How can smart health communities improve our health and wellbeing?

My Take

How can smart health communities improve our health and wellbeing?

By David Friedman, Federal Health Consulting leader, Deloitte LLP

It has been 100 years since Charles-Edward Amory Winslow launched a public health program at Yale University. He defined public health as "the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts.”¹ While the health sector has undergone tremendous change over the past century, the connection between community and health has never been more important.

The communities in which we live, and the people with whom we interact (both virtually and in-person), can have a powerful effect on our health. Communities can influence everything from what we eat, where we live, and how often we exercise. And communities continue to evolve. The internet, mobile technology, apps, and the widespread adoption of social media have all played a role in the emergence of virtual communities—influential groups that aren’t restricted by geography or socioeconomics. Unlike physical communities, where individuals might have little in common outside of their shared geography, virtual communities are scalable and can be focused on a particular issue. Virtual communities on their own, or in combination with geographic communities, can be highly influential in reducing disease, empowering consumers, and improving the overall well-being of their populations. These are smart health communities (SHCs).

Between 80 percent and 90 percent of health outcomes are caused by a host of factors not related to the medical system, according to the National Academy of Medicine.² Creating SHCs could help to address some of those factors and improve health outcomes. The Deloitte Center for Health Solutions and the Deloitte Center for Government Insights recently interviewed innovators who are using new approaches to engage people through virtual and geographic communities. These SHCs are often led by technology companies, start-ups, and other non-traditional health stakeholders that are highly effective at engaging with and influencing consumers.

Government agencies could play key role in smart health communities

Some government agencies are beginning to play a collaborative role in SHCs by funding innovative pilots, or by establishing data-sharing agreements that allow them to collect, analyze, and share data about local population needs. Such collaboration between government agencies and other stakeholders could lead to innovative communities that work to improve the health of a particular group of people. Additionally, governments can help SHCs by developing and/or supporting their technological infrastructure and governance, including the standardization and security of data. My hope is that the health sector will grow to view government agencies as collaborators, rather than entities that might hinder innovation.

In my role as leader in Deloitte’s Federal Health sector, I am proud of the work our clients are doing (and that Deloitte is supporting) to address type 2 diabetes prevention. Between 15 percent and 30 percent of people who have prediabetes will develop diabetes within five years unless they change their lifestyle habits, according to the American Diabetes Association (ADA). Early intervention can prevent or delay the onset of diabetes among those who have prediabetes.

The National Diabetes Prevention Program (DPP) was established in 2010 and is an excellent example of federal agencies, hospitals, health centers, technology companies, and community organizations coming together to build an ecosystem aimed at improving health and wellness. The Centers for Disease Control and Prevention (CDC) developed the program framework around an evidence-based lifestyle-change intervention and engages with more than 1,500 in-person and digital providers who offer the program across the US.

The DPP is delivered in community group-based settings where coaches encourage participants to proactively manage their weight and exercise. The US Centers for Medicare and Medicaid Services (CMS) pays these programs for their services if they meet CDC’s standards. Many private health plans also cover the program for their non-Medicare enrollees. Examples of organizations that provide the DPP intervention include YMCAs, Weight Watchers, Omada Health, and many others.

The five core features of a Smart Health Community

With billions of people around the world now interacting and sharing experiences via social media, digital communities have the potential to help combat disease. The most effective SHCs typically use some or all of the following capabilities to encourage their community members to adopt or maintain healthy behaviors:

