Digital Transformation in Healthcare

Wilner Samson working with ICP to transform and improve more than 80 practices for future state, including preparing for downside risk, piloting new care delivery model, enhancing and standardizing the role of virtual medicine, working with the hospital service to improve transition of care capture rate, supporting effort to achieve balance score card, MSSP and ACO clinical metrics.

What are Some of The Major Challenges and Trends That have been Impacting The Healthcare Industry Lately?

About five years ago, the Geisinger health system launched their Fresh Food Farmacy. Their doctors initially identified 95 patients who had food insecurity and who also suffered from poorly controlled type 2 diabetes. In addition to their regular drug therapy, these patients were given a prescription for fresh fruits, vegetables, lean proteins, and whole grains that would feed them and their families two meals a day for five days per week through their “farmacy.” After 18 months, the patients saw very significant improvement in blood sugar and an estimated 40 percent reduction in serious health complications, including death. The claims data for 37 of the patients enrolled in that program showed a decrease in average annual cost from $240,000 to $48,000 annually. This and other examples highlight the reason for the current national and local trend in the healthcare industry to transition the business model from a primarily fee for service system to one that relies increasingly on bundle payment.

Fee-for-service healthcare was designed to provide care for people who are sick. It was not created to prevent sickness or to maintain a healthy population. This episodic care model has proven over the years to be very expensive relative to other western nations, while only achieving mediocre health outcomes. Meanwhile, we have accumulated evidence that bundled payments, also known as value-based care, can improve quality of life for patients and can correct misaligned incentives. The attraction towards a bundled payment model is based on the expectation that, in the long run, a healthier population with more accessible preventative care as well as sick care will reduce health care costs by reducing the subsequent treatments for medical complications. Moreover, a healthier population will result in fewer work[1]related absences and potentially better overall productivity at the macroeconomic level.

The transition to value-based care requires increased coordination among care providers. Instead of waiting for sick patients to seek care, clinicians will need to proactively seek out patients who will benefit from sick and preventative care. Health organizations need to be able to identify and track the medical conditions for the population of patients it serves, so appropriate resources can be requested from the payers in order to adequately care for that population.

Strangely enough, a healthier population will undermine the financial health of many health care organizations unless they are receiving bundled payment within an integrated system, such as in the case with Geisinger and now here at Hartford HealthCare. That is, the reduced revenue from decreased hospitalization and utilization of ancillary services need to be balanced by cost savings and an adequate level of bundled payment. Integrated health systems that provide care throughout the spectrum of the patient’s health journey are potentially best suited for this transition.

What Keeps You Up at Night When it Comes to Some of The Major Predicaments in The Healthcare Industry?

The recent news that CVS, which only acquired Aetna a few years ago, was now spending $10.6 billion to acquire Oak Street Health reverberated across the healthcare industry. What is Oak street and why was it so highly prized by CVS? The entry of many nontraditional players into healthcare — including retail, insurance, private equity, and technology firms — has certainly kept many of us up at night. It is easy to explain why this is happening: Healthcare takes up more than 18 percent of the national GDP (more than $4 trillion). Yet, many who consume healthcare remain unsatisfied in spite of this massive cost. The direct cost of healthcare for the average American remains prohibitively high. The quality of care delivered in aggregate continues to be plagued by unnecessary clinical variations and medical harm. Hence, this environment is ripe for disruption from outsiders.

The CVS/Aetna/Oak Street merger is an intriguing model that will create an organization with an extensive retail pharmacy footprint, a national health insurance business now with an organization that has shown particular talent in scaling its value-based healthcare model. It will be able to insert various degrees of the Oak Street healthcare model in its existing retail space that is already within reach of most Americans. This geographical advantage can potentially meet the transportation challenges many patients face.

However, at this point, Oak Street includes only about 600 physicians across 169 medical centers located in 21 states. They will need to overcome the challenge of scaling that model across the country. Like all other healthcare organizations, they will be challenged to find high-quality providers to staff their locations. Will these new entrants understand the local cultures to the same extent as the legacy organization? Still, the local traditional healthcare organizations will face stiff competition from this new entrant into their local market.

The long-term survival of many healthcare organizations will be based on their capacity to demonstrate that they can, in fact, deliver a superior value proposition for healthcare consumers relative to what the CVS/Aetna/Oak Street model offers.

Can You Tell Us About The Latest Project That You Have Been Working on and What are Some of The Technological and Process Elements That you Leveraged to Make The Project Successful?

Last year, Hartford HealthCare’s leadership asked my administrative colleague, Cherie Kerzner, and I to co-lead a multidisciplinary group tasked with developing a system-wide strategy to improve overall diabetes control and thereby reduce the relative inequities for patients living in underserved communities. 

