Lab Soft News

Actions by Amazon May Be a Preview of Expansion into Primary Healthcare

I have posted previous notes considering the changes that are now occurring in the primary healthcare market including the efforts of CVS/MinuteClinic, Walgreens, and Walmart to gain market share (see, for example: Walmart Shapes Its Own Primary Care, Unbundling Strategy; The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems). This is in contrast to health systems that are not keeping pace because of the lower profit margins of such practices. Meanwhile, Amazon with its Prime business unit, seems to be positioning itself as a primary care provider. Some of these ideas were covered in a recent article (see: Amazon made another bold move into healthcare that went relatively unnoticed). Below is an excerpt from it:

Amazon expanded into the Medicaid market by announcing that it will offer beneficiaries a Prime membership of $5.99 a month, a discount of 54 percent. And while that revelation last week may not have raised quite as many eyebrows as the company's blockbuster partnership with Berkshire Hathaway and JPMorgan Chase it holds the potential to have a major impact sooner. "What Amazon is doing, they are trying to position themselves for a different market," ....They are disrupting healthcare at all levels. They're trying to be competitive with Walmart."....The Medicaid population isn't courted by providers because the lower reimbursement rates threaten their bottom lines. Insurers right now appear more interested in the Medicare Advantage market, though specialized government payers such as Centene are making the Medicaid segment work....

Amazon has been studying the healthcare market for at least a year...and began a competitive focus on Walmart last year with the start of Amazon Cash, which is a way to add money to an account to make quick ordering easier -- even for people who may not have a bank account, credit or debit cards. Taking that a step forward,...[a spokesperson] said she envisions Medicaid consumers talking to a physician via their smartphone for a $5, or even free, telehealth visit. "You can talk to a doctor with one click on Amazon Prime, who can tell you whether you need the emergency room," ...[an analyst said]. This helps keep beneficiaries from going to the emergency room for care, but may also cut into PCP services.....Amazon could also be considering a move into primary care.

To summarize, Prime has lowered its monthly membership for Medicaid subscribers and is now offering Amazon Cash membership to Prime members as a payment substitute for those lacking credit/debit cards or checking accounts. This will allow them to purchase items on Amazon and also, potentially, to take advantage of virtual care health (i.e., telemedicine) visits at low cost. Now that Amazon also controls retail store space in the form of Whole Foods stores, it could also potentially carve out drop-in clinic spaces like MinuteClinics in these stores. It will be fascinating to watch the next healthcare moves by Amazon (see: Amazon overtakes Google as the world's most valuable brand). The now huge company will surely pursue this line of business because healthcare is such a large proportion of the GDP and lower income and rural populations are not always well served by the current system. 

Specialized Diabetes Clinics Arise in India; New Trend in Healthcare Delivery?

I recently was told about the growth of a chain of clinics in India called Lifespan Diabetes focusing entirely on the care of diabetic patients. Here's a short summary of the services offered by the company copied from its web landing page:

We are India's First and Largest Chain of Diabetes Clinic. It's a caring endeavor founded by Ashok Jain, who is a diabetic himself for 21 years. With 40 Clinics across 10 cities, we have already reached out to help 81,000 diabetics. Diabetes is a hassle-some disease. So we don’t want the added hassle of waiting for a doctor, going to a diagnostic centre, finding products in another place etc....We provide everything a diabetic might need, under one roof. Right from diagnosis to speaking to a dietician, educator, diabetologist. As a patient, you don’t have to keep going from pillar to post. The phlebotomist comes home to take patient’s blood. So life is easy and convenient for the patient.

Various plans are offered by the company based on factors such as the stage of the disease, organ involvement, duration of the disease, and even for patients in a pre-diabetic state. Full Care 12 is the plan designed for those with newly diagnosed disease and "glycated hemoglobin not more than 9." The cost of yearly care for this group of patients is Rs.15900 which is equivalent to about $227. I am sure that the plans for more complicated patients are priced at a higher level.

To set the stage, here's some data on the prevalence of diabetes in the U.S. from a 2017 article (see: New CDC report: More than 100 million Americans have diabetes or prediabetes):

More than 100 million U.S. adults are now living with diabetes or prediabetes, according to a new report ...by the Centers for Disease Control and Prevention (CDC). The report finds that as of 2015, 30.3 million Americans – 9.4 percent of the U.S. population –have diabetes. Another 84.1 million have prediabetes, a condition that if not treated often leads to type 2 diabetes within five years. The report confirms that the rate of new diabetes diagnoses remains steady. However, the disease continues to represent a growing health problem: Diabetes was the seventh leading cause of death in the U.S. in 2015. 

