Virtual Care and Beyond: The Advent of Omnichannel Care

Omnichannel just has so much wind behind it that it will blow down the regulatory barriers.

Tune into a discussion about the recent explosive growth of the virtual care market and the potential effects on payers, patients and providers. We’ve seen a boom in this sector due to COVID-19 in 2020, and there has been a great deal of development in tools, innovation and integration even as the pandemic’s effect on care delivery has slowed in the U.S. This discussion comes in advance of our upcoming Virtual Care Market Trends Report which will dive deeper into this topic. [Scroll down for the session transcript.]

Our expert panelists:

• Alex Lennox-Miller, Senior Analyst at Chilmark Research
• Dr. Don Rucker, former National Coordinator of HIT at HHS
• Julia Millard, VP of Customer Success at BrightMD
• Mike McSherry, CEO at Xealth

High-level talking points include:

• Where are the areas virtual care can make the biggest difference today?
• Where can it make the biggest difference a year from now?
• Where do virtual care tools best fit into the provider toolbox?
• What are organizations most lacking when it comes to a virtual care strategy?
• What are the systemic or regulatory changes most needed to support virtual care strategies?
• Are the drivers for virtual care going to come from payers? Providers? Government? Patients?
• What’s going to offer the most value to providers from virtual care tools?
• What’s going to offer the most value to patients?
• What are the infrastructure and resource needs that are most necessary to support broad adoption of virtual care?

Session Transcript

John Moore III: [00:00:39] Good afternoon and thank you for joining us today for our latest roundtable session with health care leaders. Today, we’ll be talking about what is happening in the world of virtual and remote care and how virtual care is now shifting into what we are terming omnichannel care. Today’s panel will consist of Alex Lennox-Miller, Dr. Don Rucker, Mike McSherry and Julia Millard. I’ll be providing intro’s about each of these momentarily, but I want to give people a little bit more time to trickle in. We always start our webinars a couple of minutes after the hour just to make sure that people do have time to catch the beginning. And this webinar is scheduled to go for 75 minutes to make sure that we allow plenty of time for the audience engagement, as we had noticed in previous sessions that we were having to cut that a bit short. So we want to make sure that we have plenty of time to engage the attendees today. So about us here at Chilmark Research, we view it as our mission to help organizations adapt, deploy and utilize modern information technologies to improve the health care experience. That is why we host sessions like this so that we can have experts that are really knowledgeable sharing what they know with the rest of the community and disseminating that knowledge so that we can all do better and we can all help health care in America be as good as it can possibly be. We really do strongly believe that it is going to vastly change how we can deliver this care and how we can truly modernize care delivery.

John Moore III: [00:01:59] So that’s why we focus on health I.T. And if you have any questions about your own implementations, please feel free to reach out. So the agenda for today, I’m going to jump into some introductions about our panelists, and then Alex will provide a brief introduction to some of the key market trends that are taking place in virtual care today, as related to his upcoming research on this topic. And then we’ll have the brief panel’s presentations, followed by the moderated discussion, followed by audience Q&A. So, Alex Lennox-Miller, your moderator today, joined the Chilmark research team in 2018 as a research analyst specializing in provider-payer convergence. His work focuses on value propositions for HCOs and payers, particularly in the implementation and potential use cases of analytic and workflow packages for clinical, administrative and financial areas from value-based payments and population health quality, to revenue cycles and staff appointments. Alex believes that improved understanding and use of health I.T. is essential in providing the best possible care for patients, as well as improving the lives of clinical providers. Before joining Chilmark, Alex was the senior business analyst for process improvement operations at Lahey Health System, where he learned firsthand the challenges and value in implementing analytic programs and an analytic mind set in the health care setting. He’s the author of Virtual Care Management: Beyond Telehealth Towards Omnichannel Care, which provides a deep dive into the technologies, buyers and vendors which will be central to the virtual care experience going forward.

John Moore III: [00:03:22] We profiled 16 vendors in three categories, 12 product and five market measures and market value projections for established and new buyers of these products. So be on the lookout for that report that will be released probably late next week and we will definitely notify everybody that’s attending today when that is available. So next is Mike McSherry. He is the CEO and co-founder of Xealth, which enables digital health at scale, helping clinicians to easily integrate and prescribe digital health tools. Previously, Mike was the CEO of Swype–which I think we can all thank him for making our lives easier for text messages and emails on our phones–an innovative touch screen keyboard which made communication easier, faster and more inclusive and has been installed on over one billion smartphones and tablets. Mike brings with him more than 20 years of experience in the tech industry, cofounding several consumer electronics businesses, including Boost Mobile, drawing from his background in consumer engagement with electronic devices. Mike’s mission is to make digital health tools an integrated part of health care.

John Moore III: [00:04:18] Next, we’ll be hearing from Julia Mullard, who is the VP of Customer Success at Bright MD. She brings more than 15 years of experience successfully introducing new technologies to the health care industry, including in health care I.T. implementation at EPIC and in health care I.T. consulting and operational experience at one of the country’s largest health systems. Julia has led or supported more than 30 EHR implementations at major health systems nationally. She ensures Bright M.D. clinical partners achieve maximum value from their products, working with them to assure successful outcomes with adoption, engagement, clinical quality and more. She is an active member of the American Telehealth Association Policy Council and serves as president of the Oregon chapter of HIMSS.

