Who delivers chronic care?
A recent webinar Primary care vs. chronic care: what’s the difference? Can they co-exist? brought up several points that resonated with me:
Large patient panels compound the growing burden of illness that can only be dealt with a new hybrid model of care with a 24/7 virtual multi-disciplinary team. Longitudinal care with best intentions in the current model is reaching capacity challenges and has plateaued in terms of impact for patients.
Majority of patients start their healthcare journey on a search engine because it’s on demand and it’s free. Digital health consumers do not have to be forced to choose in-person versus virtual care. When done right, it facilitates the realistic need for having both and ensuring smooth transitions of care.
Connected tools give us a richer data set on what happens outside of the doctor’s office. Giving actionable data points without overwhelming primary care providers is a priority.
Healthcare workforce is excited about incremental changes, not disruptive changes.
Tough to see ROI on digital health interventions in one year, especially for lower acuity patients. Need to plan for 3-5 years. Employers and payers do not share the same time horizons as community primary care physicians.
Need a real-time data system that examines when quality care gets delivered as opposed to the status quo way of prompting feedback by suboptimal outcomes.
Does digital health save healthcare costs or increase them? The million dollar question.
With much discussion about evolution of chronic care, it’s worthwhile to appreciate some takes on primary care from different stakeholders in the industry.
Bryce Platt, PharmD is a pharmacist that has created multiple programs that utilize pharmacists to enhance patient health and lower healthcare costs. He has experience in Medicare, Medicaid, and commercial programs, with a focus on quality improvement efforts including HEDIS and Star measures.
What role do you see pharmacists play in the delivery of primary care in the coming decade?
Pharmacists are moving into a more clinical role in the community, primarily in chronic care management. Pharmacy schools have been teaching chronic care management for almost a decade now. Over multiple semesters, students are taught how to decide what new medication or medication adjustments should be utilized for optimal management of the chronic condition when provided the diagnosis and full medication list. These skills are going mostly unutilized by pharmacists in retail pharmacy, even as there is a shortage of primary care physicians.
What are the roadblocks? What are the unrealized opportunities to make your vision even better?
Paying pharmacists for clinical services has always been the biggest barrier. Pharmacists are not currently categorized as “providers” by Medicare, so they can’t receive payments for these kinds of services. Some states and private insurance have started paying pharmacists for their clinical skills, but those are the minority. This is why pharmacist professional organizations have been pushing for “provider status” in Medicare for decades. The data is already out there on the great ROI pharmacists bring to healthcare.
What’s one resource you wish you had to make this happen faster or on a larger scale?
Support from primary care physicians and the AMA would be huge for making this transition quicker. The AMA’s position has long been to protect physicians from encroachment on their careers (see opposition to PAs and NPs), but with the shortage of primary care physicians and increasing need for chronic care management in an aging population, pharmacists can be the support to physicians that allows them to focus on giving the best diagnoses and care to their patients.
Yair Saperstein, MD, MPH is the Co-founder and CEO of AvoMD, a no-code platform for building and using trusted clinical decision support. He is a physician with dual board-certification in internal medicine and clinical informatics.
What role do you see clinical decision support (CDS) companies play in the delivery of primary care in the coming decade?
Clinical decision support has classically been thought of as “alerts.” As the clinical informatics literature shows, 98% of alerts are dismissed with no intervening action by the physician. Thus, clinical decision support companies are now going beyond alerts to truly help clinicians make decisions – guiding them down algorithms, interpreting labs and offering suggested differential diagnoses, helping them know which medications to prescribe based on the patient’s insurance, and generating documentation, orders, and labs as needed.
CDS companies will enhance the delivery of primary care for clinicians. Primary care providers are at the nexus of clinical care, and are therefore expected to have a broad knowledge base of the specialties. Now that we are in 2 PCE (Post-COVID-era), many primary care providers I have spoken with relate that their patients’ primary complaint is mental-health related, and that they wish there were more support in knowing how to treat these patients. With new diseases emerging (ex. monkeypox), and primary care clinicians always on the front lines, we need to empower these providers to be knowledgeable in emerging diseases. The next decade will only bring more. Regulations will increase that require the use of these supplementary systems that are increasingly showing the ability to allow clinicians to deliver better care. In addition to efficiency gains for the interaction, improved diagnostic efficacy, and improved outcomes, true clinical decision support allows for improved shared-decision making, with both provider and patient better informed in making decisions.