I believe that it is inevitable that a similar type of diabetes clinic chain will arise in the U.S. The demand is certainly present. Such a large scale type of operation should also be able to reduce costs for treatment with economies of scale. Such an organization could also potentially increase the quality of care with such a specialized approach. I think that payers would be in favor of such clinics and perhaps could even mount such an effort themselves (see: Major Trends for the Year: Payers Use IT to Provide Total Care Management).

Private Specialty Practices Get Gobbled Up

(see: Dealmaking stayed hot in 2018, with a focus on physician practices)

This year, buyers hungry for acquisitions paid particular attention to specialty practices in such areas as orthopedics, cardiology, dermatology, gastroenterology and dentistry. Primary care is in strong demand, too. As far as who is buying practices, it's a three-way race between the old hats—health systems—plus private equity firms and, a relatively new entrant: payers. UnitedHealth Group's OptumCare has been particularly aggressive about buying physician practices as part of its strategy to get as close to consumers as possible. But Centene Corp., Humana and Anthem are adopting a similar strategy as they work to control spending. Private equity investors and payers may have the upper hand. Health systems are known to struggle when it comes to integrating practices into their operations, and often aren't willing to make the capital investments physicians demand....Groups like Optum, by contrast, are more inclined to support physicians' instincts. “I think their strategy is one that's quite remarkable relative to what's going on in the industry today,” Caine said....

Fifer agreed providers are hesitant about the move toward value-based care given its potential to cut into their revenue. “It's human nature to be hesitant and quite honestly, it's human nature to gravitate toward something that's familiar,” he said. On a broader scale, it's healthy for providers to look at such arrangements strategically and analytically to understand how they'll work, Fifer said. The year also saw a heavy emphasis on data analytics. Providers are investing more and more into being able to harness and analyze data to better understand their finances and operations. It's also been an important component in the evolution toward value-based care. In some ways, 2018 saw examples of breaking from the traditional merger and acquisition strategies of the past as a way to rise above the disruption that's dogging the industry.....

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Major Trends for the Year: Payers Use IT to Provide Total Care Management

Approaching the end of years in the past, I have cited articles in Lab Soft News that summarize healthcare tech trends for that year. Here is a link to such a current article (see: 12 trends that will dominate healthcare IT in 2019) and below are the 12 trends cited as being relevant for 2018:

1. Using IT to help achieve patient engagement and experience
2. Rising efforts to achieve digital health
3. Accelerating the use of AI and data visualization
4. Rising importance of population health management
5. Growing efforts by payers to provide total care management
6. Pressing on toward interoperability
7. Pushing to achieve EHR optimization
8. Protecting health information and data security
9. The rising tide for value-based care
10. Growing the role for virtual care
11. The increasing influence of the cloud
12. Making wider use of clinical decision support and real-world evidence

One of the items on list that attracted my attention was #10, virtual care, about which I have blogged extensively. Here is one such example (see: Reducing Healthcare Costs with Virtual Visits; Tangible Evidence Provided). However, the most important item in the list, I think, was the reference to payers providing total care management (#5). Here are more details about this trend from the article:

Information technology will undergird payer efforts to migrate from pure claims administration and payment to burgeoning initiatives that help insurers offer care management and health optimization for those who they cover. Payers will embrace technology innovation more than ever before—companies like Bright Health, Devoted, Oscar and Clover are continuing to attract a lot of investment from the venture and private equity world because they’re seeking to offer a better user experience, and collect and utilize data in ways that will drive better outcomes—at lower costs.

This idea reminded me of recent blog notes in which I suggested that MinuteClinics were also using IT to improve the primary care experience and compete with health systems (see: CVS Offers Telemedicine Visits for MinuteClinic Patients; A Visit with a MinuteClinic Nurse Practitioner; My Observations and Conclusions). One of the companies in the above list, Clover, offers 24/7 access to doctors via phone, video call, or mobile app as part of its health insurance plan. This is thus an example of IT-enhanced services provided by a health insurance company.

Application of Information Technology to Improve the Primary Care Experience

In a recent blog note (see: A Visit with a MinuteClinic Nurse Practitioner; My Observations and Conclusions), I discussed how IT was being deployed to make a visit to a MinuteClinic more convenient for patients and efficient for the NP caregiver. There was nothing earthshaking about the IT from my perspective -- making an on-line appointment, displaying wait time for patents in the waiting area, and news about the availability of a vaccine in short supply on the web. I immediately thought about how Uber and other ride-sharing apps have shaken up the previously stable taxi industry using IT. Many people now prefer Uber over taxis because you can summon a ride from any location in a city, you are messaged with the arrival time and shown the location of the Uber driver, you know the name of the driver, you can input your assessment of the driver, and your credit card number is kept on file so that payment is simplified. In the face of these conveniences, It has never occurred to me to take into consideration the skill of the Uber driver, assuming, that the skill of a random Uber driver was roughly equivalent to that of a random taxi driver. 