John Moore III: [00:04:57] And finally, we have our distinguished guest today, Dr. Don Rucker, who is the former national coordinator for health information technology at the US Department of Health and Human Services, where he led the formulation of the federal health I.T. strategy and coordinated federal health I.T. policies, standards, programs and investments. Dr. Rucker has three decades of clinical and informatics experience, including developing the world’s first Microsoft Windows-based electronic medical record. He’s then spent over a decade serving as CMO at Siemens Health Care USA. Dr. Rucker has also practiced emergency medicine for a variety of organizations, including Kaiser in California, Beth Israel Deaconess Medical Center here in Massachusetts, University of Pennsylvania’s Penn Presbyterian and Pennsylvania hospitals, and most recently at Ohio State University’s Wexner Medical Center. He is a graduate of Harvard College and the University of Pennsylvania School of Medicine with four certifications in emergency medicine, internal medicine and clinical informatics. In addition to all that. He also holds an MS in medical computer science and an MBA from Stanford. So we should have a really good discussion with all these well versed experts on this topic. And without further ado, I will let Alex take it away.

Alex Lennox-Miller: [00:06:09] Thanks, John. Thank you to our panelists. Thank you for everybody joining us. I’m really excited for this conversation; I think we have a lot to talk about and a lot to cover. One of the things that we’ve seen over the course of 2020 is obviously the explosion in telehealth and a rate of adoption that I don’t know we’ve seen in any other technology in health care at a rate that is almost unprecedented, but one that we’ve been expecting for probably 10 to 15 years. As a result of that, we’ve seen a lot more acceptance of virtual care technologies probably, and a lot more interest in seeing what they can bring to bear and the differences that they can make for patients and providers. One of the biggest areas where those differences can be made is in care management.

Alex Lennox-Miller: [00:06:58] But I want to talk about not just virtual care and the individual tools that can be brought into the care management space, but the care models that they produce and the ways that access to these tools and innovation in these technologies is really bringing us to new ways to engage with patients and new models of care. When you just look at virtual care, when you look at telehealth in all of its various forms, when you look at home technology, different forms of patient engagement, different forms of data collection, all of those result in really significant improvements in care management. Certainly they give better insight into patients’ activity at home, better ways to communicate and engage with patients, and a better understanding of not just where patients are in their current medical journey, but where they might be going.

Alex Lennox-Miller: [00:07:56] However, there are also a lot of challenges to these technologies. We’ve seen that home apps don’t get the greatest use long-term. Patients don’t engage with them always, going forward. We’ve seen that patients sometimes don’t trust the information that they’re getting or don’t respond to some of the communications. And so what we’re looking at is a further evolution of this, something that recognizes the essential nature of the in-person trust relationship between patients and providers, something that recognizes that there are important and intrinsic elements of health care that need to be delivered in person. But that also recognizes the value in these tools and the incredible amount of change and difference that they can make in people’s lives. It recognizes that increasingly, people are getting care from a variety of different sources, not just from their PCP or from a health care provider, but from retail clinics, from their insurance, from their employer, that there are elements of the health care journey that aren’t even necessarily part of the direct clinical interaction, things like access to food, access to transportation that are really vital to improving the outcomes of patients, sustaining and improving their health long-term. And that can be accessed, that can be integrated into technology infrastructure, but aren’t necessarily part of that subset of virtual care. So what we’re looking at really is a bigger picture, and that’s what we’re calling omnichannel care. So why do we need it and what does it offer? Well.

Alex Lennox-Miller: [00:09:44] It gives us opportunities to make things easier, to make it easier for patients to access care, that makes it easier for providers and staff to offer care to patients, that diverts patients into the right care setting and to the right provider at the right time, so that costs are reduced both for patients and the total cost of care is reduced for employers, for payers and for health care systems. This requires a lot of work. It requires, in many ways, rethinking some of the silos or boundaries between different types of care, different types of applications, and sometimes even different organizations. It requires rethinking how patients approach their health system and how they get the kind of care that they need, not necessarily the kind of care that is most expensive or easiest. Why do we need it? Well, chronic care patients and polychronic patients make up the biggest subset of cost in health care spending. The lack of access to the proper kinds of care and to the kinds of care that address the most frequent comorbidities make those costs skyrocket. These are the patients that require the most attention, the most number of encounters or appointments, and yet their health outcomes don’t seem commensurate with the amount of work that goes into caring for them. So as we look at new technologies, new ways of approaching these patients, new ways of addressing their needs, let’s go forward and talk to Mike McSherry from Xealth. Mike, we’ve given you a quick introduction, but can you introduce people to Xealth, and what it is you guys do?

Mike McSherry: [00:11:31] Sure. Thank you, Alex and John. Mike McSherry, the CEO of Xealth. Xealth is a platform for enabling hospital systems and clinicians to digitally engage patients. Prior to the world of digital health, there were lots of pills and papers, patients that either would be given a prescription to go pick up a medicine at a pharmacy, or here’s your photocopy of some rehab exercise that’s been done multiple times over and barely legible. And we brought that into a digital fold to engage patients. And we served hospital systems as the customers and we manage their digital formularies of whatever apps, tools, devices that they think are relevant for their patient patients to engage against a specific disease management or against a surgical prep or just generically patient ed. against some new diagnoses or concern about potential diagnoses.

Mike McSherry: [00:12:29] And so what we do is we manage the formulary for the hospital systems and allow them to easily prescribe these apps or tools or devices to patients, then subsequently monitor it within their clinical workflow. So we’re deeply embedded into the EHR infrastructure of these hospital systems to allow the clinicians to recommend a digital asset appropriate for that patient, given all their conditions and criteria, as well as then subsequently monitor the patient’s engagement compliant usage of that and then bring back a benchmarking view of the digital health effectiveness for a hospital system. So we work with a number of the leading provider systems across the country. We were incubated inside of Providence in Seattle and that’s where I’m based. And again, on behalf of the hospital systems, we integrate vendors that they deem appropriate for their patient care.