• Empower proactive health and wellbeing: SHCs should encourage healthy lifestyle choices and help individuals make decisions that allow them to play a more significant role in their own health—and reduce adverse health outcomes in the future.
• Foster a sense of community and belonging: Group activities could have a bigger influence on health than what someone can do alone. Sharing goals and outcome data with peers, for example, can help motivate some individuals to continue with diet and exercise regimens despite feeling like giving up. In addition, online discussion boards and social media groups can give individuals a place to share information, discuss challenges and successes, and seek support from each other. Case in point: Virtual National DPP groups and online discussion boards such as Cancer Survivors Network allow individuals to share success stories and challenges and seek support from each another.
• Incorporate digital technology: The use of technologies such as mobile apps, fitness trackers, and GPS-enabled devices is a key function of advanced SHCs. But such digital technologies aren’t limited to virtual communities—some geographic communities are leveraging technology, too. Case in point: Louisville, Ky. was recently ranked as the seventh most challenging US metropolitan area for people living with asthma.³ AIR Louisville, a private-public collaboration launched in 2015, made GPS-enabled “smart” inhalers available to residents who have asthma.⁴ Each time an individual takes a puff, the inhaler logs the location, time, weather, and pollutants in the air. The individual then receives notifications about bad air quality days and information that helps predict the time and location of asthma attacks. Participating organizations include the Institute for Healthy Air Water and Soil and the Department of Civic Innovation. The initiative is funded by the Robert Wood Johnson Foundation.
• Use data to improve health outcomes: As technology makes data collection and data sharing easier and cheaper, many SHCs are using the information to build models that predict risk, create a continuous learning loop through experimentation and innovation, and conduct research and evaluation. Case in point: The Chicago Department of Public Health and the Department of Innovation and Technology created a predictive-analytic model to help prioritize health inspections of retail food establishments. The tool combines information from various sources on Chicago’s open data portal with sophisticated analytic techniques to identify risk factors most likely to result in health code violations. The project includes a range of 311 data such as nearby sanitation complaints, previous inspection results, food license history, and outdoor temperatures.⁵ The city was able to use predictive analytics to identify violations most likely to lead to food-borne illness.⁶
• Enable new and innovative ecosystems: Enabling new and innovative ecosystems of public and private entities is another essential element of SHCs. Case in point: In 2016, Mayor Rahm Emanuel and the Chicago Department of Public Health launched Healthy Chicago 2.0, a four-year program that includes 200 strategies to improve the health of all Chicagoans by focusing on social, economic, and other issues that negatively impact health.

Technology is helping to break down geographic barriers while building up new types of communities. With billions of people around the planet now sharing their experiences with each other, smart health communities offer the potential to improve our health as they become larger and more influential. In the future, we expect many more of the communities in which we live, work, and interact (both virtually and physically) will include a web of interconnected SHCs.

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¹ C-E.A. Winslow, who launched public health at Yale a century ago, still influential today, YaleNews, June 2, 2015
² Social Determinants of Health 101 for health care, National Academy of Medicine, October 9, 2017
³ Asthma Capitals 2019, Asthma and Allergy Foundation of America
⁴ AIR Louisville home page
⁵ 311 is a non-emergency phone number that people can call in many cities to find information about services, make complaints, or report problems
⁶ Food inspection forecasting, City of Chicago

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In the News

Senate committee recommends solution for ‘surprise billing’

On June 18, the Senate Committee on Health, Education, Labor & Pensions (HELP) held its first public hearing on draft legislation aimed at lowering health care costs and targeting “surprise billing” (see the June 4, 2019 Health Care Current). Last month, the committee introduced a discussion draft of the Lower Health Care Costs Act, which contains several options for addressing surprise medical bills. Surprise medical bills can occur when a patient is unable to choose an in-network provider, such as during an emergency. The committee's bill proposes capping the payments that hospitals and physicians receive for out-of-network care. In a similar bill, the House Energy and Commerce Committee proposed limiting payments for out-of-network care to a regional insurer’s standard rate, known as a "benchmark payment" (see the May 21, 2019 Health Care Current). Air ambulances, which can be especially expensive, were not included in the discussion draft or in any of the other proposals introduced in Congress. About two-thirds of the more than 34,000 air ambulance transports recently examined by the Government Accountability Office (GAO) were not included the patient’s health plan network.

During the hearing, HELP Committee Chair Lamar Alexander (R-Tenn.) expressed his preference for paying for surprise medical bills with a policy called an "in-network guarantee," which would require hospitals to either include their physician employees in their insurance networks or absorb the extra billing costs. A witness representing the Pacific Business Group on Health suggested that Congress set the benchmark for hospitals at 125 percent of the Medicare payment rate. The director of a health policy collaboration effort between a university and a think tank calculated that benchmark payments could reduce private insurance premiums by half a percent nationally, based on the Congressional Budget Office’s (CBO’s) projected $25 billion in federal savings. A witness from the American Hospital Association (AHA) criticized the benchmarking option as being "unworkable."

