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Hotspotting, Superutilizers, and Avoiding “RTM Traps”

Thomas Wilson
Vince Kuraitis

By THOMAS WILSON PhD, DrPH and VINCE KURAITIS JD, MBA

A recent study in the New England Journal of Medicine reported on the results of a “hotspotting” program created by the Camden Coalition of Healthcare Providers (Camden Coalition). Hotspotting targets interventions at all or a subset of healthcare superutilizers – the 5% of patients that account for 50% of annual healthcare spending.

The results of the study were disappointing. While utilization (hospital readmissions) declined for the hotspotting group, the declines were almost identical in the control group.  At least three headlines implied that the conclusion of the study was that hotspotting care management approaches have been proven not to work:

“’Hot spotting’ doesn’t work. So what does?” Politico Pulse

“Reduce Health Costs By Nurturing The Sickest? A Much-Touted Idea Disappoints.” NPR

“Hotspotting” Apparently Doesn’t Reduce Superutilizers’ Readmissions” NEJM Journal Watch

NOT SO FAST!

As we’ll explain, we believe that much of what’s going on here can be explained by one or both of what we call “RTM Traps” (regression to the mean traps).

In this essay, we will:

  • Define RTM (regression to the mean)
  • Explain the RTM Traps and how many have fallen into the traps
  • Suggest how to avoid the RTM Traps

We believe our POV is relevant to clinical, technical, and executive staff in the many organizations focusing on the superutilizer population – hospitals, physicians, ACOs, health plans, community groups, etc.

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How Hospital Systems Invest in Digital Health | Brent Stackhouse, Mount Sinai Ventures

By JESSICA DaMASSA, WTF HEALTH

Savvy health tech startups can learn how the differing investment priorities of venture capital funds and strategic investors (those tied to large healthcare organizations like health plans, pharma companies, and health systems) can impact everything from their capital raise to their ability to gain new clients. Brent Stackhouse, Managing Director at Mount Sinai Ventures, talks about the nuances of investing as a strategic, trying to balance a health system’s inherent aversion to risk with the gusto it takes to place good bets on the future of health. Where does a hospital system find investments? Are they looking for clinical solutions or consumer solutions? Brent shares the details behind Mount Sinai’s investment thesis and talks ‘big picture’ about trends he’s seeing in healthcare investing worldwide.

Filmed at Frontiers Health Conference in Berlin, November 2019.

How eConsults Can Help PCPs Benefit From the Primary Cares Initiative

By CHRIS JAEGER MD, MBA

The Primary Cares Initiative provides new value-based payment models aiming to enhance the delivery of primary care to promote efficiency and quality while decreasing healthcare costs. In the second part of this two-part series, we explore how eConsults directly support this new initiative across several key metrics.

Introduction

The Primary Cares Initiative aims to enhance the delivery of primary care through value-based payment models. In Part One of this two-part series, we broke down the five payment models offered through this initiative, including two performance-based models (Primary Care First) and three risk-sharing plans (Direct Contracting). Alongside previous programs such as Patient-Centered Medical Home (PCMH), the Comprehensive Primary Care (CPC+) program, and the Medicare Advantage Value-based Insurance Design (VBID), the Primary Cares Initiative represents the most recent push for enhancing primary care within health care systems.

Yet, as programs such as these continue to emphasize primary care providers as a locus of optimal care, the question becomes: how can primary care providers (PCPs) best work within initiatives such as these to enhance care delivery efficiency and effectiveness, and what kinds of services and technologies can support this?

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Health Tech Investor Outlook for 2020 | Bryan Roberts, Venrock

By JESSICA DaMASSA, WTF HEALTH

Bryan Roberts of Venrock, one of healthcare’s leading venture capital firms, weighs in with his view on the health tech market ‘state-of-play’ as we roar into 2020. With a track record that includes athenahealth, Illumina, Grand Rounds, Castlight, and Lyra Health, Bryan’s not a bad investor to ask when it comes to identifying the “next big thing” in healthcare innovation.

Filmed at J.P. Morgan Healthcare Conference in San Francisco, January 2020

Time Really Can Be Money

By KIM BELLARD

If you are not an IKEA fan, or haven’t been spending any time in Dubai, you may have missed the chain’s marketing campaign to help promote its second store in the area.  Titled “Buy With Your Time,” customers got store credits for how long they spent getting to the store. 

Gosh, that’s something that should make any self-respecting critic of the U.S. healthcare system perk up.  Count me as intrigued.