Mike McSherry: [00:13:24] We’ve done a number of content vendors, the catalogs, the articles, the videos. A lot of hospital systems produce their own custom content with PDF or videos around upcoming procedures or oncology care. The apps which have the lion’s share of attention, I’d say, the diabetes management, the behavioral health, maternity care. And we’ve done a number of the perioperative, both the prep, what to bring, what to do two weeks before, stop being here and then as well as on the postop recovery of MSK, PTOT recovery. On the prescribed, as well as the subsequent monitoring, we’ve integrated a number of devices so Phillips and Resmed CPAP Devices, glucometers, RPM Platform Kits, a remote patient monitoring for those. And then in our prescribing workflow we’ve also bridged into some social determinants of health, if you will. We’ve done a number of meal delivery services, product recommendations for patients. We’ve done transportation for patients to get them to appointments or surgeries on time.

Mike McSherry: [00:14:32] So instead of digital health, in a sense, we almost digitally facilitate health and use all the proper engagement techniques stemming from my prior experience in the consumer world. And we bring that to modernize the provider digital engagement with their patient populations. Specific to COVID response and the rise of omni channel care here; this was the ordering volume that Xealth did on behalf of our provider systems. We did over four million prescribed activities across those content apps, devices and services with our hospital customers last year.

Mike McSherry: [00:15:11] You’ll see the dark blue. That was in March. The rise of COVID and the dark blue constitutes COVID-specific information. And I’ll talk about that in a second. The lighter blue is diabetes management, behavioral health prep, surgical prep. So as you can see, as the COVID-specific elements sort of waned off of the onset and then brought into the longer term trend of rising digital health tools across all the disease management and surgical prep and transportation needs for ongoing patient care directly. And we have a pretty good purview working with over a dozen of the largest systems in the country and having integrated over 50 different vendors in the very, very initial March response to covid, we stood up a number of RPM solutions specific for COVID or positive or suspected patients. Again, we’re in Seattle. Providence had the very first COVID patient and we had the first big outbreak here. And so a number of people are flooding the ERs with with cold sniffles, concerns, fevers that may or may not have been COVID, but they didn’t need to get checked in to the hospital system. So we literally prescribe thousands of RPM apps for patients to self-monitor pulse oximeter and temperature readings and bring that back into the clinical diagnoses to escalate and bring the patient in if necessary. We also did a number of Kroger quarantine kits for COVID or positive patients; you didn’t want those patients going into the grocery stores at that point in time. The second wave of COVID response was telehealth prep. Literally 95% of Americans had never done a telehealth visit before.

Mike McSherry: [00:16:59] And you’re trying to educate that 95% with how to set up a MyChart account, how to create a patient portal, how to be prepared with a video screen, be it on PC or mobile associated with that telehealth. The third wave, I would say, is a direct response to the community needs for behavioral health. There is a huge recognition of the community needs; the anxiety, the stress, the job loss, economic uncertainty. And so almost all of our customers added a behavioral health solution into the mix on enrolling patients to help alleviate the lack of clinical access for mental health specialists and services there. The fourth wave, I would say, is digital X, so every single service line now needed to think what their digital strategy was. And because there was so much telehealth, a lot of these appointments could not be correctly diagnosed or assessed without RPM added to that. So blood pressure cuffs and scale weights associated with pregnant patients, for example. And then lastly, and I think as we get into the omnichannel care, is: this is the new normal. This is going to be here to stay. What is the governance structure? Instead of digital health being a reactive response for hospital systems, how do they now contemplate how to digitally engage patients? And there’s a huge competitive threat now of the new entrants and the payers coming after providers and patient volumes. So I think you’re starting to see this set in as the new care. Thank you.

Alex Lennox-Miller: [00:18:36] Thank you, Mike. That was really helpful, really informational along those lines. That question, how do you engage? How do you interact with patients? We’ll introduce Julia Millar from BrightMD. Julia, thank you so much for joining us. Please walk us through what what BrightMD is and where you guys operate in this space.

Julia Millard: [00:18:55] Happy to Alex. So Julia Millard, VP of Customer Success at BrightMD. And I think I will start with the fact that BrightMD is improving hybrid care delivery. So to do this, we offer a virtual care solution that integrates asynchronous care with pre-visit interviews, automated clinical workflows and care navigation to improve both patient and provider experiences and drive to operational efficiency. So far, about half of primary care conditions providers are using BrightMD to treat patients fully asynchronously. What that means is that providers can treat a patient in about two minutes on average compared with a traditional 20 minute visit. And for a patient, that means tapping through an easy to use, dynamically changing clinical interview that collects all of their symptoms and more. And then they have a six- to seven-minute wait time to get a treatment plan from their provider.

Julia Millard: [00:19:53] Earlier this year, we expanded our product to include pre visit clinical interviews ahead of any type of treatment, whether in-person video chat, et cetera, as well as easy navigation to guide patients to optimal care based on their symptoms and preferences, both of which are critical for the omnichannel care that we’re talking about today. What’s exciting about what we’re seeing at BrightMD is that the right virtual care tools, that power hybrid care delivery can play a huge role in improving efficiencies and building a more sustainable care model. One of our customers, Presbyterian Health Care Services in New Mexico, they serve roughly a third of the state’s residents and are 70 percent capitated. They’re realizing clear value through BrightMD across a variety of key metrics. And because efficiency is so important for them, I’m going to share one of their case studies.

Julia Millard: [00:20:46] So last year, a small designated group of employed urgent care providers handled fifty thousand asynchronous visits for low acuity care and spent an average of two minutes on each encounter. I’m not going to do the math, but imagine what that would equate to, right? Of those, fifty thousand had come in and needed twenty minutes of provider time per. This also led to a reduced workload at their onsite urgent care centers, decreasing both the time and expense of urgent care staffing, and I think one of the keys for us is that the providers love our solution, so it’s a delight for them to be able to deliver care this way.

Julia Millard: [00:21:24] What sets us apart, truly, is our clinical content. It’s evidence-based, updated regularly. According to the latest guidelines, the interview is available in both English and Spanish with a medically certified translation. And all of our content is created at a very basic reading level, removing any medical jargon and using images as guides for patients. So we’re consistently hearing from clinical teams that our interview is more thorough than any they could produce and replicate on their own. One of the clinical champions at a customer recently shared that he reviewed all of our content in detail and was, quote, “extremely impressed,” adding that it would take thousands of hours of clinician time for them to even attempt to recreate it.

