Lab Soft News

Walmart Expands the Range of Services of Walmart Health

I have posted a number of recent notes about CVS' initiatives in primary care (see, for example: Push-Pull at Work in the Expansion of CVS Health into Primary Healthcare). Its major competitor in this space (i.e., healthcare offered in big-box and retail drug stores) is Walmart and a recent article discussed how the company is greatly expanding its range of services (see: Walmart tests dentistry and mental care as it moves deeper into primary health), Below is an excerpt from it:

Walmart is opening up a new health clinic, called Walmart Health, in Georgia....At the new clinic, the company will offer hearing tests, 60-minute counseling sessions and vision tests....It also went online with the site “Walmarthealth.com,” where patients can set up appointments....The Dallas location, which is set to open its doors next month, will give patients access to comprehensive and low-cost primary care, including...mental health issues. The clinic is in a separate building next door to a Walmart store to give a sense of privacy for patients....Walmart is already one of the largest pharmacy companies in the U.S., offering in-store sections for prescription drugs in almost all of its 4,700 locations across the U.S. The company said health and wellness, which includes pharmacy, clinical and optical services, accounted for about 9%, or $36 billion, of its roughly $332 billion in U.S. sales last fiscal year....Primary care is a newer market for Walmart and puts it in competition with a different set of companies, ranging from large health systems to emerging businesses like One Medical, Circle Medical and Forward. Walmart’s distinct opportunity is that roughly 140 million people visit its stores every week, and it has about 1.5 million U.S. employees spread across cities of all sizes, including in rural areas where there’s a shortage of health-care services.

Here's a list of the range of services being offered in the Walmart Health (see: Walmart’s First Healthcare Services ‘Super Center’ Opens):

The larger Walmart Health Center puts “key health services under one roof,” a first for the world’s largest retailer when it comes to offering primary care, dental, optometry, counseling, laboratory tests, X-rays, hearing, wellness education and behavioral health.

I came up with four points about this Walmart news that struck me as interesting:

• The goal for the company seems to be to offer a comprehensive set of primary services under one roof including dental, optometry, and behavioral health. I recently blogged about how this latter type of care is emerging as the health service favored by employers. Walmart may be angling to attract some of this business on a referral basis from companies. 
• I was unaware of the fact that pharmacy, clinical, and optical services, accounted for about 9% of Walmart sales in the U.S. as noted above. This is on the basis of $332B in U.S. sales. I suspect that this percentage could double in the near future as a result of its expanding healthcare unit.
• Not to be ignored is that Walmart has a keen interest and financial stake in serving rural populations in the U.S. where healthcare is dangerously faltering, certainly from the perspective of hospitals (see: Nearly a quarter of rural hospitals are on the brink of closure). Thus, this expansion of primary healthcare will face little market competition and will also be highly valued by its customers. 
• I anticipate that Walmart will graft some types of virtual specialty care onto its current primary care offerings, a continuing need for rural populations. CVS is already providing such services utilizing the NPs who staff its Minute Clinics.

Amazon Launches Amazon Care, Providing Virtual Visits for Its Seattle Employees

Amazon is launching a virtual care (i.e., telemedicine) choice for its Seattle employees in collaboration with Oasis Medical Group, a family medicine clinic in Seattle (see: Amazon launches Amazon Care, a telemedicine-driven care offering for Seattle employees). Here is an excerpt from the article:

Amazon is launching Amazon Care, a virtual primary care offering for its Seattle-based employees....Amazon Care will include telemedicine, online chat with a nurse, medication delivery, and app-enabled house calls to the employee's office or home. Amazon is not employing any doctors; instead the company is contracting with a local clinic called Oasis Medical Group....It is not being offered or recommended for emergency care. The news comes after more than a year of rumors that Amazon was considering its own clinic for employees, and the industry has already seen plenty of speculation about what the move might mean. A key question is whether this will remain a service for Amazon employees only, or if the company is planning to eventually offer it as a direct-to-consumer healthcare product in its own right. Amazon is following in the footsteps of Apple, which quietly launched its own employee clinic network called AC Wellness in early 2018. If Amazon Care is going to be offered more broadly eventually, it could connect with several other Amazon entreés into healthcare, such as the company's PillPack acquisition or Haven, its much-ballyhooed JV with Berkshire-Hathaway and JP Morgan.

