TECH/CONSUMERS: Quality, Cost and Connected Health by Joseph Kvedar

Joseph C. Kvedar, MD is the Director of the Center for Connected Health at Partners
Healthcare System in Boston. Given that so many organizations are talking about Connected Health in one flavor or another, I thought it might be interesting if he gave his view of where it would go and what it means for health care quality.

Connected health is the use of messaging and monitoring technologies to bring care to where the patient is, when the patient needs it. This approach has enormous opportunity to increase quality while lowering the overall cost of care. Early returns on this approach are quite encouraging. We are starting to weave connected health into the fabric of our health care system, with good results.

Is There a Doctor in the House?

The growth in the number of patients with chronic illness has outpaced our growth in provider capacity. We talk publicly about nursing shortages and, in private, policy makers and healthcare executives acknowledge that there are physician shortages too. Just ask your primary care doctor how he/she is doing these days, and you’ll get a reality check on how stressed that part of our workforce is. We have no choice but to rethink today’s model of care delivery, where a patient comes to the doctor’s location for care when the doctor has time to see her. Technology makes it possible for physicians and other clinical workers, as well as patients themselves, to take part in continuous healthcare, where data collection and feedback are more frequent and more complete. The sharing of this information between patients and providers can take place in any number of ways thanks to the availability of inexpensive communications technologies.

Let’s take blood pressure as an example. Most physicians who manage blood pressure do so on a few – and often as few as two – readings per year taken in the doctor’s office. With simple, inexpensive technology it’s possible to take blood pressure readings daily or more often and present the doctor with a trended report on how blood pressure is varying and what aspects of the patient’s life impact the readings. Once that richness of data is in hand, why travel to the office for a medication refill? Why not do the whole thing online? Further, the immediacy of information in this type of model allows patients to self-manage through diet, exercise or lifestyle decisions as never before, preventing exacerbations of their condition or the onset of complications that would necessitate intensified use of healthcare resources.

Reimbursement Trends are Creating Fertile Ground for Innovation

There are a number of reasons why this is not happening to the
degree we’d like to see. Chief among them is that the current system is
designed to compensate physicians for face-to-face visits. But there
are trends in physician reimbursement that prompt a different view. Pay
for performance is gaining traction and this method of payment
encourages doctors to look at the quality of care over populations of
patients, and compensates them according to their adherence to good

The quality measures are specific. In diabetes, for example, physicians are generally asked to:      1. make sure all of their patients have an HbA1c drawn n times/year.      2. Make sure no more than 20% of their diabetes patients have HbA1c > 10 and      3. Make sure that 40% have HbA1c < 7.

In the not too distant future, we’ll be accountable for keeping our patients’ blood pressures below 140/90.

Likewise, CMS is conducting a number of demonstration projects
looking at the possibility of sharing risk with provider organizations
over high-risk populations. 3% of Medicare patients consume 50% of
their resources and CMS is determined to manage these folks better.

These are all good things, but challenging for the beleaguered
primary care physician. Risk-sharing programs encourage groups of
doctors to contract together and to implement systems that enable
population-based care.

What have we learned to date?

-Feedback changes behavior-

One of the pillars of the connected health approach is the
collection of patient physiologic data using biometric sensors. These
data are trended, subjected to rules and presented to the patient in an
educational context, as well as to the provider.

Initially, we thought this approach would lead to more rich
and accurate patient information (there are numerous studies showing
how humans are notoriously inaccurate at reporting data about
themselves). While this has been confirmed, what we didn’t anticipate
is how the patient’s participation in gathering this data and their
knowledge that health care providers are reviewing is enough to draw
them into their care — and dramatically improves adherence. My
favorite example of this is the congestive heart failure patient who,
in commenting on his required daily weigh-in said, "I can’t cheat
on my diet anymore. If I have too much salt today, it will effect my
weight tomorrow, and I’ll get a call from my nurse, Rebecca, to make
sure I’m OK."

-Adherence is a forgotten opportunity-

For a number of reasons, members of the healthcare industry have
not focused on helping patients achieve better adherence to prescribed
medications, which is an enormous opportunity for quality improvement
and cost reduction. While policy makers see pharmacy benefits as a cost
problem to be solved, a number of observations and studies have shown
that when more pharmacy cost is passed on to patients, they take fewer
needed medications and end up more often in the truly high cost parts
of the system – the emergency room and the inpatient setting. Couple
this with ongoing studies that estimate adherence to be 50% in
aggregate and one gets a sense of how big the impact for strategies to
increase adherence could be.

Our observation is that the market availability of tools to
promote and measure adherence is poor compared with solutions for
monitoring physiologic data. There is in fact very little available
that allows patients to engage in any form of self care. This will be
an important void to fill if we are to realize the vision of connected
health, especially in the context of the supply and demand challenge
noted above.