Julia Millard: [00:22:08] So that is our sweet spot. What we’re learning from customers in terms of designing that optimal efficient hybrid care delivery model is one with omnichannel care. It’s key that you find the right balance between offering patients choice that respects their preferences and then nudging them to the recommended modalities or venues of care based on their condition, time of day, expected cost, et cetera. Two, it’s also critical to map the consumer-patient journey as you’re designing that omnichannel care experience, and that includes the third point, which is really taking into consideration those on and off ramps for patients. How do they easily transition from one modality of care to another and have that be seamless as possible? And a key component of that is the last point that you see here, which is going to be that ability to write or push data in a structured way to the EMR. And that’s not just reading or pulling it; that is table stakes. The last thing I think any of us wants is to further fragment health care in the US. And key to not having that happen is getting the [00:23:15] data where it needs to be in the patient’s chart. [00:23:17]

Alex Lennox-Miller: [00:23:18] You guys are giving me really fantastic transitions, one to the other. The last member of our panel, Dr. Rucker, you are probably responsible more than anybody in the country for building the infrastructure and the rule sets that enabled this kind of care to enable these kind of solutions, the data on interoperability standards, data transparency and being able to really bring a level of cooperation and market forces to bear within health care. Thank you so much for joining us.

Don Rucker: [00:23:53] Yeah, thank you, Alex. I think we’ve just seen two wonderfully intriguing approaches to a modern vision of health care. And I think it is exactly what we’ve seen from Xealth and BrightMD is exactly what Congress had in mind back in the end of 2016 when they passed the Twenty First Century Cures Act, which really has given a legal framework to all of this. What Congress realized, and this has been very bipartisan–was passed almost unanimously and supported by both administrations heavily–is if you’re going to have all of these things, ultimately the data has to be at somewhere under the patient’s control.

Don Rucker: [00:24:40] So the patient needs to be able to have access to their data. And it’s not just to visualize it, but it’s actually to have control of it. If we’re going to get the full app economy and its full integrated bloom, if you will, the patient needs to control that data. And so Congress put into the Cures Act sort of two provisions. One is that there shouldn’t be information blocking. So that established in a simple kind of way the right for the patient to get at their data. Obviously, lots of details. If you go to healthit.gov, you can see our handiwork over the last number of years and putting that into ONC Twenty First Century Cures Act interoperability rule.

Don Rucker: [00:25:29] The other part that really is fundamental from a legal policy point of view is standardized APIs. We’re not going to have useful electricity if everybody’s wall socket is different and everybody’s appliances are different. So Congress said there should be application programing interfaces without special effort. What I think that the march of technology and evolution, we know we we all see that.

Don Rucker: [00:26:00] But what’s worth noting for the audience is that these modern API tools–so Restful, JSON, APIs–you can Google them if you have a little bit of nerd anxiety about what what they might be. But suffice it to say, they’re sort of the building blocks for communications behind pretty much every app that is out there these days, in some greater or lesser part. Those APIs are now required by effective end of ’22, ’23, depending on the exact data payload for providers to make available to patients. So we think that’s going to be very transformative. What’s also happened in health care is the advancement of FHIR technology. So FHIR spelled F-H-I-R, fast health care interoperability resources. There won’t be a quiz, but you’ll hear it’s like what they told us in med school. If it’s important, you’ll hear it ten times. That gave us all hope that that lead actually maybe learn all the stuff. Well, FHIR sort of fits into the same category. You’ll hear about it lots and lots. But that is the glue for omnichannel because ultimately, omnichannel approaches need lots of information sharing to make that seamless consumer experience. And Julia sort of put it as table stakes, but the table stakes have a fair amount of technology with them, and that’s out there, what we’ve seen in this last year with the pandemic is the willingness of CMS basically said we’re going to pay for telehealth and how that plays out. I mean, telehealth has been around for a long time.

Don Rucker: [00:27:55] The reason it wasn’t paid for in scale before was because of CMS concerns about moral hazard. And, you know, but you’re going to see a refinement in how we pay for this. And I hope one of the big ideas, obviously, is today in America, health care is largely paid for on an outpatient basis by zip codes, kind of procedural terminology code. That’s a licensing system of coding owned by the AMA. And I think as payers, as systems policy makers, we’re going to have to really think about–is that format with these sort of game codes really the best way to get to unleash innovation in health care? Right. That’s a very, very tight filter that I think a lot of people aren’t even aware of, the amount of filtering of the services that are never provided, never imagine because of that. So I think there’s certainly work to be done on the reimbursement side. But as consumers are forced to get control with high deductible health plans, we’re going to see this. It’s quite exciting. And I’m very optimistic that if you look a couple of years down the road–I won’t say the exact number of years that gets you in trouble, I thought EMRs were going to be addressed 30 years ago, so my predictive powers are limited–but I think we’re going to see the level of consumer engagement in their personal health to all of the devices, all the apps that we’re seeing in the rest of the economy. So I think omnichannel just has so much wind behind it that it will slow down the sort of regulatory barriers.

Alex Lennox-Miller: [00:29:50] The question of reimbursement is so central to this. And it’s a question that a lot of people ask. How do we turn this into something that that is meaningful for our patients, that is meaningful for our organization? Mike and Julia, I’m very curious from your perspectives as people who have actually had to deploy these these tools into health care organizations, have you seen the different reimbursement modes that exist, whether it’s fee for service, value-based care capitation, or how have you seen them affect the willingness of organizations to adopt virtual care tools? Where have you seen it? Maybe incentivize the organization depending on the contracts organizations have.