The campaign involved checking the customer’s Google Maps’ Trip tab to determine how long it took them to get to the store.  IKEA benchmarked the average hourly wage in Dubai, and converted the travel time into how much credit they’d generated.  It works out to about $29/hour, or $0.48 per minute.  Spend long enough getting there and you could get a free coffee table or even a bookcase.  Prices in the store include the equivalent time currency.

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Back Pain Treatment Under the Watchful Eye of Your SmartPhone Camera | Konstantine Mehl, Kaia Health

By JESSICA DaMASSA, WTF HEALTH

With a holistic mind-body approach to treating chronic back pain and COPD, Kaia Health is a digital therapeutics startup gaining a lot of attention from some really big players, including Optum Ventures (the venture arm of U.S. health insurance giant United Healthcare) which recently made an $8M follow-on investment to the startup’s Series A. What makes Kaia standout in a crowded field of digital health solutions focused on chronic pain? CEO Konstantin Mehl points to their proprietary tech, which uses a smartphone camera to provide real-time corrections to patients as they complete their physical exercises. As digital therapeutics like Kaia gain greater clinical validation and show widespread improvement to patients’ lives, Konstantin shares his hopes for the future of reimbursement for clinically-proven health tech.

Filmed at Frontiers Health Conference in Berlin, November 2019.

American Primary Care and My Soviet Era Class Trip: Sensing the Inevitable Collapse of a Top Down Bureaucracy

By HANS DUVEFELT, MD

Swedish Healthcare seemed competent but a bit uninspired and rigid to me but my medical school class trip to the Soviet Union showed me a healthcare system and a culture I could never have fully imagined in a country that had the brain power and resources to have already landed space probes on Mars and Venus by the time my classmates and I arrived in Moscow in the cold winter of 1977.

The first time we sat down for breakfast at two big tables in the restaurant of the big Россия hotel near the Red Square, our two male waiters asked if we wanted coffee or tea and people started stating their preferences. The waiters shook their heads and put their hands up in the air. No, they couldn’t split the beverage order, they explained. We had to all decide on one beverage with no substitutions.

The restaurant obviously had both coffee and tea, and as far as I know, they cost about the same. The only thing standing between the tea drinkers and their favorite morning beverage (the coffe crowd won the popular vote) was convention and attitude. I don’t know if this was a policy set by the hotel management or a complete lack of service-mindedness by he staff, but my classmates and I felt as if we, the customers, did not matter.

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Advice for Health Tech: Focus on Results, Mission, & Critics | Molly Coye, AVIA

By JESSICA DaMASSA, WTF HEALTH

Molly Coye has spent more than two decades working to advance technology initiatives in healthcare, serving roles as diverse as the Commissioner of Health for the State of New Jersey, Chief Innovation Officer for UCLA Health, and now Executive in Residence for AVIA, which mentors more than 50 large health systems on tech selection, adoption, and implementation. With such rich experience working with healthcare incumbents, we asked Molly to size up the current class of innovators, technologists, developers, and investors bringing the latest health tech solutions to market. What have they gotten right? Where do they need to improve? “We’re not so good at cost of care and lack of access,” says Molly, who also sees potential for that to change thanks to the work of organizations like Health Tech for Medicaid and an increased focus on solutions that address the health needs of ALL patient populations.

Filmed at J.P. Morgan Healthcare Conference in San Francisco, January 2020.

Advanced Professionalism and Fitzhugh Mullan

By MIKE MAGEE, MD

As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today. 

Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.

Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:

“From my own perspective, I have no reservations about accepting any, or all of the foregoing articulations of various qualities, attitudes, and activities of the physician as legitimate representations of important attributes for the trustworthy professional. In fact, I find it difficult to choose one list over others, since they each in turn seem to refer largely to the same general set of admirable qualities. While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”

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Mainstream Adoption of Virtual Care is Like…Online Dating? | Stephany Verstraete, Teladoc Health

By JESSICA DaMASSA, WTF HEALTH

The shift in thinking required to go to a “virtual first” healthcare system may not be as unique to the health industry as we think. Teladoc Health’s new Chief Engagement Officer, Stephany Verstraete, got her start at Match.com — and explains the parallels she sees between the mainstream adoption of telehealth and what she experienced introducing online dating to the masses. Think about it: overcoming skepticism, addressing privacy concerns, and what Stephany says is most important, changing an ingrained behavior — are all challenges currently being faced by virtual care co’s. It’s not a bad idea to flirt with as we talk bigger trends in telehealth engagement.

Filmed at J.P. Morgan Healthcare Conference in San Francisco, January 2020.

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