Lab Soft News

Humana's Launches New Venture: Medicare-Centric Primary Care Clinics

Humana is expanding its primary care presence (see: Humana's Broussard calls latest primary care venture an 'expensive, complicated deal'). Below is an excerpt from this article describing this new initiative:

Humana's recently announced joint venture to launch senior-centric primary care clinics was far from easy or cheap....The clinics will be payer agnostic and operated by Humana’s primary care subsidiary, Partners in Primary Care....[The company CEO] was addressing a question about the acquisition as well as Humana's deal to acquire home health care provider Kindred at Home in 2018. It's part of Humana's shift from being an insurance company to a healthcare company. Humana also operates a mail-order pharmacy, has more than 300 owned or alliance primary care clinics and is building out its capabilities to address members' social determinants of health.... He also said it was crucial that the deals are payer agnostic and "that it’s not a slave of internal Humana." 

Here are some details about Humana from Wikipedia (see: Humana):

Humana is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014 Humana had over 13 million members in the U.S., reported a 2013 revenue of $41.3 billion, and had 41,600 employees. In 2018, the company ranked 56 on the Fortune 500 list, which made it the highest ranked (by revenues) company based in Kentucky. It has been the third largest health insurance in the nation.

For me, the take home message from the article above is that the third largest health plan in the U.S., Humana, is extending its presence in primary care, geriatric care, mail-order pharmacy, and hospital-at-home. If successful, this constitutes a "bookending" of the business model of our health systems. I made some similar points in a recent blog note (see: Hospital Outpatient Visits Drop for First Time; Long History of Similar Inpatient Declines). Below is a quote from it:

For me, the key question raised by the declining number of inpatient admissions and outpatient visits is the following: What steps can health systems take now to continue to succeed in our competitive and pluralistic healthcare delivery system?....The common theme [of the points raised] here is the enhancement of the consumer experience. These steps are necessary to staunch the loss of patients to other providers such as CVS, Walmart, and health plans like UnitedHealth (see: UnitedHealth Group Soon to Be Largest Employer of Doctors in the US). 

My sense is that primary care and geriatric patients may be of lesser priority for some health systems despite the fact that "decisions made by primary care physicians influence almost 90% of total hospital costs through referrals, testing, and hospitalizations" (see: PCPs Responsible for Allocating About 90% of Total Hospital Costs). Contrariwise, health insurance companies like UnitedHealth and Humana are very attracted to these types of patients because of the opportunity to control the healthcare costs. 

"Deaths of Despair" in the U.S. Require Broad Federal Policy Initiatives

It seems to me that there has been relatively little written about the current major public heath crisis in the U.S., the opioid epidemic and deaths of despair. (see: Every American family basically pays an $8,000 ‘poll tax’ under the U.S. health system, top economists say)

...[Princeton University economists Anne Case and Angus Deaton] have risen to prominence in recent years for their work on America’s “deaths of despair.” They discovered Americans between the ages of 25 and 64 have been committing suicide, overdosing on opioids or dying from alcohol-related problems like liver disease at skyrocketing rates since 2000. These “deaths of despair” have been especially large among white Americans without college degrees as job options have rapidly declined for them. Their forthcoming book, “Deaths of Despair and the Future of Capitalism,” includes a scathing chapter examining how the U.S. health-care system has played a key role in these deaths. The authors call out pharmaceutical companies, hospitals, device manufacturers and doctors for their roles in driving up costs and creating the opioid epidemic.

Why is the opioid crisis not the subject of intense debate in the public health community and among state and national politicians for solutions beyond limitations on opioid prescriptions (see: Overwhelmed by all the multi-million dollar opioid settlements? Here's everything you need to know)? The root causes of this problem were stated clearly in a recent opinion piece in the NYT (see: Who Killed the Knapp Family?). Below is an excerpt from it:

It would be easy but too simplistic to blame just automation and lost jobs for [deaths of despair]: The problems are also rooted in disastrous policy choices over 50 years. The United States wrested power from labor and gave it to business, and it suppressed wages and cut taxes rather than invest in human capital, as our peer countries did. As other countries embraced universal health care, we did not; several counties in the United States have life expectancies shorter than those in Cambodia or Bangladesh.