Julia Millard: [00:30:37] I think Alex and Don, so great questions and great points, what we’ve seen with with asynchronous care specifically is that it’s essentially two flavors. Whether you’re working in a model where you’re completely value-based or you’re sitting in fee for service. And I think I’ll start with the difference for the patient. So if you’re in a capitated arrangement, most often asynchronous care comes at no cost to you because there’s a really strong alignment within those models of care to lower the cost of care, while still maintaining the quality and using asynchronous care to alleviate the access challenges that often exist right across the board within health care. And then on the fee for service side, because there isn’t an exact match on a zip code like Dr. Rucker was just articulating, what we often see is that it’s the patient who is then paying twenty, twenty-five dollars for that visit because there is no good way to submit it for reimbursement without that CPT code. So this is definitely, I think, an issue that hasn’t so far impeded innovation, but maybe it’s impeding the rate at which these new modalities and venues of care are being adopted.

Mike McSherry: [00:31:53] I would speak as well to that, and I think it does fall along the fee for value versus fee for service kind of segment. Again, we’re agnostic to what our hospital systems choose to deploy for their patient populations. And almost all of our customers will adopt maternity care. They care about the pregnant mom, the lifetime customer value, the CEO, the medical household medical spend. There are a lot of justifications for attracting and retaining that mom and then the subsequent family into the care provision of that hospital system. They will digitally engage patients around surgical prep and recovery. They have penalties for readmits and it’s intensive with all the information needs and preparation and much less a patient not even showing up, either prepared or showing up at all for a surgical procedure. So they want to make sure that the patient is is arriving on time and prepped.

Mike McSherry: [00:32:49] When you get into chronic care, though, on patient populations–and you had a slide to that out earlier, Alex–that’s the high cost component, but to hospital systems, they only get paid to treat that patient more. So there’s a perverse incentive actually to see that patient more, not digitally engage in preventative measures with that patient.

Mike McSherry: [00:33:09] So the poster child of digital health success, Livongo, if you will, very, very few hospital systems are prescribing that to the patient because they don’t get reimbursed for that level of activity, much less holding the capitation exposure for that patient population. So where we’ve done much of our chronic care app distribution, it’s lined up against hospital systems on an employee base where they’re limited on ACO structures, but not for the broad based patient populations. We did see that jump the shark against the behavioral health that I referenced earlier, but that’s the first broad based chronic care app distribution that we’re seeing across our hospital systems, whereas most are still in sort of pilot modes or against their limited capitation exposure. So I think bringing the reimbursement into the provider ecosystem is going to change behaviors, as we found in everything in the US health care industry. And I can address the competitive dynamic of where payers are more aligned and now how they’re trying to get in care delivery as well. So that’s going to cause some burden on provider systems, finances and at least pressure in the future.

Alex Lennox-Miller: [00:34:25] That’s also a really interesting topic. And along those same lines to the question of omnichannel care and where is care being delivered from, how much are you seeing? Distribution of different resources, different tools from payers, employers and sort of alternative sources.

Mike McSherry: [00:34:48] You talk about digital health. I mean, the consumers. There’s four hundred thousand health care related apps in the app store. Obviously consumers that found value across a multitude of apps, treating whatever nutrition or exercise management or stress or karma or whatever. So consumers are finding value in even paying out of pocket in many cases for those level of apps. Payers and employers have all adopted digital health, the PBMs that followed suit with their own “formularies” of tools that they think are beneficial for patient care.

Mike McSherry: [00:35:24] Hospitals systems have been the laggards in adoption against that. And I don’t think that’s lost on anyone and a lot of it is just due to the structural incentives with lack of reimbursement against a fee for service model towards that. But we all recognize that 99% of health is outside the walls of the clinical visit, so how do you subsequently engage the patient in more preventative, healthy lifestyle choices and then remotely monitor the patient to potentially risk intervene when when some of that data is falling outside of safe ranges? So RPM plus prevention is what’s really going to drive transformation in the US and the cost of the US health care industry.

Alex Lennox-Miller: [00:36:09] We’ve gotten a question in the Q&A, it lines up to a couple of questions we we received ahead of time. So I’m very curious to hear all of your reactions to this. How do presenters see virtual and omnichannel care playing into the safety net for people where there’s a strong digital divide and most providers are still stuck in the fee for service model? That’s from Jennifer. And we also got asked ahead of time, how do we address Medicaid and low-income patients virtually when they have a lot of inherent barriers? There are generally more infrastructure barriers, technology barriers. How do we make sure these are addressed and that some of these patients who, again, when you look at the numbers, are some of the highest new patients, some of the most expensive and difficult patients to care for, are being included in these kinds of digital transformations?

Julia Millard: [00:37:12] I think it’s a great question and maybe I’ll start and then others please chime in. I can’t speak for all modalities of care, but at least on the asynchronous side, I think that’s something that we really lean into with the digital divide. And I think that’s a difference, too, to highlight between asynchronous and video where you do need a fairly strong Internet bandwidth. Right. Like today I had to make sure I was hard wired, that we didn’t lose connectivity. And that challenge exists if you’re trying to do a virtual visit. So it is absolutely there. And I think that’s where some of these other maybe kind of less bandwidth intensive tools actually can work to serve the underserved communities because you don’t need that strong Internet connection. You maybe need a cell phone with 3G coverage. And that truly is what is needed to go through from the patient’s perspective, our clinical, adaptive, dynamic interview. So we think there’s potentially pretty strong alignment and opportunity there to bring these types of tools into the hands of those who don’t have access today yet to that really strong Internet connection.

