medicare members. milliman.com. Retrieved on November 13, 2020, from https://us.milliman.com/-/media/milliman/pdfs/articles/more_accurately_assessing_opioid_risk_in_medicare_members.ashx

3Computer learns to detect skin cancer more accurately than doctors. (May 28, 2018). The Guardian. Retrieved on November 13, 2020, from https://www.theguardian.com/society/2018/may/29/skin-cancer-computer-learns-to-detect-skin-cancer-more-accurately-than-a-doctor

4AI and Healthcare. (February 11, 2019). Forbes. Retrieved on November 13, 2020, from https://www.forbes.com/sites/insights-intelai/2019/02/11/ai-and-healthcare-a-giant-opportunity/#156b16f64c68.

 

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