Lab Soft News

Companies Emerge Offering Remote Text-Based Primary Care Consultations

In a recent note, I explored the difference between virtual care and telemedicine (see: Understanding the Distinction between Virtual Care and Telemedicine). Here is the explanation copied from the note:

Simply put, the term virtual care is a way of talking about all the ways patients and doctors can use digital tools to communicate....While telemedicine refers to long-distance [direct and visual] patient care, virtual care is a much broader term that refers to a variety of digital healthcare services.

This made a lot of sense to me when I wrote the note but long-distance care is growing more complex. A recent article described a new example of remote primary care but without the "tele" feature (see: Smartphone Apps Enable Healthcare Consumers to Receive Primary Care without Traditional Office Visits....). Below is an excerpt from it:

Two companies on the forefront of such advances are 98point6 and K Health, and they provide a glimpse of primary care’s future. The two companies have developed smartphone apps that incorporate AI and the ability to interact with real physicians via text messaging....The [98point6] service involves “providing virtual text-based primary care across the entire country, 24/7 of everyday”....It’s text-based delivery of care overlaid with an AI platform on top of it.....98point6 offers the service through individual subscriptions or through deals with employers, health plans, health systems, and other provider organizations. The personal plan costs $20 for the first year and $120 for the second, plus $1 per “visit.”

Here's a cut-and-paste from the K Health landing page:

It’s not a visit—it’s a conversation We’ve redesigned the doctors’ visit and turned it into an ongoing conversation that feels like texting with a friend. Chat with the doctor on call throughout your health episode for a diagnosis, advice, prescriptions and lab test orders. It costs less than a typical copay and there’s no insurance required.

At first glance, this business model made little sense to me, However, on additional reflection, it would seem to be a good option, particularly for younger consumers. Here why it might work:

• Text-messaging requires inexpensive technology for both the physician provider and the consumer. Only a cell phone is necessary. It would seem to be perfect for use by consumers on the road for their work or on vacation. 
• Younger consumers will probably be most comfortable with text-based communication. Lack of video interaction may also be less threatening and intimidating for some consumers.
• Younger consumers who use the service will be less apt to have serious and chronic diseases. Most of them will have only minor ailments and will be looking primarily for drug prescriptions which these texting services can provide.
• In summary, long-distance care seems to be differentiating into low-tech (text messages only) and high-tech (video calls) with broad appeal perhaps to different sets of consumers.

 

What Part of the Wellness Economy Should Be Pursued by Health Systems?

I came across an article in Forbes discussing beauty and wellness trends for 2020 (see: 9 Beauty And Wellness Trend Predictions For 2020 And Beyond). Included in the article was the graphic shown below that categorizes the global wellness economy for 2017 into various segments. All of this raised the question in my mind about how health systems can pursue a portion of this huge wellness market without straying too far from their roots. First, take a look at the graph below.

I believe that it would be relatively easy for health systems to become more engaged in three segments of the global wellness industry as shown above. They are: (1) traditional and complementary medicine (2) preventive and personalized medicine, and (3) nutrition and weight loss. Many health systems have already embraced complementary and alternative medicine (CAM) with enthusiasm in  (see: Complementary and Alternative Medicine in the United States.). Similarly, most health systems have also developed nutritional and weight loss programs. Many physicians tend to be the most enthusiastic about bariatric surgery because the results can be dramatic. Some diseases like Type 2 diabetes can also be ameliorated by bariatric surgery (see: How Weight Loss Surgery Helps Type 2 Diabetes).

In my mind, however, the segment of wellness that is, and will continue to. be most important for health systems is preventive and personalized medicine. To be very specific, such engagement by hospitals will involve embracing and recommending wearable health ecosystems (WHEs) which are home-based networks of smartphones, smartwatches, and attached diagnostic tools (see: Apple's iPhone and Watch Function as Medical Research Tools). Health systems will come to view such WHEs as extensions of their primary care programs. This will require engagement by their PCPs with monitoring and interpretation of home-generated health data. This will then be one of the major means by which health systems compete with health plans and walk-in clinics like those offered by CVS and Walmart for primary care (see: Walmart Shapes Its Own Primary Care, Unbundling Strategy; Walmart Expands the Range of Services of Walmart Health).