I believe that virtual care will inevitably become an important element in first-tier healthcare (see: Defining and Delineating the Changing First Tier of Healthcare) whether offered by CVS, Walgreens, Walmart or a health system like Cleveland Clinic, Kaiser, or Intermountain. This approach to healthcare is now being adopted by providers like CVS with its Video Visits program. CVS has generally staffed its walk-in MinuteClinics with nurse practitioners (NPs) and they also appear to be providing the virtual care visits.

This is in contrast to the virtual care visits offered by the Cleveland Clinic which launched its program more than four years ago with family practice MDs (see: Cleveland Clinic Launches Web Site to Offer Physician Visits to Ohio Residents) but is now branching out into allergy and immunology, dermatology, and pediatric visits. Once a provider builds its virtual care IT infrastructure, it can then then offer visits with specialist physicians in addition to PCPs. Dermatology visits are a good example of such an initiative because diagnoses can be made in many cases on the basis of the gross appearance of a skin lesion.

Behavioral Health as the Wellness Component Favored by Employers

It makes perfect sense to me that employers would be very enthusiastic about behavioral health as a component of their corporate wellness programs. The term is defined in the following way (see: Defining Behavioral Health):

Behavioral health is the scientific study of the emotions, behaviors and biology relating to a person’s mental well-being, their ability to function in every day life and their concept of self. “Behavioral health” is the preferred term to “mental health.” A person struggling with his or her behavioral health may face stress, depression, anxiety, relationship problems, grief, addiction, ADHD or learning disabilities, mood disorders, or other psychological concerns. 

A recent article stated that behavioral health is now a major focus of employer's wellness programs (see: Employers' latest focus when it comes to wellness). Below is an excerpt from the article:

Employers looking to continue investing in their well-being programs are eyeing services targeting behavioral health and women’s health....Optum surveyed 544 employers in three size categories.....[E]mployers see wellness offerings as more than just health options, but also as tools that improve recruitment and retainment, address absenteeism and boost employee morale....[B]ehavioral and mental health is a central concern—87% of respondents said they were concerned about employee’s access to behavioral healthcare. So, they’re taking several different approaches to address the issue: 61% said they would invest in new digital tools for behavioral health, while 56% said they were examining their provider networks. In addition, 51% said they would implement virtual visits and 46% said they would offer near-term appointment scheduling....The vast majority (88%) of respondents said they plan to address mental health stigmas within the next year....There’s little evidence wellness programs work. Employers remain bullish on them anyway, survey finds (see: Defining Behavioral Health).

I can't think of a better place to start than behavioral/mental health for corporate wellness programs. First of all, such interventions could potentially help an employee be more productive at work. Secondly, they could also improve the physical health of an employee, given that a high percentage of chronic ailments like cardiovascular disease are related to lifestyle choices like smoking and lack of exercise. A better psychologically adapted person may be incented to avoid harmful behaviors. As to the process by which an employer wellness program addresses behavioral health, the answer is given in the paragraph above: digital tools (e.g., apps on a smart phone), provider networks, and virtual visits. The advantages of a virtual visit in this regard was detailed in a recent article (see: The Virtues of Virtual Behavioral Health) and below is an excerpt from it:

....[V]irtual visits occur through secure videoconferencing technology that is compliant with all provisions of the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). On the patient side, that means someone can connect with...[a therapist] from anywhere, through their computer, smart phone or tablet, and trust that they have a safe, confidential connection. Virtual visits are convenient — no worries about driving or traffic, no need to reschedule appointments every time something comes up....Having a virtual option also gives you a broader pool of providers to choose from ....And, regardless of location, some people just feel more comfortable getting mental health services in the privacy of their home or office.