Deaths of despair are a national problem that require a national solution that can be described in the following way: how do we bring decent jobs back to "small town America" in an information economy that requires a high degree of education to qualify for the higher paying jobs? Some of the federal money that is now being used to prop up authoritarian regimens abroad should be redirected to assist our own citizens as they struggle to earn an adequate income and stay healthy.

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).

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.   

Plasma Proteins Used to Monitor Health Status; Emerging Science for Lab Testing

A recent article proposed a new way of analyzing patient serum as a means to broadly assess health status (see: Plasma protein patterns as comprehensive indicators of health). Below is an excerpt from the abstract:

Proteins are effector molecules that mediate the functions of genes and modulate comorbidities, behaviors and drug treatments. They represent an enormous potential resource for personalized, systemic and data-driven diagnosis, prevention, monitoring and treatment. However, the concept of using plasma proteins for individualized health assessment across many health conditions simultaneously has not been tested. Here, we show that plasma protein expression patterns strongly encode for multiple different health states, future disease risks and lifestyle behaviors. We developed and validated protein-phenotype models for 11 different health indicators: liver fat, kidney filtration, percentage body fat, visceral fat mass, lean body mass, cardiopulmonary fitness, physical activity, alcohol consumption, cigarette smoking, diabetes risk and primary cardiovascular event risk. The analyses were prospectively planned, documented and executed at scale on archived samples and clinical data, with a total of ~85 million protein measurements in 16,894 participants. Our proof-of-concept study demonstrates that protein expression patterns reliably encode for many different health issues, and that large-scale protein scanning coupled with machine learning is viable for the development and future simultaneous delivery of multiple measures of health. 

To state that the approach described in the paper is a totally new way to monitor health status is an understatement. In the study, about 5,000 different serum proteins were measured from about the 17,000 subjects, accounting for about 85 million assays. The authors labeled this new lab testing approach as a liquid health check. The protein-phenotype models were then developed using AI techniques. My eye was immediately caught by one of the possible uses of this liquid health check -- to identify excess alcohol consumption in a patient. Here an excerpt from an article on the common alcohol use biomarkers from ARUP (see: Alcohol Use Biomarkers): 

Approximately 20% of primary care patients in the United States drink alcohol (ethanol) at levels harmful to health....Diagnostic criteria for alcohol use disorder (AUD) vary, but the most widely used criteria are found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Laboratory tests for acute alcohol ingestion include ethanol, ethyl glucuronide (EtG), and ethyl sulfate (EtS) tests. Carbohydrate-deficient transferrin (CDT) and phosphatidylethanol (PEth) are useful markers for monitoring abstinence following long-term use.

Given that about one primary care patients in five has a serious drinking problem, it seems appropriate (or even necessary) to provide some sort of routine screening test and the liquid health check may provide such a test. Here's a quote from an article about clinicians' acumen in diagnosing this problem (see: Clinician Suspicion of an Alcohol Problem: An Observational Study From the AAFP National Research Network):

Clinician suspicion of alcohol problems had poor sensitivity but high specificity for identifying patients who had a positive screening test for alcohol problems. These data support the routine use of a screening tool to supplement clinicians’ suspicions, which already provide reasonable positive predictive value. 

In medical diagnosis, test sensitivity is the ability of a test to correctly identify those with the disease (true positive rate) whereas test specificity is the ability of the test to correctly identify those without the disease (true negative rate). Clinicians thus have trouble identifying patients with an "alcohol problem" based on a positive screening test but little trouble identifying non-alcoholics with a positive test. 

The "Amazoning" of Health Care; What Exactly Does This Mean?

A recent blog note raised the topic of the "Amazoning" of healthcare (see: The ‘Amazoning’ of Healthcare Will Bring Challenges and Opportunities for Health Plans). In the article, the term "Amazoning" was defined in the following way:

At a recent healthcare conference I attended, it sure sounded like it. I heard healthcare professionals using “Amazoning” as a verb referring to the rapid delivery of products and services, relentless focus on customer experience and cost optimization, and threat to various industries like retail, computing and entertainment.