Virtual Personal Assistants as a Key Factor in Wearable Health Ecosystems

I have posted a number of notes pertaining to wearables and wearable health ecosystems (see, for example: Sony Develops Health Wearable Providing Connectivity, Stipulating That It's Not a Smartwatch; The Evolution of "Wearable Health Ecosystems" and Associated Partnerships; Status Reports and Hospital Referrals from Wearable Health Ecosystems). I have not yet raised the issue of providing a virtual personal assistant (VPS) with these home-based health systems. This idea was discussed in a recent article (see: Wearables Hold the Key to Connected Health Monitoring) and below is an excerpt from it:

As voice interaction with virtual personal assistants (VPAs) becomes standard on consumer devices and wearables, their functionality will become more personalized, opening up new opportunities for healthcare services. Some services will come straight from the next generation of AI features and could include alerts to health professionals or designated caregivers, as well as predictive algorithms to help prevent or manage lifestyle diseases such as type 2 diabetes and hypertension. Gartner estimates that by 2020, no-touch user interfaces (UIs) will account for about 15% of personal devices, wearables and Internet of Things (IoT) endpoints. A more natural product interface delivered with voice, movement and gesture will increase ease of use and help bring devices into mainstream healthcare use cases.

I had not heard the term no-touch user interface as a synonym for a virtual personal assistant but it makes perfect sense. Consumers are growing increasingly comfortable with the use of virtual assistants in their homes using technology like Amazon Echo Dots. Such virtual assistants will obviously be integrated into our home health technology  (see: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships). They can remind us in a non-threatening way when we need to take certain health measurements such as blood pressure or take our prescribed medications (see: Cigna Unveils App to Monitor and Improve Medication Adherence).

Under dire circumstances such as a fall or extreme change in health status, the virtual assistant can also call for outside help. Virtual assistants can also be used to scan the web for suitable medical advice when queried. I have referred to this as "paging Dr. Google" or "Dr. Alexa" in older notes (see: Dr. Alexa Will See You now -- An Extension of Paging Dr. Google). Virtual assistants can also be programmed to only seek information from most reliable web sites and will thus improve the quality of the information being sought.

Cigna Unveils App to Monitor and Improve Medication Adherence

It's well known that non-adherence to prescribed drugs is a major problem in healthcare (see: Medication Adherence: The Elephant in the Room). A quote from this article places the problem in the proper context:

According to the World Health Organization, medication adherence can have a more direct impact on patient outcomes than the specific treatment itself.1 Medication adherence can affect quality and length of life, health outcomes, and overall healthcare costs. Nonadherence can account for up to 50% of treatment failures, around 125,000 deaths, and up to 25% of hospitalizations each year in the United States.

Putting aside the question of the non-adherence because consumers can't afford their drugs, it seems to me that some of this problem is due to memory lapses, confusion, and carelessness on the part of patients. Given this, part of the solution may be periodic reminders from a smartphone app. Insurance giant Cigna is moving in this direction (see: INSURANCE GIANT CIGNA UNVEILS AI TOOL TO MONITOR MEDICATION ADHERENCE). Below is an excerpt from this article:

...[W]hile a new AI-driven [medication] monitoring system from US health plan Cigna aims to take big steps toward resolving that challenge, some experts fear that the new technology could also work against the interest of millions of patients. According to the Wall Street Journal, “(t)he product, called Health Connect 360 (see: Health Connect 360: Better Health Outcomes – Guaranteed), integrates data from a combination of sources and analytical tools and was originally developed for treatment of chronic diseases, including diabetes and heart disease, as well as for pain management. The system aggregates medical, pharmacy, lab and biometric data....into a dashboard that is accessible through an online interface.” Via that interface, doctors and nurses will be able to constantly keep an eye on patients' health and step in when they have cause for concern.