 

 

 

Fitbit Shifts Its Business Model Toward Services with Attention to Chronic Diseases

Pursuing a strategy shift similar to a number of IT companies like IBM and Cisco, health wearable companies like Fitbit are beginning to emphasize services rather than hardware as discussed in a recent article (see: Fitbit expands healthcare ambitions with new devices, subscription service). Below is an excerpt from it:

Wearables company Fitbit is deepening its reach into healthcare with a new premium subscription service for users that offers coaching and personalized insights mined from the health data it collects from 27.3 million users....Fitbit executives...announced the company plans to roll out a one-on-one coaching service in 2020 to help consumers manage chronic conditions like diabetes, which puts it in competition with digital health players Livongo and Onduo....Six in 10 adults have a chronic condition, and 4 in 10 adults have two or more chronic conditions....The cost of managing chronic diseases globally could reach $47 trillion by 2030....The company is transforming its business model from one of episodic device sales and hardware to focusing on services to support consumers' long-term health....The subscription service is part of that shift to being a services-based company,....Fitbit plans to leverage its consumer health data, collected over 10 years and 27.3 million users, to provide actionable insights on both an individual level and a population level....Fitbit's new premium subscription service will cost $10 a month or $80 a year out of pocket. It will also be available through the company’s one-year-old Fitbit Care business, a connected health platform for health plans, employers and health systems that combines health coaching and virtual care. Fitbit's Health Solutions business currently works with 100 health plans including Humana, UnitedHealthcare and Blue Cross Blue Shield as well as 1,700 employers. That business saw 42% growth in the first half of 2019 and is on track to reach $100 million in revenue this year....

A major focus on chronic diseases is not only the emerging strategic direction for wearable companies like Fitbit but also other health industry players like CVS (see: CVS Expands Its Healthcare Presence with Its New HealthHUB Stores; Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care; Defining and Delineating the Changing First Tier of Healthcare). The first question to ask regarding this new direction by Fitbit is why the company is now favoring services over hardware. This question was answered in a recent Deloitte article (see: The shift to flexible consumption):

Over the last several years, the technology industry has seen a significant shift toward the adoption of flexible consumption business models. Flexible consumption models (FCMs)...offer customers product delivery and payment options that allow them to purchase access to products as a service. FCMs provide compelling benefits to companies that effectively deliver them to the market: They enable predictable, renewable revenue streams, deliver greater value to the end customer by allowing them to pay for only what they consume, enable deeper insights into customer consumption patterns to help inform add-on sales, and lower operational costs by enabling a company to serve customers at scale through a common platform. 

The advantages of focusing on patients with chronic diseases seems to be obvious but I will restate them briefly here: (1) There are a huge number of such patients globally; (2) the cost of managing chronic diseases globally could reach $47 trillion by 2030; (3) many such patients are motivated to seek help to manage their diseases as opposed to younger people pursuing mainly fitness goals; (4) lifestyle choices, amenable to behavioral therapy, are the root cause of a  high percentage of chronic diseases (see: Lifestyle Choices: Root Causes of Chronic Diseases); (5) many such patients are not very mobile and thus receptive to coaching via telemedicine in their homes; (6) health coaching and virtual care can be outsourced, allowing rapid growth and higher corporate profits; (7) providing remediation of chronic illnesses is appealing not only to individual healthcare consumers but also to health plans, employers, and health systems.

Technology Enables the Monitoring of Complex Patients at Home

I have blogged frequently about the decreasing number of inpatient hospital admissions (see, for example: Talking to Patients Helps Reduce Hospital Readmissions; Inpatient Admissions Decreasing; Implications for Hospital-Based Labs). One of the factors contributing to this decline are new healthcare models such as "hospital at home" for the care of sicker patients in their homes (see: Are Hospitals Becoming Obsolete; Consequences for Pathology and the Labs; Reducing the Cost of Care; Provide Home Care for Sicker Patients with Remote Monitoring). The majority of the patients suitable for this care approach are CCC patients as described in a recent article (see COMPLEX, CHRONIC, CO-MORBID: THE CCC PATIENT). Below is an excerpt from it:

...31.5 percent of all Americans suffer from multiple, difficult to manage diseases — a patient population we define as complex, chronic, co-morbid, or CCC patients. Patients with complex, chronic, co-morbid conditions command disproportionate healthcare industry spending. In fact, the nearly one-third of the U.S. population that have multiple chronic conditions drive a staggering 71 percent of U.S. healthcare spending....Managing this population’s care and identifying which patients are at growing health risk, and when, is especially challenging....

We define CCC patients as:

Complex: Their health is influenced by socioeconomic, cultural, environmental, and behavioral factors, along with health-related factors.

Chronic: They require ongoing medical care and have long-lasting physical and mental health conditions, such as heart failure, diabetes, COPD, hypertension, and depression.

