As the new administration settles in at the White House, it’s clear that a major focus of attention is on the very important industry of healthcare. The ongoing Covid-19 pandemic has increased the urgency of ensuring that all Americans have affordable, equitable access to quality healthcare. But as efforts are made to address many short-term needs, consideration must be given to also making changes that are sustainable, beneficial, and endure long into the future.
In late January, President Biden signed executive orders designed to improve access to quality, affordable healthcare and reduce disparities. In a statement issued at that time, the White House acknowledged that this is even more critical as we continue to battle Covid-19. With the recent passage of the $1.9 trillion Covid-19 relief bill, the American Rescue Plan Act of 2021 that includes significant measures to expand access to healthcare, Democrats in Congress have signaled that health is one of their top priorities as well.
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Lucienne Marie Ide and Brian Scarpelli Brian Scarpelli is the Senior Global Policy Counsel for ACT | The App Association, the convening organization of the Connected Health Initiative. Brian leads the collation in advocating for policy and legal changes to drive the uptake of digital health tools throughout the American healthcare system. For the App […]
Outlook for the Future of Healthcare: Value-Based Care 2.0
Designed to strengthen Medicaid and the Affordable Care Act, the executive orders included opening a special enrollment period that is extended through May 15 so Americans have sufficient time to get needed healthcare coverage. This is a critical first step, as nearly three million Americans have lost employer-based coverage during the pandemic, and about 15 million are uninsured, yet eligible for marketplace coverage.
The Covid-19 relief bill includes $7.6 billion to expand public health department workforces, $7.6 billion to help community health centers, and a provision to allow Medicaid plans to cover a mother for a full year after giving birth. All of these measures will help address major health disparities highlighted during the Covid-19 crisis. For many Americans, the most important feature may be the expansion of Affordable Care Act subsidies for two years, including completely subsidized coverage for those making 150 percent of the federal poverty level. In all, the package expands access to affordable healthcare for millions of Americans through both insurance coverage as well as improved resources in their communities.
The current wave of healthcare reform and innovation must emphasize equitable access to care and deliver greater value to patients, with incentives for quality care and a focus on proactivity and heightened patient engagement rather than a reactive system structured around treating illness and disease that rewards visit quantity. Key in this transformation is the regular collection and use of patient-generated health data (PGHD) from outside of the doctor’s office, enabling trends to be identified and proactive interventions to prevent health crises before they occur using new predictive clinical decision support tools.
Such a shift has long been a bipartisan priority, with Congress mandating in the Medicare and CHIP Reauthorization Act 2015 that the Medicare system transition from a fee-for-service (FFS) approach to one that incents improved outcomes. But the Medicare system continues to take an FFS approach six years later. While efforts to realize a value-driven system have been admirable, the Covid-19 crisis has highlighted the need for rapid progress.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Why is 2021 the Perfect Time for the Next Phase of Value-Based Care?
Technology has played an integral role in this “value-based care 2.0” approach. The grand natural experiment that Covid-19 forced on the healthcare system accelerated the adoption of virtual care solutions such as telehealth and remote patient monitoring (RPM) by five to 10 years. While these technologies were being implemented in a limited manner before 2020, the pandemic pushed them squarely into the mainstream. In fact, the RPM market is expected to double in the next five years, and a recent Consumer Technology Association (CTA) survey found that 68 percent of physicians said they strongly intend to use RPM in the future. This Administration has the unique opportunity to capitalize on this key trend to mold the future of U.S. healthcare policy and delivery in the context of all that we have learned over the past year.
For example, hospitals around the country debuted RPM programs during the pandemic to monitor vital signs and symptom data—including oxygen levels, heart rates, and other key indicators—as patients recovered from Covid-19 at home, instead of occupying hospital beds needed for sicker individuals. Other providers leveraged remote monitoring to continue caring for patients with chronic conditions, such as diabetes, heart disease, and obesity. This approach allowed these at-risk patients to avoid in-person office visits and minimize potential exposure to the virus. And for countless caregivers and patients, the uptick in RPM use is increasingly begging them to question why they haven’t been using these tools already. They are realizing that the success of these innovative tools will be critical long after the pandemic subsides.
Enhanced Reimbursement, Expanded Broadband, and Interoperability Mandates
The call to action for this Administration is to provide access to healthcare in a way that is helpful, affordable, and sustainable. There is great opportunity to make transformational changes to accomplish this goal today by addressing reimbursement, broadband infrastructure and access, and enhanced bidirectional flows of health data. Again, reform in each of these areas has seen bipartisan support over the years. But what has held back the progress?
Improving access to care means ensuring reimbursement for virtual care solutions long after the pandemic is over. While the Centers for Medicare and Medicaid Services have strengthened some reimbursements for virtual care in the Medicare Physician Fee Schedule to make permanent some changes that were initially introduced on a temporary basis during the Covid-19, a lot of work remains to be done. Those wishing to responsibly use digital health tools to keep their patients healthy continue to have to deal with a system that incents in-person care. And some key providers continue to be effectively prevented from using digital health tools at all.