There is no question that Big Tech companies like Amazon, Google, and Apple are aggressively pursuing healthcare projects (see, for example: What Are the Consequences of Big Tech Entering the Healthcare Market?; Big Tech Is Knocking on Hospital Doors; It's All About the Data; Healthcare Will Contribute a Sizable Portion of Future Earnings for Apple). The key question with regard to Amazon and its competitors is what component of healthcare is most appealing to them for business ventures. I feel certain that they are not interested in competing in the area of inpatient care. Health systems already have invested huge amount of money in infrastructure. The field is also too regulated and health systems lag considerably in their expertise and foresight in IT deployment. Moreover, Big Tech companies have had little difficulty incentivizing large health systems to share their clinical data with them (see: In a ‘Wild West’ environment, hospitals differ sharply in what patient data they give Google). 

No, the focus of Big Tech will inexorably be on wellness and primary care. This lends itself well to (1) rapid delivery of products and services, (2) relentless focus on customer experience and (3) cost optimization. I have recently blogged extensively about the increasing sophistication of health wearables and their integration into what I have called wearable health ecosystems (WHEs) (see: The Evolution of "Wearable Health Ecosystems" and Associated Partnerships. 

In my opinion, a large percentage of health-oriented consumers in a few years will have many of their health diagnostics monitored by home-based smart phones, smart watches, and integrated diagnostic devices (see: Digital Health Wearables Can Be Used to Detect Gait Disorders, Undiagnosed Diseases). I have suggested that WHEs in the future will generate specific referrals to health system specialists, bypassing one of the primary roles of PCPs (Status Reports and Hospital Referrals from Wearable Health Ecosystems; Fitbit to Be Acquired by Google). It has been estimated that hospital PCPs are responsible for accounting for about 90% of hospital costs on the basis of clinical referrals. If my prediction about WHE-generated referrals is correct, Big Tech will have a significant grip on a large percentage of hospital referrals and thus revenue.

Addressing Some of the Social Determinants of Health

Discussions about the social determinants of health have been much in the news lately. Here's a definition of the term from the WHO (see: Social determinants of health)

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

If you believe that a person's healthy life can be predicted by his or her zip code, the next question one needs to ask is how to help to ameliorate this situation. One small but important step is to ensure that lower income patients have reliable transportation for their medical appointments. Cerner is addressing this problem by integrating Uber ride booking into physicians' work flow (see: Cerner teams up with Uber to help patients get to appointments). Below are the details:

Cerner and Uber are collaborating to help get patients to and from their doctor's appointments – addressing a major social determinant of health that hinders the cost-effective management of chronic conditions. The Uber Health app will soon be available for integration into Cerner’s electronic health record, enabling easy access within physician's workflow. Doctors will be able to schedule a ride for their patients wherever Uber service is available....A patient’s information – name, phone number and pick-up address – will auto-populate from Cerner technology directly into a ride request with Uber.....Finding ways to address that key SDOH barrier to more cost-effective care – reducing the number of appointment no-shows preventing needed treatments from being delayed – is critical to good population health management and value-based care. 

Another facet of how social determinants have a major effect on health status is the under-representation of minorities in clinical trials (see: Minorities in Clinical Trials Fact Sheet). This is important because of the need for a heterogeneous group of subjects in trials and also because minorities deserve equal access to them because of the benefits they may bestow such as access to new experimental therapy. Here's a quote from this article from the FDA about minorities in trials:

Participants in clinical trials should represent the patients that will use the medical products. This is often not the case--racial and ethnic minorities are underrepresented in clinical research. This is a concern because people of different ages, races, and ethnicities, may react differently to medical products. We are committed to working with companies to change this. Joining a clinical trial might be a good choice for you if:

* You and your doctor believe current treatments aren’t good options and a clinical trial offers additional alternatives.