I think that such an app is a very good idea. For a relatively minor cost, a serious problem can be addressed. Part of the drift of the article cited above, is that the risk of such an app is the loss of privacy by allowing health professionals to "spy" on a patients. Moreover, it is also stated that the primary goal for this app is to create a dashboard that can be viewed by a patients' physicians and nurses rather than to suggest that it would have value for the consumer himself or herself. This is a reflection of the paternalistic view of healthcare, often paying scant attention to the wishes and interests of consumers who may be the prime users of such a dashboard.

Possible Funding Tension Between Wellness Programs and End-of-Life Care

It is a well known that a large percentage of the total U.S. healthcare spend is devoted to end-of-life care (EOLC) for a small number of patients (see: How We Spend $3,400,000,000,000). To quote the subtitle of the article:..."[M]ore than half of America's healthcare spending goes to five percent of patients." I think that we are approaching the time for an earnest discussion about this disproportionate allocation of healthcare resources and whether some of these resources could and should be reallocated to wellness programs. In my mind, it is out of the question about whether to increase spending for both wellness and EOLC given that the total healthcare expenditure, currently about 18% of the GDP (see: How has U.S. spending on healthcare changed over time?), is more than double that in other developed countries.

In this current note, I want to first raise some of the reasons why expenditures for EOLC have grown so large:

• Organized medicine is generally focused on the treatment of disease rather than the promotion of wellness. Expensive and prolonged end-of-life measures are a consequence of this focus on disease.
• In a parallel manner, the training of physicians and nurses is devoted almost entirely to the diagnosis and treatment of disease, suggesting that this disease treatment orientation among healing professionals will continue in upcoming years.
• In our system, physicians and hospitals are reimbursed almost entirely for the diagnosis and treatment of disease with little devoted to the promotion of wellness. 

By way of contrast, I offer below a bulleted list of forces that are now coming into play such that some percentage of the EOLC resources may be reallocated to wellness:

• Our for-profit health care plans, with an eye toward their own bottom lines, are promoting wellness programs. Corporations are also eager to see this happen.
• More Americans are dying at home of natural causes for the first time since the earliest part of the 20th century (see: More Americans are dying at home. Is that a good thing?). The surely represents a "vote" on the part of consumers against extended and expensive EOLC in hospitals and extended care facilities. 
• Big Tech is a new driver regarding wellness, including Apple, Google, and Amazon. These companies see this market as ripe for innovation and sales of their home-based healthcare devices. As I have commented in previous notes, health plans, Big Tech, and CVS/Walmart are controlling a growing percentage of primary care (see, for example: Walmart Shapes Its Own Primary Care, Unbundling Strategy; CVS Expands Its Healthcare Presence with Its New HealthHUB Stores). They will also thus control some of the referrals to health systems for more complex care and will soon be able to exert more control over the cost of this care.

Competition Between CVS and Amazon's PillPack Extends in New Directions

I have gotten very interested in the competition between CVS and Amazon's PillPack for the retail drug market. CVS had more than 9,600 retail establishments in 2016 (see: CVS Pharmacy). It's original business model was the traditional one of "corner drug stores" where prescriptions were dropped off and drugs picked up. The PillPack fulfillment model is virtual -- prescriptions are submitted via a web site and the drugs are delivered back to one's door, often by Amazon Logistics. In response to this business model, CVS began to provide individualized dose packaging and home delivery with Rx Delivery. CVS also began to slow-walk prescription customer transfer requests to PillPack (see: Resistance to PillPack's Requests for Prescription Transfers from Retail Drug Stores).