Co-morbid: They have multiple diseases, disorders, or conditions, and may develop more with age. Comorbidity adds complexity to caring for patients.

Medtronic Care Management Services (MCMS) can play an important role in addressing unmet needs of the CCC patient population. Our remote monitoring program is designed to give patients a more active role in their care management while helping to enable clinicians to gauge their patients’ health status outside the hospital setting. Through daily symptoms data and biometric readings, clinicians can track the patient’s multiple conditions over time, aggregate patient data, prioritize patients for further assessment, and potentially intervene before an acute event occurs. 

So we now see a large healthcare technology company like Medtronic calculating that the hospital-at-home market is sufficiently large that it is willing to develop a monitoring system enabling care of CCC patients at home. This reminds me of virtual critical care (see, for example: Telemedicine Transforms Intensive Care Units in Smaller Hospitals with Remote Monitoring; Centralized Cardiac Monitoring Center Developed by Cleveland Clinic). This latter technology was deployed by health systems with some smaller hospitals with a small number of critical care beds. These patients could be monitored by intensivists based in their larger hospitals at some distance. The technology at that time was too expensive to justify installation in homes for individual patients. Fast forward to the point today when CCC patients can be monitored at home by hospital personnel.

Telemedicine Finds Key Target: Working Moms Seeking Pediatric Care

I am personally very enthusiastic about the future of telemedicine and believe that it will account for a relatively large share of patient visits in upcoming years. However, often missing in the telemedicine literature thus far has the identification of key target audiences for the service but a recent article now seems to fill this void (see: Telemedicine apps are thriving because working moms love the convenience of their smartphones). It should have been obvious from the outset -- telemedicine is perfect for working moms seeking pediatric care for their children. Below is an excerpt from the article:

Telemedicine, as this burgeoning practice is known, is gaining particular traction with working mothers...who are juggling child care with a full-time job and struggle to find time to go to the doctor unless it’s truly an emergency.....Many such services are covered by employers or health plans. CNBC spoke with executives at American Well as well as telemedicine providers Teladoc, MDLIVE and Doctor on Demand. They all said they rely heavily on mothers to use the service and to spread the word. According to Global Market Insights, the U.S. telemedicine market is poised to top $64 billion by 2025. Recognizing that women are their key demographic, the providers are targeting their marketing dollars in that direction. Teladoc, which went public in 2015, credits much of its success to courting moms through Facebook and other online forums. Mothers over age 25 now represent about 45% of all of their general medicine and behavioral health visits, according to CEO Jason Gorevic.....A study from the Kaiser Family Foundation from 2017 found that mothers make 79% of the decisions when it comes to selecting their kids’ doctors and take them to 77% of appointments. Roy Schoenberg, CEO of American Well, said mothers are driving the majority of virtual visits for things like bladder infections, strep throat and other acute infections. More than 60 percent of its users are women, and more than half are between ages 25 and 44.

It's now clear that telepediatrics will be one of the major drivers for the telemedicine market. Another major target will certainly be geriatric patients. Such patients are more chronically ill than pediatric patients but are also less mobile and thus ideal candidates for being cared for in their own living rooms. Because they are sicker, remote monitoring of vital signs may be necessary for their virtual visits (see: American Well Offers Remote Physical Monitoring for Telemedicine Visits). I have also blogged about how telemedicne reduces the cost of care which is increasingly important in this era of value-based care for all patient categories (see: Reducing Healthcare Costs with Virtual Visits; Tangible Evidence Provided).

As noted in the excerpt above and now that mothers of young children are an obvious target for marketing telemedicine services, they can be "courted" using Facebook or other on-line forums with their skew toward younger individuals. I am inclined to believe that health systems. as opposed to for-profit telemedicine companies, could easily attract this telepediatrics business because mothers would probably prefer to interact on a repetitive basis with a pediatricians whom they know. However, many of the large health systems have been relatively slow to adopt telemedicine in a robust manner. Kaiser and Intermountain are notable exceptions to this statement (see: Telemedicine Used in New Healthcare Settings Like Coaching; Intermountain Healthcare Launches Telemedicine Program with Connect Care).