Finally, as the democratization of information becomes more widespread – including making guidelines freely available and accessible, allowing patients access to their own data and control over how it’s used, and putting the two of these together – clinical decision support companies will allow for patients to autonomously take control of their own healthcare.
What are the roadblocks? What are the unrealized opportunities to make your vision even better?
EHRs are still the central area of physician life. It’s a sad reality that clinicians spend more time in front of the computer than in front of the patient, and this centrality has stilted innovation, as everything built has to integrate with this mainframe of current healthcare delivery. While many CDS companies integrate with EHRs, it might be more innovative to work outside. HIPAA regulations as they are currently implemented ironically restrict sharing of patient data even when patients truly do wish for it to be shared.
Many CDS companies and innovators in healthcare are working together. Startup Health and Health Tech Nerds are two forums that I highlight that foster collaboration for even more innovation.
What’s one resource you wish you had to make this happen faster or on a larger scale?
Having the backing of the WHO/CDC can help push this forward.
Rachel Menon, PA-C is a Senior Clinical Director, Innovation and Technology at Buoy Health and has been a health tech product development leader and Physician Assistant of 10+ years with clinical expertise in Family Medicine and OB/GYN.
What role do you see digital health companies play in the delivery of primary care in the coming decade?
There’s no question that primary care is an integral part of a patient’s journey. In fact, it’s been proven that patients who have interaction with a primary care provider (PCP) actually receive higher value care. Nevertheless, we’re seeing fewer adults engaging with the sector. So the question becomes, how do we think out-side-of-the box to ensure primary care and its delivery is suitable for all - both those who yearn for the traditional continuity of care and those who prefer a more non-longitudinal interaction? We must marry innovations in health tech with the 4 C’s of primary care for a virtual hybrid and brick-and-mortar approach: first contact, comprehensive, coordinated and continuous.
Keeping in mind the numerous barriers to healthcare access, including convenience, finances, and emotional and cultural factors, the best care solutions will engage individuals at the point of acute care, educate about the benefits of primary care receipt, and enable comprehensive, coordinated and continuous care. Now, with so many “front doors” to healthcare, patients need a way to simplify the experience. The right technology should be able to serve up the best care option for someone based on their needs at a specific moment in time, regardless of symptoms. For example, health tech company Buoy Health has a marketplace approach to offering care solutions that includes vetted virtual-first primary care options like HealthTap, but also more hyper focused solutions like Paloma Health, for hypothyroidism. A marketplace approach like this could allow an individual to achieve the right “portfolio” of care (primary and specialty; virtual and in-person) to achieve comprehensive and longitudinal care coverage.
While much care today can be delivered virtually, the need for in-person physical care, via hybrid health tech companies and traditional brick-and-mortar, will always exist. In fact, a recent analysis by Chrissy Farr, Omada Health, and Komodo Health evaluated in-person vs. virtual care on an annual basis and came up with a suggested 30/70 percent split. That is, roughly 30% of services patients receive in a given year are feasible virtually. In response to this publication, the physician founder of Sherpaa, virtual primary care company acquired by Crossover Health in 2012, stated that “80% of their 500,000 visits never needed to be seen in-person.” While more information about the methodology in arriving at these figures would be helpful, I strongly suspect that more than 30% of adult primary care is feasible virtually. For preventive and chronic care management, much screening, testing, counseling, and guidance can be delivered or coordinated by a virtual care team. For common new problems, a diagnosis can often be made on history alone without the need for any physical services, like exams or labs, to establish the cause and develop a treatment plan.
What are the roadblocks? What are the unrealized opportunities to make your vision even better?
With so many care options and the lack of clarity from the typical consumer’s perspective about what the most appropriate care venue is, patients need help deciding the best way forward for each unique circumstance. Buoy’s marketplace operates to help patients understand when something can be treated virtually or when it’s time to be seen in person; then navigate them to the best care option.