PBMs are a key element in this retail drug competition because they partly control the retail price of drugs and also have a record of consumers' meds. CVS owns one such major health plan, Caremark. Amazon-PillPack is now seeking to establish its own PBM (see: Amazon-PillPack Pushes Against CVS with Prescription Deliveries; Also Seeking PBM Status). The one missing element in this tit-for-tat discussion is an affiliation with a health plan which, of course, pays for drugs. Recent news is that Blue Cross Blue Shield of Massachusetts (BCBSMA) has developed an app that coordinates a consumer's drug history with PillPack (see: BCBSMA’s new app coordinates meds with Amazon’s PillPack). CVS, of course, already owns a health plan, Aetna. Below is an excerpt from this article:

Blue Cross Blue Shield of Massachusetts is launching a new pharmacy integration app and website that will help members manage prescriptions by using Amazon’s own Internet pharmacy. The new service will enable BCBSMA members who are on multiple medications to seamlessly manage and fill their prescriptions with PillPack by Amazon Pharmacy. PillPack features convenient packaging, modern technology and personalized service. BCBSMA is the first health plan to offer this type of integration with PillPack, the Boston-based health plan reports. Members can use PillPack to order, pay for, track and get prescriptions delivered to their homes.

I believe that the major driver for the retail drug market in the future will be an app with links to a web-based, drug provider like CVS and PillPack and also with close ties to a PBM and a health plan. One special aspect of this future scenario is that CVS has a trump card that PillPack can't match -- a bricks and mortar presence in communities across the country. CVS is capitalizing on this advantage with its HealthHub and MinuteClinic units that will, I believe, evolve as as a major source of primary care. It has been estimated that PCPs account  for about 90% of hospital costs via their referrals to specialists (see: PCPs Responsible for Allocating About 90% of Total Hospital Costs). Stay tuned for more developments.

"Porch Pirates" and the Theft of Home-Delivered Drugs

In response to my recent note about the increasing competition between Amazon-PillPack and CVS in terms of home delivery of drugs, Andrea Pitkus submitted the following comment:

It'll be interesting to see how this evolves, especially with the increase of porch pirates. It would be disastrous to patient safety if porch pirates steal meds from these unsecure delivery mechanisms. It would harm patients who need vital medication and also the receivers of the stolen (black market) meds. Hopefully, narcotics and other important meds are not delivered in the pill packs. Although "preset" pills are valuable for patients that don't have dynamic changes with medications or dosing, they may not be as valuable for patients who are on medications that are titrated regularly such as coumadin.

Andrea raises a significant concern that transcends the theft of home-delivered drugs -- billions of dollars of goods are sitting on consumers porches monthly with little security. I discovered  a number of published articles about "porch pirates" with the following being of particular value: Security Moves to Prevent Amazon Package Theft. It offers a number of solutions for the theft of packages but not all of them seemed practical. For example, I suspect that many consumers ordering home-delivered goods will be unwilling to give up the convenience of this service by picking up their goods at an Amazon locker.

Another option suggested in the article is to install a curbside locking mailbox which runs about $100 but would also entail some installation costs. However, it might not be big enough to accommodate the delivery of larger packages. For people who are at serious risk from porch pirates, one practical flexible solution might be a so-called smart doorbell. Here's a description of the device (see: Security Moves to Prevent Amazon Package Theft).

A smart doorbell might be the simple solution you need to keep purchases safe. These Wi-Fi enabled doorbell cameras let you see—and talk to—whoever is at the front door, whether you’re in the kitchen or at the office. The Ring Video Doorbell includes a motion-activated camera, two-way audio, and an app that sends alerts to your smartphone, tablet, or computer.

As to the problem of critical drugs being stolen from porches, I am sure that such items would be readily replaced by CVS or PillPack when notified about their loss. They will surely recognize such losses as the cost of doing business. It's clear to me that one's front porch will become increasingly important as a delivery site. However, some technologies are now available to make the porch more secure. Look for Amazon to offer some solutions to protect such deliveries such as a discounted price for a smart doorbell for Amazon Prime customers.