(Source: Government Accountability Office, Available Data Show Privately-Insured Patients Are at Financial Risk, March 20, 2019)

Related: Nearly one in five insured people (18 percent) who visit a hospital emergency room (ER) receive at least one out-of-network charge, according to a June 20 report from the Kaiser Family Foundation. Researchers also found that 26 percent of patients who are admitted from the ER receive a surprise medical bill—but incidents of surprise billing vary widely by state. The study also found that 39 percent of insured non-elderly adults said they had received an unexpected medical bill in the past 12 months, including 10 percent who said the bill was from an out-of-network provider. The study is based on 2017 claims data from patients who had health coverage through a large employer.

(Source: Kaiser Family Foundation, June 2019)

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Drug makers file suit against mandatory price disclosures

On June 14, three pharmaceutical manufacturers and the Association of National Advertisers (ANA) filed a lawsuit to block the requirement that drug makers disclose their drugs’ list prices in television advertisements. According to the final rule, which takes effect July 9, manufacturers must include the Wholesale Acquisition Cost (WAC) in direct-to-consumer (DTC) ads for certain prescription drugs and biologics that are available through the Medicare and Medicaid programs (see the May 14, 2019 Health Care Current).

The drug makers contend that CMS lacks the authority to regulate drug prices in advertisements—which the agency claimed in the proposed rule. Forcing drug makers to disclose prices violates the companies’ First Amendment rights to free speech, according to the suit. The manufacturers also claim that CMS has not shown that mandatory price disclosures will help to lower drug costs, noting that few consumers pay full list prices for drugs. However, CMS affirms that it does have the authority to help Medicare and Medicaid beneficiaries reduce their out-of-pocket costs for prescription drugs.

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MedPAC issues June report, which includes new policy approach to restructure Part D

In its June 2019 report to Congress, the Medicare Payment Advisory Commission (MedPAC) introduced a new policy approach to restructure the Medicare Part D benefit and explored several other payment policy changes. Among the other payment policy proposals, the Commission recommends eliminating “incident to” billing for physician assistants and advanced practice registered nurses, discusses an option to replace the Medicare Advantage (MA) quality bonus payment program, and examines strategies such as applying reference pricing and binding arbitration to improve competition in Part B.

To address the recent growth of specialty drugs, MedPAC offered a comprehensive policy approach to restructure Part D and improve financial incentives for managing drug spending. The proposal explores the following policy actions:

• Eliminating the coverage-gap discount provided to non-low-income subsidy (LIS) beneficiaries
• Requiring brand-name drug manufacturers to provide a discount during the catastrophic phase of coverage
• Reducing enrollee cost-sharing or setting an overall out-of-pocket spending cap

(Source: MedPAC, Report to the Congress; Medicare and the health care delivery system, June 14, 2019)

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MACPAC recommends changes to payment policies for drug, hospital payment updates in June 2019 report to Congress

The Medicaid and CHIP Payment and Access Commission (MACPAC) made several recommendations for drug and hospital payment policies in its June 2019 Report to Congress, including:

• Providing a 180-day grace period to states for covering recently approved outpatient drugs. MACPAC seeks to alleviate states’ concerns that they do not have enough time to determine appropriate coverage criteria as new drugs enter the market.
• Removing the cap on drug rebates in Medicaid, which is now set at 100 percent of the average manufacturer price (AMP) of a drug. According to MACPAC, this action might lead to higher rebates—and major cost savings.
• Changing the statutory definition of “Medicaid shortfall” for purposes of the disproportionate share hospital (DSH) payment formula to exclude costs and payments for Medicaid-eligible patients for whom the program is not primary payer. In March 2018, a federal court vacated previous CMS guidance for calculating Medicaid shortfall, which is the difference between a hospital’s cost of care for a Medicaid beneficiary and the payment a hospital receives for those services. According to MACPAC, the court’s decision could allow hospitals to receive DSH payments for services paid for by another insurer. The change to the definition—which would require legislative action to implement—would help prevent this from happening going forward.