Mike McSherry: [00:38:21] As we talk to Julia, I agree with you. And as you talk through the digital divide, the poor and vulnerable, oftentimes their cell phone is their only digital connection. They don’t have laptops. They don’t have desktop machines. It is their phone and that is the lifeline. So even SMS can be can be a strong driver of engagement, whereas snail mail can’t reach these people in other kind of tools. As you continue down that thread, though, on Medicaid, I referenced that we’ve done a number of almost SDoH, social determinants of health services. We’ve done transportation specific for Medicaid patients. Some of the meal delivery services had a bifurcated approach and differentiated product offering against Medicaid populations. Some of the maternity care, I think over 50 percent of the children born in America now are due to Medicaid coverage and some of the maternity apps that we enroll patients in to do different segmentations of the available resources under Medicaid coverage for for those expectant moms. And so there’s a lot of information that’s there. But it’s it all goes back to the economic incentives in the reimbursement structures. I think CMS, both the Medicare as well as Medicaid, can be a huge driver of what the incentives are on the prevention as well as the engagement against these populations, because again, in this country, nobody pays for prevention. It’s all reactive care for the most part. And and I think if there’s a broader based coverage around some the preventative measures and the remote monitoring asynchronous engagements, you’d see a lot of overall cost reductions over the long term, I’d say.

Don Rucker: [00:40:12] Yeah, I think those are great points. I think, you know, first, the government policies in general that take care of folks who cover this population really have remarkable little computerization. So you can go up and down the elevators in the Humphrey building, which is where the Health and Human Services is and where they’re spending over a trillion dollars on health care and related services. And there is almost nothing that you would recognize as customer relations management. We’re talking about advanced things here today. Our federal agencies don’t even have the most basic sort of tools to help manage this population. That’s a huge, huge gap to really think about. And, you know, think about the electronic health record sort of on steroids type of thing. That’s ultimately some of what may be needed just from from a programmatic point of view. I think as patients gain agency over time, hopefully with these application programing interfaces that will allow this population to, as Mike mentioned, use their cell phones more effectively. I think we’re going to–I think that’s inevitable. As somebody who’s done a lot of inner city medicine, almost everyone has a cell phone these days or some some member of the family unit, as it were, even a lot of homeless folks.

Don Rucker: [00:41:53] I don’t know how they charge it, but at any rate, they have they do have cell phones. And then I think the other thing that is worth pondering here is as patients gain agency and as they gain consumer control, I think that’s going to put pricing pressure on some of the most efficient things because that, you know, it’s the price levels that are really ultimately preventing a lot of care in America and the mismatch of prices to services and as market forces. And maybe I’m just being an optimist here and I’ll plead guilty to that. But I think as market disciplines creep back into health care, where they’ve essentially been absent since the 1940s to World War to Stabilization Act and to other laws, we’re going to see lower prices. And that is empowering for all consumers and most especially the poorest consumers. So I’m optimistic about this. It’ll come in probably a different way than many of us are expecting.

Alex Lennox-Miller: [00:42:59] That’s a really fascinating question to me. And I think a lot of people sort of waver back and forth on where should the pressure to make some of these changes come from? You know, as Mike said, CMS has a lot of power to change and adjust policy. They can do it with a light and or a heavy hand. Certainly, we’ve seen Medicare Advantage plans grow as a proportion of Medicare beneficiaries and those changed the incentive structure have a lot more opportunity to offer this kind of care and incentivize it a lot more. Is this something that we should be looking to increased regulation or increased rulemaking on the government level to try and make some of these changes? This is something that, as you said, Dr. Rucker, will come from increased consumer power within the marketplace, or is this something that health systems and providers should be pushing simply because this is a better way to provide care and improves outcomes for patients?

Don Rucker: [00:44:02] Probably be all of the above, right. I mean, CMS can do some things under executive branch authority, obviously. Arguably, they could do more right now with the executive and the legislative branches in the same party control. But I think it’s going to come from all of the above. I think we have to think about what, you know, the economic incentives are. And ultimately, patients have to have more control over their money that is being spent on their behalf. And these things will happen. It’s sort of happening in a very odd kind of way because a lot of large employers are walking away with high deductible health plans. So if you look over the last 25 years, most of the economic growth the United States has, actually much of it has shifted into health care costs, certainly for the American middle class in terms of a wealth effect. So in other words, no wealth effect because it’s gone into higher health care costs. And I think if consumers had more control over those dollars, I think you would find very different payment plans and I think you would see the app economy explode because ultimately there’s a lot of complexity here. I mean, I looked at my slide of all the apps that they can prescribe today, and there’s a lot of stuff on that slide. But there’s a lot of apps, a lot of illnesses, a lot of approaches. So that that’s what happens in consumer markets.

Mike McSherry: [00:45:55] If we’re talking about how to change the US health care industry and the new dynamics and it will bridge back to omnichannel. I’m going to go out on a controversial limb here, but there is there’s been a cozy duopoly here or oligopoly between payers and providers. Providers raise prices, payers pass that along in increased insurance or insurance premiums. And either the government’s been paying those higher bills or employers have been paying those higher bills. Now, government has started slashing Medicaid and Medicare reimbursement rates so that employers get hit with these higher bills.

Mike McSherry: [00:46:30] The rise of digital health and telehealth now has allowed a lot of these employers to really, really seek cost containment measures and more virtual tools to reduce some of that cost burden. I think in light of the telehealth that just happened here, hospital systems lost billions of dollars, hundreds of billions of dollars in revenue last year in lost procedures. The payers pocket that in profits and now the payers have national scale. And telehealth is–at least virtual primary care–and then referring to disease management of diabetes and apps and tools and COPD and hypertensive and etc., you’re now seeing payers start to more aggressively build national virtual care offerings, buy more retail provider care, and bring the fight on cost containment directly to the providers. So I think whereas the payers have been living in a cozy duopoly for a long period of time, they’re now going directly competitive against providers and they’ve got an economic model that works in their favor. So I think providers are going to have to figure out lobbying as well as a new virtual omnichannel, more asset-like care delivery model than than what they’ve been living in in the past couple of decades, that they’ve built up more clinical volumes and in buildings.