Apple's iPhone and Watch Function as Medical Research Tools

As someone who is currently participating in an Apple/University of Michigan research study, I have a front row seat to a project that combines an iPhone, Apple Watch, and a blood pressure monitor to gather data. I have referred to this home-based technology as a wearable health ecosystem (WHE) (see: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships). A recent article in the NYT delved into the emerging Apple role in medical research (see: Apple’s Reach Reshapes Medical Research). Below is an excerpt from it:

....[The] Harvard school [recently] announced an...ambitious women’s health study, one that aims to enroll a million women over a decade....To enroll in clinical trials, patients [normally] have often had to travel to medical centers to be briefed by researchers and fill out the study paperwork in person. Many studies also follow patients only intermittently, in periodic surveys and visits to hospitals.....[Apple] has developed a research app for iPhones — which participants can download from its app store — that is helping researchers quickly and easily recruit hundreds of thousands of study volunteers. Researchers at Stanford Medicine, who studied whether an app on the Apple Watch could detect an irregular heartbeat condition, were able to enroll more than 400,000 participants in just eight months....[D]octors...[do] not yet know whether monitoring people en masse through smartphones and consumer-wearable devices would significantly improve health outcomes....

Apple’s involvement in the research studies is the latest example of how the biggest tech companies are edging their way into the country’s $3.5 trillion health care market. The companies are making inroads in medicine in part by exploiting their scale, along with the technologies that have helped them dominate markets like cloud computing, search, productivity tools and consumer apps....Apple is striking out in a different direction [than other Big Tech companies]....[It has] has acquired health and wellness start-ups and hired prominent medical researchers.....Another study, by researchers at the University of Michigan, will collect noise level data from headphones and an iPhone app to examine how long-term sound exposure can affect hearing.

So what are we to make of this Apple initiative that takes advantage of IT to gather information for medical research from consumers? These devices allow researchers to gather data inexpensively and on a scale never imagined before. Parameters of such studies such as daily activity can't be fudged by the subjects. One legitimate criticism of these studies is that the subjects tends to be skewed toward more affluent consumers who can afford an iPhone and Apple Watch. This problem can be ameliorated partly by donating an Apple Watch and blood pressure monitor to the subjects as in the case of the MIPACT study. This provides a leg up for Apple when it wants to gather health data.

The most important question about these Apple collaborative studies is raised in the excerpt above: [D]octors...[do] not yet know whether monitoring people en masse through smartphones and consumer-wearable devices would significantly improve health outcomes. I am personally very optimistic about such studies. I think that researchers will rapidly come to understand how to design them to take advantage of the data gathered by wearable health ecosystems in subjects' homes.   

Amazon-PillPack Pushes Against CVS with Prescription Deliveries; Also Seeking PBM Status

In a previous note, I discussed how CVS was fighting back against its retail drug competitor Amazon-PillPack by slow-walking its prescription transfers to PillPack when requested by customers (see: Resistance to PillPack's Requests for Prescription Transfers from Retail Drug Stores). Here's a quote from my blog note about CVS's response:

CVS certainly can't be counted out of this battle yet on the basis of pressure from PillPack and its web competitors (ExactCare Pharmacy, Remedi SeniorCare, PharmaPoint, Blink Health and PipelineRx). For example, CVS has announced same-day home delivery of drugs (see: CVS to offer customers same-day delivery for prescriptions). With its current retail pharmacy operation, consultation with pharmacists is [also] possible.