Let's now talk about a primary healthcare visit. For most visits, I believe that the skill level of an NP is equivalent to that of PCP. For certain unusual cases, the diagnostic acumen of a physician will obviously be superior. However, the NP can be supplied with computer-based algorithms that can provide alerts when a case needs to be turfed to a physician. Their own training, obviously, comes into play here and personal warmth also goes a long way. In other words, operational efficiencies, as in the case of Uber, often override any possible doubts about the skill level of the healthcare provider.

Theoretically, then, the patient experience during a MinuteClinic visit can be viewed as analogous to a ride with Uber. It can perhaps be enhanced to a level superior to a physician office visit using IT. The goal of CVS/MinuteClinic executives then, like the Uber executives, will undoubtedly be to consider a list of the items that irritate/satisfy patients regarding a visit to their primary care physician and try to ameliorate them with IT. Here is my first crack at such a list:

• Inability to make an appointment with little wait time.
• Parking and convenient access to the clinic.
• Wait time in the office. 
• Skill set and professionalism of the healthcare professionals.
• Attentiveness/friendliness of the healthcare professionals.
• Cost of the visit, particularly if uninsured.
• Inability to solve the problem that prompted the visit.
• Inadequate follow-up, particularly if the health problem persists.

I am not sure how many of these challenges can be "improved" with IT by MinuteClinic executives but it would be a good list to start with. I would welcome comments about how IT can be used to attend to the issues in this list.

 

 

 

New CMS Reimbursement Guidelines: Support for Provider-to-Provider Consults

Here's a link to a high quality webinar from AmericanWell about telehealth (see: A Guide to Integrating Cross-Continuum Telehealth into your Health System). Starting at about 11:00 minutes in the recording, the discussion turns to new CMS telehealth reimbursement guidelines for FY2019 that include new services such as remote patient monitoring (see: CMS to Reimburse Providers for Remote Patient Monitoring Services). Another new type of service that will be reimbursed is provider-to-provider consultations (see: CMS wants to expand telehealth coverage. Here's what that means for you). Here's the key passage from this latter article relating to provider-to-provider consults:

Internet-based inter-professional consultations: New reimbursement for provider-to-provider consultations via online messaging applications or portals. Both the initiating physician and the consulting physician would be eligible for reimbursement.

I have previously covered diagnostic management teams (DMTs) in Lab Soft News (see, for example: Deploying a DMT at the Front-End of Lab Orders for a Complex Patient). One of the challenges for DMT's in the past has been the lack of reimbursement.There is now a ray of light with CMS-approved reimbursement for provider-to-provider consultations which accurately describes the DMT process. A team of expert diagnosticians provides advice to a clinician caring for a patient about the ordering and interpretation of complex laboratory tests. There are, of course, additional benefits attributable to such consults such as decreased medical errors and decreased length of stay but at least some degree of reimbursement can provide an incentive for launching a DMT team in a health system. 

Does a DMT consultation fall under the general rubric of telemedicine? First of all, I think that collaboration between the members of a DMT, even within the confines of a single hospital, will often take place via telephone or a video call. Secondly, discussion of the case between members of the team and with the consult-ordering clinician may often be more effective using video calls. Plans are now underway in collaboration with Sunquest and Epic to develop an app that will work in the following way after a DMT consult has been ordered: (1) enter the name of a patient into the LIS; (2) select the organ and/or disease state driving the DMT consultation; (3) the app will then interrogate the lab and EHR databases and generate a report with all of the relevant lab test results and clinical findings for the patient that will form the basis for the DMT report.

A Visit with a MinuteClinic Nurse Practitioner; My Observations and Conclusions

I recently visited a local CVS MinuteClinic for a vaccination. I have previously blogged about MinuteClnics because I believe that they, along with the Walgreens and Walmart clinics, will attract a substantial share of primary care visits in the near future. Here are some of my previous notes about MinuteClinics (see: Details about CVS' MinuteClinic POCT Strategy; CVS Offers Telemedicine Visits for MinuteClinic Patients; The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems; Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care).