Alex Lennox-Miller: [00:48:01] Julia, I’m going to give you the chance to get the last word before we go to the audience Q&A.

Julia Millard: [00:48:06] Yeah, I think Dr. Rucker and Mike summarized it really well. Maybe the only point I would also add is in addition to the payer networks and coming out of that duopoly, which I think was really well stated, Mike, I would bring in the competition that both payers and providers are also facing from direct to consumer players. And I think if done right, there’s an opportunity for the traditional health care players to actually come together to provide a more holistic offering, especially in terms of the omnichannel strategy, than what any direct to consumer company could potentially offer independently or on their own. So that’s something that I think the more we can see the traditional players leaning into, the better they will be able to compete against that righteous ease of what we’re seeing in the direct to consumer landscape coming forward to disrupt how care is delivered.

Alex Lennox-Miller: [00:49:01] We’ll start moving on to the audience, too. And if anybody out there ask questions, please feel free to put them into the chat. We’ll start off with a question you received ahead of time. How do you expect the consumer patient experience to change as we see more adoption of this technology? And I’ll add another add on to that. How do we expect the providers experience to change?

Mike McSherry: [00:49:26] We sometimes liken Xealth to the SureScripts of digital health, if you will, and for those who don’t know, SureScripts is the prescribing platform for most of the med distribution. When the doctor clicks, I’m going to prescribe you X and it shows up at the Walgreens in the corner of Third and Broadway. It’s SureScripts that aggregated that. And so on the clinical efficiency side and adoption side, we think we’re bringing that clinical efficiency to providers to easily enroll patients into these tools, the clinical decision making as to what tool is appropriate for that patient, and then the subsequent monitoring, but not just 24/7 monitoring. How often do I need to look at this? Only alert when care intervention is necessary in the clinicians to find that PHQ9 Depression score reading above X or this A1C is trending in this wrong direction, or X, Y, Z. So we’d like to think that we alleviate clinical burden. And as much as instead of clicking a button like a med to prescribe a medication, the doctor actually has to click and sort of sign and give their credentialing authority to that medication.

Mike McSherry: [00:50:42] Much of digital health gets prescribed under an automation routine if a patient fits this clinical criteria. Then you can auto enroll them in the solution on your behalf without needing to click buttons. So that’s one element of the clinical side that we try to solve. On the patient side, I mean, they’re all consumers of technology in their personal lives. The health care system has been integrated. Much of health care delivery, I liken it to the lowest common denominator–just because not 100% of all patients have used an app on their phone, we can never prescribe an app! We have to make a phone call. We have to give someone a piece of paper. And that’s not how the world works. You mass market, you meet the needs of most and then you deal the exception on those that don’t have the capability or tool or access. And so I think what we’re trying to just do is bring a more modernization effort to consumer experiences that they have in their consumer lives, just not in their health care lives.

Julia Millard: [00:51:45] I would absolutely echo that last point, Mike, that you just made. So from that patient experience perspective, and when we look at the omni channel strategy and all of these different tools and ways of delivering care that are coming to the forefront, it’s recognizing and understanding that we’re not forcing patients into any one of those. But really, I think it’s an opportunity for the patients to strongly express what their preferences are and kind of force the health care system to deliver care in the way that they need that care to be delivered. And really, I think meeting them where they are.

Julia Millard: [00:52:21] On the provider side, we also, I think very clearly with BrightMD, we cannot overburden our overburdened providers with all of these new tools. So I think they’re already at a tipping point to some extent, or maybe they’re beyond it. And so one of the things to me to be successful with this virtual care strategy and omnichannel care, there is still in most, if not all cases, the provider on the other end of those tools. And how do we make sure whatever we’re bringing forward with new technologies is also working to decrease kind of the onus of the provider in learning that new tool, incorporate it into their existing workflows, removing some of the administrative burden that exists for them today and giving them the ability to truly practice as close to the top of their license as they can get. I think that is where we’re going to see hyper adoption of an omnichannel strategy is that when the providers start to feel like it’s making their day easier and they can really focus on, I think, what brings them to work every day, which is caring for the patients in the best way possible for them and not having to become clerks or doing administrative tasks that are unnecessary.

Don Rucker: [00:53:41] I think that the part of what this whole technology is going to unleash is actually much, much richer diagnostics at a much earlier, we today have the ability to prevent a lot of cancer and cardiac disease and stroke, which are the big things with modern diagnostics and potentially very low price points when you think about the implications of what you’re buying, but for a variety of reasons, haven’t used those haven’t incorporate those part because people are paid for acute care. I think as people go in, they’re going to think a lot more about, you know, a 50 or 70 dollar cardiac angiogram that’s going to let them know whether they have plaque or stroke risk before their heart attack. You know, these blood tests that have literally hundreds or thousands of analytes in them. We’re able to do these things: we just haven’t. And I think when folks realize that, there are going to be all kinds of tools so that the diagnostic interplay between the patient and the app is going to be vastly enhanced in the entire spectrum is going to be moved 10, 15 years earlier in disease, which will have obviously profound preventative effects, as Mike pointed out, not paid for now. But people realize how inexpensive it is. They will, you know, many of the folks will buy it. That’s on the patient side.

Don Rucker: [00:55:28] What I suspect will happen on the provider side. It’s very interesting, having been a member of the guilds, a number of the guilds and trained the guilds and trained within the guilds and train the next generation of the guild where we are just as medical specialties. And I’m not just talking about doctors, I’m talking about nurses, OT, PT, the often mimeo sheet that was mentioned of instructions. We just have absolutely no idea about the kind of workflow redesign that somebody like Jeff Bezos shepherded in changing retail. Those are businesses to be started and grown. And we’re going to have to, among other things, rethink the software stack we use in health care. The EHR, which grew up as a tool for documentation. And getting a higher CPT code is a distant cry from what modern enterprise and consumer grade software should be. You know, I’m pretty positive and I don’t know the technology stack at Amazon and probably a thousand things if you look at their website, but I’m pretty sure they’re not using mumps as thick as the guidepost for their technology. So I think we have to rethink a lot of that. It’s going to be wrenching for providers as these things are reengineered and as all that knowledge that most provider knowledge, I believe goes to waste and to actually utilize that provider knowledge to help patients is both a challenge and an opportunity. It’s going to be quite the ride.