* You want to help ensure that the benefits and risks of new medical products are studied in the range of patients likely to need them.

* You want to help researchers find better ways to fight diseases.

Here are some of the reasons why minorities are under-represented in clinical trials: (1) lack of information that a relevant trial exists; (2) lack of understanding about the benefits of a trial; (3) inability to participate in trials because of work or family responsibilities; (4) lack of reliable transportation to appointments. I have blogged about this particular problem in previous notes (see: The Diversity Gap in Clinical Trials; Can It Be Closed?; Recruiting Patients for Clinical Trials Via a Smartphone App). 

CMS Picks 25 Organizations as Finalists in Its AI Challenge

I have posted a number of previous notes about AI and predictive analytics (see, for example: Diagnostic and Predictive Analytics and Their Possible Link to the Future of the LIS; Three Examples of Predictive Analytics in Clinical Practice). Newly emerging tools such as clinically validated algorithms will not only change the face of medical care but will also be financially remunerative. CMS has been clever in its pursuit of AI by creating a challenge with a prize of $1M. In this contest, 25 finalists have been recently announced (see: IBM, Mayo Clinic, Geisinger among 25 finalists for $1.6M CMS artificial intelligence challenge). Below is an excerpt from the article:

Out of more than 300 artificial intelligence proposals, the Centers for Medicare & Medicare Services (CMS) picked 25 organizations for the next stage of its AI challenge including IBM, Booz Allen Hamilton and Mayo Clinic. The organizations are competing for a $1 million prize to develop the best tool for predicting patient health outcomes. CMS says the AI challenge, which launched in March, will accelerate the development of AI solutions that aid clinicians in predicting health outcomes and keeping patients healthy. The central goal is to develop AI-driven predictions healthcare providers and clinicians participating in CMS Innovation Center models can use, CMS officials said.....The challenge was created in partnership with the American Academy of Family Physicians and the Laura and John Arnold Foundation. The AI challenge, open to innovators from all sectors, drew submissions from health systems, technology vendors such as KenSci and global aerospace and defense technology company Northrop Grumman Corporation.

CMS obviously has limited resources for the development of predictive algorithms on its own. Creating a contest provides publicity for health systems like Mayo and multinational consulting firms like Booz Allen Hamilton that choose to participate. Although the $1M prize is attractive, the greatest prize will be the revenue that can be gained later from running and licensing healthcare algorithms. I was searching for a succinct summary of such AI gains when I came across a relevant article in Forbes (see: AI And Healthcare: A Giant Opportunity). Below is an excerpt from it:

The total public and private sector investment in healthcare AI is stunning: All told, it is expected to reach $6.6 billion by 2021....Even more staggering, Accenture predicts that the top AI applications may result in annual savings of $150 billion by 2026. These benefits will accrue incrementally, from automated operations, precision surgery, and preventive intervention (thanks to predictive diagnostics), but within a decade they will fundamentally reshape the healthcare landscape as we know it....[An AI expert] expects that AI applications may help solve the dilemma of what’s known as the “iron triangle” in healthcare, in which three interlocking factors—access, affordability, and effectiveness—require inevitable and often negative trade-offs. Trying to improve one factor usually harms another, he explains.

High Risk Surgical Patients Have Lower Mortality Rates at Major Teaching Hospitals

I firmly believe that it's important to get oneself to a major teaching hospital if you fall into the category of a high risk, general surgery patient. A recent article put some numbers to this advice (see: High risk patients have lower mortality rates at major teaching hospitals). Below is an excerpt from the article:

New research published in the Annals of Surgery shows that high-risk general surgery patients have greater survival rates at major teaching hospitals than at non-teaching hospitals....The 30-day mortality rate for these high-risk patients was 15.9% at major teaching hospitals, compared with 18.2% at non-teaching hospitals....They examined the medical records of 350,000 Medicare beneficiaries who underwent general, vascular, or orthopedic surgery at 2,780 hospitals across the country, including 340 major teaching hospitals....The study examined costs and patient outcomes—including 30-day mortality rates—for procedures, such as mastectomy, appendectomy, gastric bypass, blood vessel repair, total knee replacement, and more. The researchers calculated the cost of care within 30 days of admission, including office visits and readmissions....The mortality rate of high-risk vascular surgery patients was 15.5% at teaching hospitals compared to 16.4% at non-teaching hospitals. The mortality rate for orthopedic surgery procedures was significantly lower overall than the rates for vascular and general surgery.