My first impression during the visit was that the nurse practitioner's office was relatively small, particularly when compared to the large CVS store in which it was embedded. This is not a criticism because the office was probably big enough for its purpose which is to see one patent at a time with a small waiting area outside the office door. What was different about this MinuteClinic practice, and perhaps differentiating it from that of some physicians, is that it is supported by relatively advanced IT that serves as a replacement for a receptionist and scheduler.

For example, one can make a MinuteClinic appointment on the web, afterwards receiving a code number which is entered into the computer outside of the office. Many of the patients seeking care in the clinic are walk-in's. Using the on-line appointment scheduler allows you to hold a place in line after inputting the code number that has been sent to you. There is a screen outside of the office announcing your approximate wait time. There is obviously a cost for the development and maintenance of these IT functions but computer system work 24-hours a day and don't take sick or vacation days.

Here's what I anticipate is going to happen with MinuteClinics and its walk-in competitors. Their existing "IT feature set" will expand because CVS + Aetna have the capital to invest in them. For example, patients may be asked to fill out a brief questionnaire and analytics will be used to help diagnose and care for the patient on arrival. Virtual care options will be grafted onto the current process so that incoming patients with more serious problems can be routed to the care of physician. EHR documentation of the visit will be automatic and generated with only a few key strokes. In short, these walk-in clinics will serve as development labs for a much higher degree of automation in primary care than is currently available. Contrariwise, I think that many health systems are reducing attention to their primary care options because the margins are slim for them.

Johns Hopkins Pediatric Hospital in Florida Suffers Soaring Surgical Mortality Rate

The prestigious Johns Hopkins Health System acquired All Children's Hospital in St. Petersburg, Florida, in 2011 (see: All Children's Hospital Joins Johns Hopkins Medicine). This was a non-cash transaction and the first U.S. hospital outside of the Baltimore/Washington, D.C., region to become integrated with JHM. As reported recently, this move has been the source of extreme embarrassment for Johns Hopkins as reported in a recent Tampa Bay Times article (see: Top All Children’s executives resign following Times report on heart surgeries). Below is an excerpt from it:

The CEO of Johns Hopkins All Children’s Hospital and two other hospital administrators have resigned following...an investigation that found dramatic increases in the hospital’s mortality rates for heart surgeries....In a statement, the health system said All Children’s CEO Dr. Jonathan Ellen, Vice President Jackie Crain and deputy director of the hospital’s Heart Institute Dr. Jeffrey Jacobs had resigned. Dr. Paul Colombani also stepped down as chair of the department of surgery....The...mortality rate at the hospital’s Heart Institute tripled between 2015 and 2017. Last year, it was the highest of any pediatric heart surgery program in Florida.....[T]he board of Johns Hopkins Medicine, which owns and operates All Children’s,...commissioned an external review of the issues within the heart program.....The...investigation reported that four physician assistants asked for a meeting with their supervisor and Colombani in 2015 to raise concerns about the surgeries performed by Jacobs and Dr. Tom Karl. At least four other employees also raised safety concerns....In June 2016, a third surgeon who had handled many of the most complex procedures was pushed out of the program.... Jacobs and Karl began performing all of the institute’s hardest surgeries. In the next 18 months, at least 11 children died after their procedures, even as the hospital began to turn away the most difficult cases....Kevin W. Sowers,..., president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, will step in and lead the hospital in a temporary capacity while a plan for interim leadership is put into place. 

One could say at this point that the Johns Hopkins strategy of acquiring a hospital outside of its home territory has been a major problem for the brand. The first idea that comes to my mind as an explanation of their problem is that "culture eats strategy," a phrase attributed to management guru Peter Drucker (see: Culture Eats Strategy For Breakfast. So What's For Lunch?). Here's a quote from this article:

...[B]oards appear to be paying only lip service to Drucker's tenet, according to a new survey by tax and accountancy firm Mazars....The study found that, despite culture being in the top three priorities for company boards, only 20% of 450 London-based directors and board members reported spending the time required to manage and improve it. Some 62% of survey respondents felt that they were primarily responsible for setting culture from the top of an organisation. However, a similar proportion (63%) either did not consider culture as part of their formal risk assessment or failed to routinely consider the risk associated with their corporate culture.

My guess is that the Johns Hopkins executives sitting in Baltimore assumed that their culture of hard work, high quality, and ethical behavior would be transmitted through the ether to their newly acquired pediatric hospital in St. Petersburg, Florida. They probably did not take the time and effort to manage and improve the local culture and are now paying the consequences for their actions in terms of a serious reputation hit. As noted above, "interim leadership" is being put into place but this will only be a temporary solution. A lot of building and damage control will be required.