Algorithmic Triaging of Patients for Routine Care; a Path to Lower Costs

Most health system executives understand that significant changes are necessary in healthcare to adapt to the preferences of today's consumers while cutting costs and delivering quality care. A recent article quoted an executive of the Cleveland Clinic about three major trends that are shaping the health systems for the future (see: Why Today’s Hospitals and Health Systems Need to Be More Patient-Centric to Fight Rising Costs). Below is an excerpt from it:

“A central challenge for the United States is that between 18 to 20 percent of GDP is going to healthcare, and it’s on track to go higher,” says Edmund Sabanegh,... President of the main campus hospital of the Cleveland Clinic....“This explosive growth in expense is not sustainable and we cannot afford it as a country.” He discussed three trends that are emerging in response to this challenge and that will shape the hospital systems of the future. All of these trends amount to one thing: making healthcare more patient-friendly.

1. [Patient centricity] “The hospitals and health systems of the future will need to be more patient-centric. Patients will not come to health systems- health systems will need to come to patients,” he says....But if there are clear algorithms in place for identifying patients who need much more advanced care, patients may be able to receive very routine kinds of services at much lower cost.”
2. Price transparency “Going forward, people are going to be able to shop for healthcare asking very specific questions....And people will be able to compare prices at different institutions. You are going to be able to compare apples to apples.” This kind of price transparency is being advanced by innovative companies offering niche services at lower cost....
3. Leveraging the digital revolution...."[G]etting patients to the right doctor in a timely fashion is still a challenge for hospitals.” Online scheduling of patient visits and online consultations with experts for second opinions are the future....[H]ospitals and health systems of the future must leverage technology to allow for remote monitoring so that specialists can intervene during a patient visit without having to be physically present at all locations. 

I have blogged extensively about the three major healthcare trends cited by Dr. Sabanegh: (1) patient centricity/consumerism; (2) price transparency accompanied by the need to lower the cost of care; and (3) digital medicine with emphasis on AI. However, as the focus for this note, I want to briefly make reference to Dr. Sabanegh's point about the use of clinical algorithms in paragraph #1. He states that clinical decision support (CDS) algorithms can be used to direct patients who only need basic care to lower cost providers. I came across an article that covers the basic of this process as it applies to telephone triage by nurses at the Mayo Clinic: How Mayo Clinic Uses CDS Algorithms to Standardize Nurse Triage. Here a excerpt from this article:

For almost a decade, Mayo has been working on a different way to deliver clinical decision support for its primary care patients. Starting with a proprietary health IT tool called ExpertRN and moving later to adopt the Curion platform from Applied Pathways, the healthcare system has relied on an algorithmic approach to phone-based triage....The nurse is able to use a guided decision tree based on the symptoms the patient presents. The algorithm leads them through a number of questions, which helps assure that key assessment points are not missed.....It gives our triage nurses a bit more structure than the generalized guidelines currently used across the healthcare industry. He or she will always use clinical judgment and experience in addition to what is on the screen, of course, but it does help to present them with a standardized series of options that lead to a very thorough assessment.

For delivering patient care whether by telephone or in person, I can't think of a more important use for clinical algorithms than triaging patients to the most appropriate provider. Such triaging not only has significant quality implications but, as noted above, it also affects the cost of care.

AT&T Offers the LTE-M, Low-Powered Network for Uploading Wearable Health Data

So-called wearables, including wrist devices and skin patches, are continuing to have a major impact on the delivery of healthcare (see: Is Healthcare Ready to Embrace the Consumer "Wearable" Revolution?). One key aspect of the adoption of wearables is uploading data from the consumers' devices to a network where is can be monitored and analyzed with subsequent notification of health professionals about the status of the patient. Part of this process was referred to in a recent article (see: AT&T’s new smartwatch will drive transformation in healthcare). Below is an excerpt from the article:

AT&T is connecting the first medical wearable certified for its LTE-M low-powered network. The carrier teamed up with OneLife Technologies Corp, a mobile healthcare software and data-collection company, to develop the OnePulse smartwatch, which is designed with telehealth and remote patient monitoring capabilities....Here's why AT&T's collaboration with OneLife Technologies Corp is important: The AT&T LTE-M connection offers medical providers increased versatility and a number of key advantages.

* The LTE-M network is an IoT-specific low-powered network variant that supports long battery life with limited power draw. This allows for the OnePulse smartwatch to have five days' worth of battery life, an always-on feature, and lightweight design. And the network connectivity enables clinicians to improve patient outcomes since they're able to monitor and cater to their patients in real time.