Alex Lennox-Miller: [00:57:29] We have a very interesting question from Robbie, asking about how do individual medical professionals survive the costs of these transitions? I imagine that applies to small clinics. It probably applies equally to independent hospitals. And I think the answer may partly lie in another question from John Moore. Will VBC be the primary driver in the future for this adoption? Is the answer that these smaller practices might need to switch up how they do their billing and where they get their revenue?

Don Rucker: [00:58:05] The solo practice model or the small practice model? I mean, as romantic as it is and as Norman Rockwell as it is, doesn’t really make sense for an industry that’s as technology-driven as health care is, and will be even at its behavioral aspects of consumer experience, let alone the raw molecular biology type of things. Part of it’s like Vermont dairy farmers, they’ve had price supports to subsidize inefficient workflows for a long time, going back into the 1965 usual customer and reasonable fee schedule adoption, which was the original CMS payment scheme. And I think in modern market based payment schemes, some of these models don’t make sense. They simply don’t make sense. It’s unfortunate, some kind of sense, but that’s the likely outcome of this. It’s a challenge for all of retail, by the way. I mean, this is no different than your independent bookstore, your independent plumber, your independent diner. I mean, it’s a challenge for everybody who’s running bricks and mortar.

Mike McSherry: [00:59:34] I think, as Don said, CMS requirements and reimbursement digital engage patients. For an individual practitioner to have to maintain that full technical infrastructure for reimbursement just doesn’t make sense. And that even stands against the small independent hospital system that are getting consolidated into the larger systems. And so I think much like lots of the US economy, it’s been driven to scale. And where you get differentiation is in the boutique elements, if you will. And there’s lots of concierge higher-end kind of services that are that are proliferating, that can provide more handholding, custom patient, customized patient experience. But it’s tough to keep abreast of the technology requirements in the modern world without a broader degree of scale.

Mike McSherry: [01:00:31] And if you take that even further, hospital systems themselves have geographic scale, but not national scale. And that goes back to the payers. And talking about complete omnichannel care experiences and telehealth, the payers are pocketing billions of dollars a year in profit and they can reinvest all of that into digital technology and solutions, whereas hospital systems run on much, much thinner margins on a geographic kind of scale. So, you know, even provider systems are going to have a broader competitive dynamic against where some of the national players are today.

Alex Lennox-Miller: [01:01:08] We’re reaching the end of our scheduled time. I’m just going to ask each of you for a quick answer to one more question. What is the most critical success factor for an organization looking to deploy these kinds of tools? What what do they need to be developing or what do they need to be putting in place now to see the best possible results?

Mike McSherry: [01:01:29] First off, it’s organizational leadership. Health care has died by the pilots. Some clinician in a somewhat random clinical setting says, I want to do X and they’ve got the budget to enact that. But to do digital and omnichannel care and kind of have a coherent care strategy across the patient population in the region, you really need organizational leadership and commitment and adoption to it and driving it at scale in sort of a standardized manner across your organization, you using technology, you can deliver customized personalized experiences to individuals based upon their care needs, but you need a common technology foundation in order to attain that level of efficiency.

Julia Millard: [01:02:17] I would absolutely echo what Mike said and then really lean into mapping and understanding the different consumer and patient journeys for your population. So as you’re introducing these new tools, especially in the digital space, how do they interact with one another? How do they hand off? Handoffs are notoriously difficult. And now we’re asking for handoffs in the digital world across multiple modalities of care that that absolutely has to kind of all come together and be as seamless as we can make it for both patients and providers.

Don Rucker: [01:02:49] I would blend those things as well and say that. Certainly hospital C suites and CEOs have to engage in active management of this as a line of business, it’s a little bit alien to them, frankly, and so do they set up a couple of experiments, who are they going to have working these things on a day to day basis? Early tools are absolutely out there today to do these things. We’ve just seen this. But I think in a delivery system, certainly I have to say one way or the other, this is going to happen and we have to make a conscious effort to do it. It should not be; were you able to get a sales call with the CIO who’s looking for, you know, three projects to report at the next quarterly staff meeting? It really needs to be driven by a more conscious approach to learning. And, you know, if a CEO doesn’t have that within themselves, you know, most of the folks have hired or have some type of growth officer and they should empower these people. You know, it’s sort of similar–I was reading something yestereday–about unempowered chief data officers and that the average duration is under two years and their lives are to, I think, quote, Hobbes or something–nasty, brutish and short. I’d have to look up where that is. But I think it’s Hobbes from hundreds of years ago. You just have to have the moxie to invest in this and imagine a world that is different than just having your next cardiac or spine center of excellence and relying on that business model. So, yeah, and if there are people out there who can help you with that, you know, we have folks on the call here who fit that bill admirably. And that’s what I think CEOs ought to think about.

Alex Lennox-Miller: [01:05:00] Well, thank you so much, all of you, for joining me today. Really appreciate your perspective. We really appreciate your insight. Thank you for everybody who was listening. If you would like to continue the conversation, you can feel free to get in touch with me, at alex@chilmarkresearch.com. If you are from a provider organization and you’d like to discuss this or like to learn more about our research, we do offer a lot of our content for free to provider organizations. And you can get in touch with me to discuss that. Mike, Julia, Dr. Rucker, thank you so much. I hope everybody has a great day and I hope that this was as informative and helpful to the rest of you as it was to me.