(Source: MACPAC, Report to Congress on Medicaid and CHIP, June 2019)

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Executive order calls on agencies to issue regulations requiring health care industry to disclose prices

On June 24, the president signed an executive order calling for agencies to issue proposed regulations about disclosing health care prices and aligning around common quality measures. The order includes:

• Instructing the US Department of Health and Human Services (HHS) to issue a rule requiring hospitals to publish—in a readable format—price information showing what patients and health plans pay for services. This includes information on standard charge information and negotiated rates
• Requiring health plans—including self-insured group plans—and health care providers to disclose out-of-pocket cost information to patients before providing care
• Developing a roadmap for consolidating quality metrics, called the Health Quality Roadmap, across all federal health care programs
• Increasing access to de-identified claims data from federal health programs and group health plans to allow researchers to identify inefficiencies—and to develop tools for patients to better understand their health needs
• Asking HHS and other agencies to address “surprise billing” in a report that would include proposals for potential regulatory options to address this practice

(Source: Improving Price and Quality Transparency in American Healthcare to put Patients First, June 21, 2019)

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Breaking Boundaries

Evidence continues to grow for virtual reality use cases in health care

Thousands of patients have used virtual reality (VR) therapies in medical situations including labor, burns, blood draws, and intravenous insertions. To secure coverage for these services, digital health startups and VR providers are working to demonstrate that this technology is effective in certain clinical settings.

Early studies into the use of VR as a potential treatment for pain—and as a training tool for surgery—go back two decades. Widespread adoption, however, was delayed by bulky systems that were expensive and difficult to use outside of research settings. Over the past few years, less-expensive and consumer-friendly VR devices have entered the market. New clinical research and investment are also advancing the VR therapy field.

A group of researchers at Cedars-Sinai Medical Center are proposing an evidence-based VR pharmacy that classifies digital therapies into different therapeutic categories, including treatments for anxiety or phobias and treatments for conditions such as chronic pain or irritable bowel syndrome (IBS). According to theory, by modifying experience and perception through VR, the technology can help people reconnect with their bodies and shift perspectives. Since 2016, Cedars-Sinai has used VR technology on more than 3,000 patients and conducted studies showing the tool’s positive effects on managing pain—and its potential cost savings—through shorter hospital stays.

More than 5,000 papers have been published focusing on VR in health care, and many startups are working to commercialize VR therapies for patients. Pain management is the most researched and common clinical use case for VR. While the science behind VR’s therapeutic pain relief is not totally understood, research has shown that the technology diminishes both physical and emotional brain responses to pain by creating what is known as “inattentional blindness,” or time contraction through distraction. VR acute-pain-management research in burn victims yielded a 35-to-50 percent pain-score reduction among users.

The opioid epidemic has driven much of the recent research in chronic pain. Some patients have used VR to wean themselves off opioids. Despite some patients using VR to avoid drugs, VR can have some side effects. One side effect is called cyber sickness, in which users experience nausea or dizziness while in virtual motion. Improvements in latency (or the time it takes for a request to travel from the sender to the receiver and for the receiver to process that request) and features that allow users to “jump” around to different locations instead of walking could help solve this. While some stakeholders worry about the addictive nature of gaming, many researchers of clinical VR say, when used as a therapy, VR hasn’t been statistically shown to lead to dependence.

What will it take to move the technology from research to practice?

Many stakeholders recognize more evidence-based studies are needed to demonstrate the value of VR to encourage health plans, health systems, or life sciences companies to cover or implement the technology. Some medical-device companies are interested in combining VR with existing products to enhance pain relief or to improve recovery from surgery. Regulators would also need to be on board, depending on how VR will be used, before more widespread market access can take hold around the world. Additionally, clinicians would need help integrating this new tool into their workflows.

(Source: Kevin Truong, A new reality: How VR is poised to make real world clinical impact, Medcity News, June 10, 2019)

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