As a glaring example, Federally Qualified Health Centers (FHQCs), community health centers that provide care to over 25 million Americans who would otherwise be unable to access or afford care, have no funding mechanism to get reimbursed for RPM. While the Medicare system has made some progress in standing up its Quality Payment Program to transition to value-based care, the system is far behind its goal in shifting the majority of providers to advance alternative payment models (APMs) that will enable flexibility and innovation in care to enhance value.
Longstanding concern that expanded reimbursement coverage of telehealth or RPM would lead to an overall increase in healthcare costs has not proven to be true over the past year. In fact, the ability to engage patients earlier and more often across a continuum of care from the home to the clinic can lead to cost reduction, and many would argue that the traditional FFS payment model is the main culprit in driving over-utilization of healthcare resources and cost escalation. Under the FFS model, the United States has ended up spending almost 18 percent of gross domestic product on healthcare. While data continues to be collected and analyzed (both before and during the pandemic), the uptake of even basic digital health technologies has shown incredible promise to reduce systemic costs and make healthcare more affordable and accessible. For example, UnitedHealthcare has estimated that a basic voice/video telemedicine consultation that would cost $2,000 or more for in-person treatment in an emergency room costs payers $50 or less.
But just as important as general access to these solutions and tools, Americans also need internet and Wi-Fi capabilities that make video visits and remote monitoring possible. As part of the $900 billion Covid-19 relief package, Congress approved $7 billion to increase access to broadband and another $250 million in telehealth funding so that more Americans can benefit from access to cutting-edge healthcare. It’s clear that these healthcare services are in demand, as 52 percent of consumers in broadband-connected homes said they wanted telehealth services that use data from connected health devices. Government at all levels must use these much-needed funds, and focus their efforts generally, to provide and maintain the infrastructure that America’s patients require to participate in a digitally-enabled healthcare continuum, particularly those in communities that are underserved.
Without the ability to share health data in a standardized way, the digital healthcare ecosystem simply cannot be realized. Congress recognized this in passing the 21st Century Cures Act, which enabled the Department of Health and Human Services (HHS) to make rules to stop the harmful practice of siloing patients’ health information for profit. As of April 5, finalized rules from HHS’ Office of the National Coordinator for Health IT (ONC) goes into effect to prevent illegal information blocking and to streamline the secure sharing of patient data amongst and between patients and their providers.
Importantly, ONC’s information blocking directly addresses such harmful actions by certified health IT developers, such as electronic health records and payers. With this deadline, ONC is holding vendors accountable through their business practices, including reasonable data exchange fees to facilitate data sharing between third-party applications. What does this mean for value-based care? Standardizing data—from the device in the home to the clinical decision support tools in the clinic to quality reporting measures in the executive offices of the hospital—means more efficient and coordinated healthcare and more timely personalized decisions about patient care. The end result is better outcomes and lower cost, not to mention a better experience for both patients and providers. In short, better interoperability is key to achieving value-based care.
It’s not just about Washington, D.C., either. The Administration’s priority is well-aligned with a wider effort to advancing health equity and reducing disparities. The Health Equity and Access Leadership (HEAL) Coalition is working to create recommendations on the greater use of technology to mitigate health disparities, particularly coordination of resources, policy advocacy, research and education. HEAL, which is an effort of the Connected Health Initiative (CHI) and Consumer Technology Association (CTA), is exploring ways in which health technology, such as mobile health, wearables, remote monitoring, clinical decision support, artificial intelligence (AI) and telehealth can be used to improve the country’s response to health disparities in diverse geographies, communities, and demographics.
While the Covid-19 pandemic has strained the healthcare industry, this Administration has the advantage of being able to leverage everything we have learned over the past year to advance the next generation of value-based care in advanced APMs and to create a more equitable, efficient, and effective healthcare system. This will require an accelerated trajectory for the American healthcare system that will, through robust infrastructure, securely facilitate the flow of PGHD to those who are incentivized to leverage it to realize a truly value-based care system. Given necessity is the mother of invention, we have plenty of innovation borne out of need over these past 12-plus months. Let’s put it to good use!
Brian Scarpelli is the Senior Global Policy Counsel for ACT | The App Association, the convening organization of the Connected Health Initiative. Brian leads the collation in advocating for policy and legal changes to drive the uptake of digital health tools throughout the American healthcare system. For the App Association, he works on a diversity of legal and policy issues impacting mobile app development companies and platforms, including disability access, intellectual property (patent, trademark, copyright, and trade secrets), privacy, cybersecurity. He often speaks publicly at conferences and in the media on challenges and opportunities to the small business app developer community.
Lucienne Marie Ide, M.D., PH.D., is the Founder and Chief Health Innovator of Rimidi, a cloud-based software platform that enables personalized management of health conditions across populations. She brings her diverse experiences in medicine, science, venture capital and technology to bear in leading Rimidi’s strategy and vision. Motivated by the belief that we can do so much better as individuals, in industry and society, Lucie left clinical medicine to join the ranks of healthcare entrepreneurs who are trying to revolutionize an industry.