We used the social vulnerability index methodology that was developed by the CDC during the pandemic to identify such socioeconomically vulnerable Connecticut ZIP codes in what the CDC described as “priority ZIP code areas. ”

The desire to eliminate health inequities in diabetes is both a moral and business imperative. Not only does poorly controlled diabetes increase the risk for complications from COVID-19, it can lead to increased medical disease burden and untimely death. The significant clinical complications of diabetes include heart attacks, strokes, limb amputation, blindness and kidney failure, among others. These conditions contribute to a high financial cost for individuals, businesses and payers both governmental and commercial. Hence, the elimination of health inequities is likely to reduce overall disease burden and their associated significant economic cost.

The initial steps for this work involved understanding the current state. This includes understanding the population’s clinical status as well as trying to understand their social determinants of health (SDOH). The SDOH factors are responsible for about half of health outcomes, while the direct role of the healthcare provider only accounts for about 20 percent. To tackle this problem, we formed a work group that included physicians, nurses, social workers, dietitians, and administrators. We identified the lack of diabetes control based on the government standards that set the threshold of 9 percent or higher for the blood test called Hemoglobin A1c (HgA1c) or the absence of the HgA1c test for more than one year. We analyzed the demographic and clinical data to understand the difference in blood sugar control between those who live in priority ZIP codes and those who do not. We also developed a process to track those affected patients. This process was facilitated by the creation of a flag in the electronic medical record so that those patients were readily identified as at risk. We discovered that about half of those patients who were considered to be in the uncontrolled category did not have any HgA1c testing in at least one year. For one reason or the other, these patients had not received the HgA1c test through their primary care physician or diabetes specialist’s office. Therefore, we developed strategies for those patients who had inconsistent medical follow-ups and those who had uncontrolled disease state with their current medical therapy.

"Healthcare organizations that transition to a bundled payment model will need to continually analyze the population they serve to assess needed interventions and to demonstrate achieved value" 

We created a plan to expand the clinical arenas where patients who are identified by the flag can receive their HgA1c monitoring — such as during emergency visits or pre-operative testing. Our data analysis also provided us with information regarding clinical adherence and the therapeutic regimen utilized by the treating providers for all patients. We shared this information with the primary care providers to help inform their decision around clinical guidelines. We plan to monitor and continue to share the practice pattern with all providers.

We also understand that the clinical needs for patients who have historically been marginalized require more intensive medical intervention. Since we have a limited number of physicians, our success will hinge on a robust team-care approach. The members of this team include the physicians, physician assistants, advanced practice registered nurses, medical assistants, patient service coordinators, as well as healthcare administrators at all levels of the organization. The recent change in Connecticut’s regulations regarding pharmacist collaborative practice will make it easier to add pharmacists to the team.

We are also considering utilizing community health workers (CHWs) to help engage those patients who have had the greatest struggle with keeping appointments for clinical follow ups. We will continue to rigorously monitor the clinical as well as financial metrics over the ensuing months and years to continually improve outcome.

What are Some of The Technological Trends Which Excite you for The Future of The Healthcare Industry?

From Medicare data alone, we know that the use of telemedicine increased in February 2020 from 0.1 percent utilization to 43.5 percent by April 2020. In many medical offices, that utilization had increased to around 90 percent for all patients at the height of the pandemic surge. While these rates of virtual visits have receded, the long-term expectation is that virtual health will become the norm for patient visits. I am most intrigued by the set of developing technologies that will support the “virtual-first approach to healthcare,” which allows people to receive care centered on their needs rather than the needs of their healthcare providers. A steady transition toward mostly virtual care seems inevitable given the available technology and the fact that the millennials, who are the largest demographic group, are essentially technology- nativists.

For more than a decade, remote technology devices have been available to assist clinicians with doing a remote physical during virtual visits. The most popular devices included the Littman Remote Readd Stand-on scale, and Tytocare, which provides a more comprehensive ear, mouth, and heart, and lung exam.

More recently, start-up companies are developing technology that can capture biometric and physiological data remotely during virtual visits without patients needing to have any special equipment.

I was also intrigued by the recent report that showed that, with the use of cognitive behavioral therapy, a smartphone app helped patients with type 2 diabetes reduce HbA1c with less medication compared to the control group. Lastly, I am fascinated by the expected contribution of AI to the practice of medicine in general. At this point two artificial intelligence programs, including ChatGPT, have passed the U.S. Medical Licensing Examination (USMLE), the test that all physicians must pass to become a doctor. ChatGPT has also co-authored original scientific papers. I eagerly anticipate their contribution to remote monitoring. It’s clear that these and other products will accelerate the transition of clinical practice from the office to the patient’s home.