In my view, the reason why major teaching hospitals provide better care for high risk surgical patients is that academic physicians tend to be more specialized than community physicians. Because of this orientation, they are more apt to be knowledgeable about new technology and techniques relating to a particular surgery and some surgeons may have performed a procedure very frequently because of this specialization. Another factor leading to lower mortality is that teaching hospitals have an organizational hierarchy with multiple layers of oversight including house officers and staff surgeons. Absent such oversight, physician incompetence can be overlooked or intentionally disregarded. One of my recent notes about malpractice in a VA hospital provides an extreme example of the consequences of weak physician oversight (see: VA Pathologist Indicted for Multiple and Continuing Errors, Resulting in Deaths).

The flip slide of this coin about which hospitals to patronize is that major teaching hospitals may provide lesser quality service for common conditions (see: Teaching Hospitals and Quality of Care: A Review of the Literature). Below is an excerpt from this article:

Despite their reputation for highly specialized care and for treating rare diseases and severely ill patients, teaching hospitals in fact rely heavily on income from more routine services, such as the care of heart disease, pneumonia, and stroke....It is possible, however, that for common conditions, teaching hospitals may offer a lower quality of care than do nonteaching hospitals, particularly if the substantial involvement of inexperienced trainees and the attenuated role of senior physicians in teaching hospitals results in more fragmented and less appropriate care. Both purchasers and patients have an interest in knowing whether teaching hospitals provide added value through a higher quality of care or whether services of comparable quality could be obtained at a lower cost in nonteaching hospitals.

Bottom line and to repeat comments above: If you are a high risk surgical patient, you can reduce the likelihood of a bad outcome by seeking care in a major teaching hospital. 

Why Would a Large Hospital Offer Telehealth Services for Its Employees

In a recent blog note, I discussed how Tampa General Hospital was deploying advanced versions of telehealth kiosks in the hospital for its employees (see: Improvements in Telehealth Kiosks; Tampa General Deploys New Version for Employee Health). In response to the note, Dr. Brian Jackson, Medical Director, Business Development, IT, and Support Services at ARUP submitted the following comment:

This sounds like great technologies for locations where it wouldn't be cost-effective to put human providers. But this is in a hospital for heaven's sake! Why doesn't Tampa General just staff a walk-in clinic for employees? We do that at ARUP and it's extremely popular.

This is a very reasonable question. I don't know what the official response from Tampa General Hospital (TGH) would be but let me weigh in with some possible reasons that I have come up with:

• I feel fairly certain that TGH does already provides employee clinic services, a not unreasonable assumption for a health system with 1,000 beds and more than 8,000 employees. I will thus assume that the telehealth kiosks highlighted in the note are supplemental to the existing employee health clinics.
• I got the further impression from the article that TGH was partnering with the manufacturer of the kiosks, OnMed, to pilot these kiosks in the hospital in order to work out some of the potential technical kinks. The health system and OnMed seem to have bigger plans, post pilot, to install and staff the kiosks in sites such as airports and colleges. 
• I will further assume that it may sometimes be difficult to schedule an appointment in TGH's employee clinics on a urgent basis. It may thus be more efficient, particularly in a hospital with a large physical footprint, to provide health services to employees on the decentralized basis that telemedicine kiosks enable.
• Finally, here's the last sentence in my blog note cited above: For me, the most limiting factor in the growth of virtual visits is the number of healthcare professionals trained to use the technology. The internal deployment of kiosk(s) at TGH provides an ideal training environment for hospital health professionals to learn how to provide care efficiently in this new "virtual" environment. 

Putting all of this together, the TGH telemedicine project seems to be an example of strategic business planning rather than one driven by operational requirements.