Amazon Launches New Medical Record Language Processing Service

One of the most significant factors in extracting information from EHR record is the use of natural language processing (NLP) which I have referred to in a number of previous  notes (see, for example: EMRs and the Data Entry Paradox; Same Concept Not Applicable in the LIS World; Assessing Drugs Using "Real World Evidence" in Addition to Clinical Trials; AI Allows Computers to "Read" EHR Records and Make Predictions). A recent article discussed why one should "care" about Amazon's new medical language processing service (see: Why Should You Care About Amazon's New Medical Language Processing Service). Below is an excerpt from it:

Keeping track of your medical records can be a complex task....One of the significant challenges of handling medical records is that for each patient there is a variety of types of "notes" entered over time by health care professionals. These may include prescriptions, observation and administration of drugs and therapies, test results, x-rays, CT-scans, heart rate measured over months, surgical history, immunization history and family history. So the data type can be anything from a string, or a time-series data to an image or a very high definition video.The second challenge of handling data is accessibility. Although there is a generic set of rules in the US under Health Insurance Portability and Accountability Act (HIPAA) governing access to medical records, that states that the patient and the health-care providers directly involved in delivering care have the right to view the record.

The patient, however, may grant consent for any person or external entity to access the record. Given the complexity of handling and managing medical record, the holy grail of health records is perhaps a global electronic health directory that has both interoperability and liability built into it...Amazon [has] announced a new service called AWS Comprehend Medical...that can potentially impact the whole medical records ecosystem. Although electronic health records (EHR) exist for more than a decade, the majority of historical patient data is still stored today as unstructured medical text, such as medical notes, prescriptions, audio interview transcripts, and printed pathology and radiology reports. Extracting meaningful information from these is still a time-consuming process, and either requires data entry by high skilled medical experts, or teams of developers writing custom code. Comprehend Medical leverages Amazon’s AI technology to build a health record industry-specific solution, that uses natural language processing (NLP) to extract health-related text and data from virtually any medical record. 

Here's a key passage from the Amazon Comprehend Medical landing page about its services:

You can use the extracted medical information and their relationships to build applications for use cases like clinical decision support, revenue cycle management (medical coding), and clinical trial management. Because Amazon Comprehend Medical is HIPAA eligible and can quickly identify protected health information (PHI), such as name, age, and medical record number, you can also use it to create applications that securely process, maintain, and transmit PHI. You pay only for what you use, and there are no minimum fees or upfront commitments.

It's no surprise that Amazon singles out clinical trial management as a suitable use case for the company's new language processing service. For patients enrolled in clinical trials, EHR notes are extremely important. Pharmaceutical companies spend billions on such trials and will not be bothered by the costs involved in using such a service. I will be sure to track the future activities of this new company.

Walmart Shapes Its Own Primary Care, Unbundling Strategy

Walmart is establishing its own version of a primary care, unbundling healthcare strategy (Walmart Care Clinics) that is both similar and different to CVS-Aetna. The details were discussed in a recent article (see: Walmart Health: A Deep Dive into the $WMT Corporate Strategy in Health Care)

...[R]eports [have emerged] that Walmart is in merger talks with Humana, a health insurer with a $37B market cap [to] make Walmart look more like an integrated health care delivery system with every passing day. On top of Walmart’s existing health care offerings, these two acquisitions would functionally give Walmart the following:

• Risk-aligned health insurance plans that incentivize the expansion of low-cost retail primary care clinics in underserved geographies.
• A distribution footprint that places outpatient primary care clinics within 15 minutes of 90% of the US population.
• A seamless online pharmacy with home medication delivery funneling into a robust e-commerce offering.

Here are two reasons why outpatient primary care is ready to be unbundled from traditional health care delivery systems, i.e. hospitals, for two reasons: (see: Walmart Health: A Deep Dive into the $WMT Corporate Strategy in Health Care):

1. Most patients that visit primary care physicians don’t need the resources of an expensive medical center on-hand for each visit, and would be better served by an experience that emphasized price, convenience, and attention.
2. Reimbursement rates for most primary care services, e.g. a blood pressure checkup or physical exam, are much lower than specialty care (imaging, biopsies, intensive procedures, etc) and thus provide a lower short-term return on invested capital.

Like CVS-Aetna, Walmart is seeking to integrate its healthcare business with a health insurance company, currently Humana. Walmart also has a web-based prescription drug program. By way of contrast to its CVS-Aetna competitor, Walmart is emphasizing the following aspects of its primary care program:

• A low-cost, rural-aligned retail program in underserved areas,
• Some emphasis on chronic care and medical referrals, at least in its web marketing materials (see: Walmart Care Clinics).
• High profile prescription program offering some drugs with a $4 prescription price tag.