It turns out that PillPack still has some tricks up its sleeve; it's attempting to morph into a PBM to compete with CVS's Caremark (see: Amazon Wants To Cut PBMs Out Of Drug Sales Pipeline By Contracting Directly With Health Plans, Employers). Here is quote from this article with more details:

Court documents in a case about personnel revealed the strategy that many in the industry fear. Amazon is seeking to contract directly with health plans and employers to sell prescription drugs through its PillPack subsidiary, a move that would cut out existing pharmacy benefit managers and potentially reshape the sale and distribution of medicines in the U.S.....The revelations are contained in a lawsuit CVS filed in April seeking to prevent one of its former executives from taking a job at PillPack, an online pharmacy based in New Hampshire. In its complaint, CVS notes that Amazon-PillPack has “already begun aggressively approaching CVS Caremark’s clients,” including Blue Cross Blue Shield, “to provide its members with prescription home delivery.” 

In order to understand how serious a PBM initiative will be from Amazon-PillPack, it's also important to understand the recent growth of Amazon Logistics which will be mainly responsible for drug home deliveries. Here's an article on this topic (see: Amazon Will Deliver More Packages Than UPS or FedEx by 2022) and below is an excerpt from the article:  

Amazon...is already delivering more of its own packages than its delivery partners like UPS...or USPS. At the pace it's growing, it'll be delivering more packages total than either UPS or FedEx...in just a few years. The online retail giant is delivering around half of its own packages through Amazon Logistics....Amazon will make about 6.5 billion deliveries in 2022, up from 2.5 billion this year....That compares to 5 billion deliveries and 3.4 billion deliveries that year for UPS and FedEx, respectively.

It seems clear to me that the Amazon attack on big box retail stores is now pointed toward the PBM/retail drug store complex. The norm in a few years regarding retail drug sales will be drug dosage packs delivered to customers' front door by Amazon/PillPack. What's the next move from CVS?

Morning Hypertension and Home Monitoring of Blood Pressure

Morning hypertension is a syndrome about which there is an increasing understanding but ambiguity remains (see: Management of morning hypertension: a consensus statement of an Asian expert panel). Below is a quote from an article on the topic:

Morning hypertension refers to high BP in the morning period, regardless of BP during the rest of the hours of the day. Morning hypertension is defined as morning BP ≥135/85 mm Hg for both ABPM [ambulatory blood pressure monitoring] and home BP monitoring. Clinic BP measurement can be used for screening morning hypertension. The diagnostic threshold is a BP ≥140/90 mm Hg. Morning hypertension in this consensus document includes but is not limited to masked morning hypertension, which was defined in the 2014 Japanese Society of Hypertension Guidelines for the Management of Hypertension as an elevated ABPM or home BP in the morning (≥135/85 mm Hg) and a normal clinic BP (<140/90 mm Hg).

As a subject in a research study called MIPACT (see: U-M launches health study using Apple Watch), I was given an Apple Watch and an Omron IntelliSense blood pressure monitor to generate data for the study at home. Because if was convenient for me, I routinely took my blood pressure in the morning as part of the study. I then discovered that my systolic pressure in the morning was occasionally in the range of 130-135 mm. It thus occurred to me my that I perhaps was a candidate for morning hypertension which would have been missed had I only relied on BPs obtained in my doctor's office (see: Masked Hypertension: A Review).

In previous notes, I have commented about health wearables (see, for example: Sony Develops Health Wearable Providing Connectivity, Stipulating That It's Not a Smartwatch; The Evolution of "Wearable Health Ecosystems" and Associated Partnerships). Historically, most of the medical information about each of us has been previously obtained in settings such as physician offices and hospitals. We are now on the cusp of a shift such that some medical data will be obtained in our homes using our wearable health ecosystems (see: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships).

As suggested by my own observations, it may be more common going forward for a new set of health data to come to the foreground that were unknown and unobserved before because they were only and periodically obtained in physician offices. These include physiological, lab, and even radiology data (e.g., portable handheld ultrasound devices) obtained by consumers at home. I have blogged previously about how wearable heath ecosystems could even generate medical consultations on the basis of these new home observations (see: Status Reports and Hospital Referrals from Wearable Health Ecosystems).