There’s still a ton of work that needs to be done on the interoperability front to achieve a comprehensive and continuous care “portfolio”. Over the past decade, the big push has been (without much success) on making electronic health records more interoperable - we’ve seen large sluggish brick-and-mortar organizations spin wheels without much advancement on disparate systems. On a more positive note, there have been promising organizations popping up like Commure focused on building bridges for these systems to unify critical data to keep clinicians and staff connected, protected, and productive in the moment of care. If a system like this can help unify the data across care solutions of all types - virtual, hybrid and brick and mortar, all while putting the patient first, we’ll finally be in a better position to make healthcare work as it should.
Emma Rayner is the Co-founder and lead of Strategic Partnerships at Ash Wellness, a B2B tech platform powering self-collection diagnostic testing in all 50 states, on a mission to make healthcare more inclusive and accessible.
What role do you see digital health companies play in the delivery of primary care in the coming decade?
Friction points in healthcare cause people to drop out of the care cycle, resulting in decreased engagement and worse health outcomes. An example of a friction point is a specialist referral generated by a primary care physician. Referrals often go unfilled because patients do not have the time, energy or resources to pursue this extra step in their care. Digital health services remove friction points from existing careflows meaning people do not drop out of care, engagement increases and so do health outcomes (hopefully). A digital health model could move this referral consultation to a telehealth visit followed by a self-collection diagnostic test to streamline the next step in the care plan. Everything is done at home at the patient’s convenience so the patient can more readily access the needed services. At Ash Wellness, we strive to help our digital health partners work within the current healthcare system. We integrate into existing careflows and provide provider and patient portals to enhance their existing offering and streamline patient health data.
Why are digital health companies uniquely positioned for this role?
Digital health services are uniquely positioned to plug the gaps in care and ensure that patients remain within the care continuum and that providers can create a more accessible patient experience. Digital healthcare is the next iteration of friction removal. As a digital health platform powering remote diagnostics at scale we are able to provide an expert service so that providers / primary care practices can focus solely on providing expert care and serving their patient population. Switching on at-home diagnostics testing is not an easy lift - it includes but is not limited to self-collection user management, coordinating a national set of fulfillment centers, managing a network of CLIA/CAP certified labs, printing facilities, inventory procurement and storage, supply chain management, logistics (shipping and tracking), last-mile customer service expertise, technical integration, and on-going technical support.
What are the roadblocks? What are the unrealized opportunities to make your vision even better?
Payers. In order for digital healthcare solutions to have the greatest impact they need to be affordable in order to be accessible. Remote diagnostics specific:
From a policy standpoint, California passed the SB306 bill that requires insurance companies to cover self-collection testing for STIs. SB 306 ensures a pathway to STI services for low-income and uninsured LGBTQ+ patients and expand access to STI testing and treatment at home and in the community.
Under the Affordable Care Act, PrEP and the testing/care associated with its prescription is required to be covered nationally by health insurers.
From a policy standpoint we need states to require insurance companies to cover the end-to-end remote diagnostics service. We need CPT codes that extend past the lab panel itself but also cover the test kit material, provider review, and return shipping.
An integrated experience is important on so many levels for the patient and providers, and at a baseline, healthcare infrastructure is currently disjointed. Health records, lab infrastructure, billing systems all struggle to interact and lack transparency. In the rush to innovate many services have come in trying to make care delivery easier but have actually added to the chaos. We need EMRs/EHRs to recognize the shift to digital healthcare and make it as easy as possible to help patients and providers transition.
What’s one resource you wish you had to make this happen faster or on a larger scale?
A team focused on payer relationships to ensure that remote diagnostics are reimbursable in all 50 states.
With so many stakeholders impacting primary care, it’s becoming something new both patients and experts alike are struggling to define. Can I list a website or an app as my primary care provider? What about my pharmacist, or the local ER or urgent care? For many patients, the function of these entities align more closely with the kind of care they expect from “primary care.” The incumbent primary care physicians are either ambivalent or unhappy about the way the primary care pie is getting sliced in the modern age. Older doctors have a sour taste of tech that wedged the EMR in front of them and their patients. The younger ones are open-minded but uncertain about how to evaluate and integrate the new tech stack into their workflows. Clinician training lacks digital health literacy. Glad to see this is slowly changing. Exploring how others are shaping the delivery of primary care provides insight not only about what’s on the horizon, but identifies avenues for collaboration.