* These advantages will likely enable AT&T to drive up adoption of the device, especially given the healthcare market's continued embrace of connected wearables....

* ....AT&T's move to introduce a medical-focused smartwatch to its network will enable it to diversify its revenue streams and expand its wireless subscriber base....In January, the carrier landed a partnership with Chicago-based Rush University Medical Center to become the first US hospital to leverage 5G.

For me, the most important point in this article is that the internet-of-things (IoT) network developed by AT&T is low-powered and supports long battery life for wearables on the basis of low power draw. The data uploaded to the LTE-M network will be stored in the cloud for screening and analysis. Initially, the majority of people with watches like OnePulse will be wellness-oriented consumers but some of the next set will be patients post-hospital-discharge who are being monitored by hospital personnel while at home (see: Some Details about Hospital-at-Home (HaH) Services for Selected ER Patients; Reducing the Cost of Care; Provide Home Care for Sicker Patients with Remote Monitoring). This idea is not far-fetched because one of the most common types of hospitals being built now is bedless (see: The Case of the "Disappearing Hospital Beds"; Implications for Pathologists). This combination of wearables plus network plus surveillance software will serve as a substitute for hospitalization in the past.

Reducing the Cost of Care; Provide Home Care for Sicker Patients with Remote Monitoring

Although changes often come slowly in healthcare, we are now in the midst of the following three major changes in the field: (1) reduction in inpatient admissions that is driving the growth of bedless or mini-hospitals; (2) provision of first-tier outpatient care in walk-in clinics such as CVS/MinuteClinics; (3) the transfer of some inpatient care to patients' homes, partly as a cost-reduction strategy. This latter topic was previously covered in one of my blog notes (see: Some Details about Hospital-at-Home (HaH) Services for Selected ER Patients) and also in a recent article (see: Commentary: Reducing the cost of acute care by going home). Below is a quote from the latter:

An ideal way to...[reduce healthcare costs while increasing quality] is to keep patients out of the hospital whenever possible through proactive, preventive care. Yet even when this fails and patients do need acute care, we can successfully treat many of them outside the hospital. Hospital at Home is an innovative program that provides hospital-level service in the patient's own home, at a fraction of the cost of hospitalization. Health systems across the country are prepared to launch such programs, which would save Medicare hundreds of millions of dollars, once an appropriate payment model is in place. Elderly patients with illnesses such as pneumonia, asthma and urinary tract infections, can be treated at home where they face less risk of falling, sleep better, receive better nutrition, and are far less exposed to drug-resistant bacteria, all of which contribute to better outcomes and greater patient satisfaction....

The acute-care team includes doctors and nurse practitioners who provide a daily visit and are on call 24/7. Nurses visit twice a day. Social workers, physical therapists and other providers are available as needed. The program brings portable medical equipment to the home, including X-ray machines, electrocardiograms, infusion pumps, and ultrasound machines, while state-of-the art communications technology can supplement in-person visits to ensure the patient is well-monitored. If clinical concerns develop, the patient is quickly brought to the hospital. Following the acute-care episode, a 30-day period of transition services provides a smooth discharge and appropriate support. 

One of the reasons that home care as a substitute for some inpatient care makes so much sense, in addition to being less expensive, is that modern telecommunications technology can provide physiologic monitoring of the home-based patient. All of this reminds me of tele-ICU which is defined in the following way (see: Tele-ICU: Efficacy and Cost-Effectiveness Approach of Remotely Managing the Critical Care): Tele-ICU...[is based on the idea of] an off-site command center in which a critical care team (intensivists and critical care nurses) is connected with patients in distant intensive care units (ICUs) through a real-time audio, visual and electronic means and health information is exchanged.

This concept of tele-ICUs has been in vogue for a number of years for health systems with smaller hospitals and a small number of intensive care beds. These critical-care patients were monitored by intensivists located at command centers in one of the larger hospitals in the same system. I first blogged about this concept eight years ago (see: Telemedicine Transforms Intensive Care Units in Smaller Hospitals with Remote Monitoring). Another reason why the Hospital at Home concept is so appealing is that CMS will now reimburse for remote patient monitoring (see: New CMS Reimbursement Guidelines: Support for Provider-to-Provider Consults.

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.