-Providers are ready to engage, but need to be led-

Physician resistance is commonly cited as a primary reason for
slow adoption of the connected health approach. Our experience is that
this is rapidly changing, perhaps because physicians are frustrated
with the current practice model. However, a new discourse is needed
that invites dialogue about changing roles for various providers to
improve efficiency and quality (e.g., rich patient data emanating from
the point of need enables algorithmic decision making by non-physician

In addition, we need to begin thinking about continuous care
and how that will be reimbursed. The construct of a ‘visit’ as the
focal point of care delivery is holding back creative thinking on
reimbursement policy and discouraging the adoption of connected health
technologies. We can start making changes now, especially within a
pay-for-performance model. Think of how quality and outcomes could be
improved for diabetics if we had trended data collected during their
daily life as opposed to four times a year in the doctor’s office.

Why now?

It takes time to change the course of a giant, slow moving ship.
Adoption challenges abound for those providers that have had the
courage to implement these types of systems. This is the territory of
disruptive innovation and a rule of thumb is that movement will take
2-3 times as long as you think. Also, the technologies are at a point
where they are usable and affordable (though both of these will get
better with time). Finally, there is a reservoir of unmet need among
patients. They WANT to be more in control of their health and their
care, and connected healthcare encourages that.

8 replies »

  1. Compound Pharmacy has gained much popularity in the field of medicine. The medications are equally effective and safe for sick patients who cannot take the actual medications due to their personal allergies.

  2. The move from payment for face to face interventions to remote monitoring and advising is a quantum leap for payors. The solution that we have instituted includes remote management as a patient pay option. Patients seem to want and appreciate this type of uninsured service and are willing to pay for it. The precondition to growing remote management for a scalable number of providers is to fix the payment issue. We have done that by creating a payment system for uninsured services. The system is described at http://www.dcc1.ca
    Seems to work for the doctors who are participating in this doctor owned, designed and managed system.

  3. All of Joe’s article and the comments following it certainly hit the issue clear on its head, in that there are several elements to the solution. One element in specific that Joe refers to, being adherence, is probably the most crucial of all. It’s not enough to have a technical and payment system that works, what’s also needed is a means of empowering the individual to want to adhere. Without that, solving these other issues will be have been a huge exercise without significant result.

  4. One of the major flaw’s with the current disease management model is the total lack of scalability which leads to a lack of member connectivity. RPM can impact by making it easy for the member to interact with a clinician. Yet RPM poses another challenge. I have not seen the cost benefit of receiving biometric measurements (beyond HF – weight, and BP). Does it really impact a member to have their blood glucose monitored every day or any other biometric measures? I think that if we can get RPM down to a very low cost PMPM for a member we could see increased adoption.

  5. > Let’s take blood pressure as an example.
    > Why not do the whole thing online?
    Great idea, especially if we can expand the notion of online to include voice response units to deal with the computer-challenged. I don’t think it will help the beleagured PCP if this technology becomes standard of care for HTN because he won’t own it, and he won’t monitor it. He’ll simply get a report that says “Mrs. Smith’s HTN is going out of bounds.” If the PCP follows up on this tidbit, and Mrs. Smith decides to go in to see the doc despite the fact she feels fine, he will get his visit, but he didn’t add the value of the monitoring. A telemetry service did, and they’ll get paid for it, not him.
    I think Walgreen’s would be smart to get into something like this as a vendor. The big insurers would pay for it, presuming prevention really does save money. It will take an outfit with more than neighborhood-level reach to make this pay.
    The idea of tech-delivered DM programs seems good to me. The traditional sort haven’t paid-off, as has been reported on THCB a couple of times.

  6. I would agree that we need ways of reimbursing providers other than the discrete visit, and that monitoring physiological indicators and providing regular feedback to patients would improve both patient and population health. But while more docs on getting on board with this, there is still significant resistance to the whole “pay for performance” approach, which is usually couched in simplistic process-driven metrics and reductionist language that is perceived by many physicians as code words for health plans to keep them under their thumb and squeeze costs.
    We’ve observed some of this in the beginnings of the Phoenix Healthcare Value Measurement Initiative (PHVMI), which involves a number of national health plans, employers, physician and hospital groups in Arizona. We learned the hard way that we won’t get very far with docs if we talk about pay for performance, but get a much better response — and far better cooperation — when we talk about pay for value, and particularly pay for value across the entire health care system, and not just in the “office visit.” For example, docs want to know, why does it take me 60 days to get paid by some plans? Where’s the “performance metric” for that? Other docs want to know who is measuring the quality of the doc who won’t prescribe the antibiotic that won’t do a damn thing for you, or suggest surgery that you don’t need. Where’s the “metric” for that?
    We need a new way of talking about quality in health care. We just released a report, “Collaborate to Compete: A Prescription for Value-Based Health Care in Arizona,” that talks about this based on coversations with a lot of people over the past several years, focus groups, the beginnings of the PHVMI project, etc. If anyone is interested, it is available at http://www.slhi.org.

  7. To bad we weren’t spending as much trying to be more efficient at preventing illness instead of treating it. But that would hurt cash flow too much.