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Perspectives

Technology could help transform the roles of nurses and radiologists in hospitals

Health Care Current | May 15, 2018

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

My Take

Six ways technology could help transform the roles of nurses and radiologists in hospitals

By Steve Burrill, vice chairman, US Health Care Providers Leader, Deloitte LLP

I’ve been on the road (and in the air) lately visiting clients and our teams. Just last week, I was in several different cities and locations. Most of the hospital and health system leaders I meet with, however, work within the traditional four walls of the organization. Most of their employees do, too.

Historically, this model has made perfect sense—doctors, nurses, and other hospital employees need to be in the same location as their patients. Technology is beginning to change that… and likely for the better. Not only can it reduce tedious and administrative tasks of employees, but it can provide virtual options to change the location of work, and potentially provide better patient care.

The augmented workforce of the future can combine people and technology in a way that improves overall productivity, according to a new paper from Deloitte on the future of work in health care. Perhaps more importantly, technology could help to make many jobs more fulfilling. Is keeping employees happy important to hospital administrators? Absolutely!

Technology could help radiologists improve their ‘image’

Turnover among burned-out hospital-employed physicians might cost US hospitals as much as $1.7 billion a year, according to a report released last month by the National Taskforce for Humanity in Healthcare, a recently formed organization of medical professionals who are examining clinician burnout.1

Diagnostic radiology, for example, is a profession often plagued by burnout and turnover. Nearly half of surveyed radiologists report feeling burned out, according to a 2017 report from Medscape, a news service owned by WebMD. Along with a high volume of repetitive activities, some radiologists are getting paid less for their services. This can push them to work longer hours. And like other medical specialties, radiology is consolidating, which could lead to larger radiology groups that cover bigger geographic areas. As a result, radiologists could lose autonomy and see an uneven distribution of work.

How can technology help? Radiology is technological at its foundation, and it involves a high volume of repetitive activities. Faster computers, combined with software that can read medical images, could help radiologists scan more images while also boosting their accuracy and efficiency. Here are three ways technology could enhance radiology:

  1. Computer-aided detection (CAD): This technology can help radiologists quickly sift through volumes of images. CAD learns from the images it sees, giving it the ability to identify relevant imaging abnormalities. As a result, a radiologist can review images at a more efficient pace, and spend less time in a darkened room looking at glowing images. A technology-augmented radiologist might then have more time to perform complex in-house procedures such as interventional radiology.
  2. Tele-radiology: The ability to scan images remotely can help distribute interpretation work more evenly across sites and organizations with varying volume. This can lead to alternative work arrangements that suit individual radiologists.
  3. Crowdsourcing: Radiologists could provide crowdsourced interpretations of images to patients via online platforms. This new care model could provide radiologists with greater flexibility, which could help ease burnout. With new technologies and diagnostic capabilities, radiologists will likely need to learn new skills and capabilities to keep up.

Tech-enhanced nurses and the quadruple aim
Along with burnout among some physicians, many hospital administrators are also facing a short supply of nurses. This is being driven in part by a generation of retiring nurses, and a steadily declining supply of new nurses coming out of school.2 Rather than trying to figure out how to hire and retain more nurses from an ever shrinking talent pool, hospital administrators should consider ways to make the job more rewarding so that high-performing nurses look forward to coming to work. Using technology to augment nursing staff could move hospitals closer to achieving the “quadruple aim” of health care:

  • Enhance the patient experience
  • Improve the health of populations
  • Reduce the per-capita cost
  • Enhance the caregiver experience

How can technology help? While nursing isn’t as tech-dependent as radiology, there are many repetitive, time-draining tasks that could be reduced or eliminated with the help of help of artificial intelligence (AI), robotics, and cognitive technologies. Addressing administrative and other non-clinical tasks could give nurses an opportunity to practice at the top of their license—and spend more time with patients and their family members providing and explaining care. Here are three ways technology could enhance nursing:

  1. Automated paperwork: I'm guessing that nurses don’t find paperwork to be a fulfilling part of their job. Paperwork takes time away from the bedside, and patient care is why many nurses chose this profession. Administrative duties that involve repetitive activities could be completed with the help of technology. Software, for example, could be used to extract data from a patient’s electronic health record (EHR) and use it to pre-populate intake forms. Advanced algorithms and alerts, possibly augmented by AI, could cut the amount of time nurses spend reviewing and validating orders, sequencing complex order sets, and linking labs, medications, and treatments.
  2. Care anywhere: Some patients might respond better to treatment delivered outside of the hospital. Telehealth and digital medicine tools could extend a nurse’s reach to a patient’s home or anywhere a patient needs care. Nurses could speak directly with patients via video chat while remotely monitoring their vital signs. The same technology could also give nurses and other clinicians access to patients in remote locations. Allowing nurses to work remotely could help them conduct high-value interactions and forge strong patient relationships. This could help to reduce burnout by giving nurses flexibility about where they work, and more time to spend providing care.
  3. Digital technology: A nurse’s assessment and diagnostic abilities could be enhanced through the use of digital technology. EHR software combined with voice-recognition abilities could reduce misunderstanding, miscommunication, and time needed to manage patient records.

While technology is likely never going to replace nurses and radiologists in hospitals, it could take over some of the repetitive, rule-based tasks that they now perform. Even in my position, technology enables me to stay in constant contact with my clients, my colleagues, and my family when I’m on the road. I’m certain technology will continue to change the way we all work, although I think a robot would have a tough time keeping up with my travel schedule.

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1 National Taskforce for Humanity in Healthcare, April 2018 (https://www.vocera.com/public/pdf/NTHBusinessCase_final003.pdf)
2 The American Association of Colleges of Nursing: Strategies to Reverse the New Nursing Shortage. (http://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Reverse-Shortage).

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In the news

President’s speech on drug pricing focuses on reducing out-of-pocket costs, increasing competition

In speeches on May 11, the president and the secretary of Health and Human Services (HHS) announced a range of proposals aimed at lowering drug prices. The president’s speech reiterated some of the potential solutions outlined in the White House Council of Economic Advisors’ February report, as well as those included in the president’s fiscal year 2019 budget proposal. Following the speech, the White House released its blueprint, American Patients First: The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs.

The proposals to address high drug prices and to help make prescription drugs more affordable to Americans are a mix of more immediate actions HHS could take, and longer-term actions the administration would like stakeholders and the public to weigh in on.

Specific proposals include:

  • Reforming Medicare Part D by allowing greater flexibility in benefit design to encourage better price negotiation; offering free generics to low-income seniors; and requiring health plans to share a minimum portion of rebates with members.
  • Exploring which modifications could be made in the Medicaid Drug Rebate Program to facilitate the development of value-based purchasing arrangements, as well as exploring indication-based payments in Medicare and Medicaid.
  • Moving some Medicare Part B drugs to Medicare Part D. The administration is seeking feedback on which drugs, or classes of drugs, would be good candidates for moving from Part B to Part D, and how this proposal could be implemented to help reduce out-of-pocket costs.
  • Maximizing competition and innovation by curbing industry practices around delaying some generics from entering the market. The administration also wants to promote competition through expediting the approval of generics, and the blueprint referred to forthcoming US Food and Drug Administration (FDA) guidance on the availability and adoption of biosimilars.
  • Developing demonstration projects at the US Centers for Medicare and Medicaid (CMS) to test innovative ways to encourage value-based care and to reduce drug prices. These models should aim to hold drug manufacturers accountable for outcomes, align with CMS’s value-based care priorities and site-neutral payments, and provide Medicare providers, health plans, and states with additional tools to manage spending for high-cost therapies.
  • Making drug prices more transparent to consumers by requiring pharmaceutical companies to list them in direct-to-consumer advertising, by making Medicare drug price increases more transparent, and by allowing pharmacists to tell patients about alternate drug options that could result in lower out-of-pocket costs. 

The blueprint also notes that the US generally pays more for brand drugs than other countries, which often have reimbursements set by their governments. The administration is interested in stakeholder input on what could be done to reduce this pricing disparity and spread the burden for incentivizing new drug development more equally between the US and other developed countries.

(Source: HHS, American Patients First: The Trump Administration Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs, May 2018)

House subcommittee discusses recent changes to Medicare Advantage

Last week, the House Ways and Means Health Subcommittee convened Medicare Advantage (MA) experts from several organizations to discuss some of the challenges that health plans and consumers experience with the program. The witnesses were largely in favor of the administration’s recent move to create more flexibility in the MA program (see the April 24, 2018 Health Care Current), but had suggestions for improvement.

One of those changes is to allow health plans to add supplemental benefits into their MA products beginning in 2019. MA plans will be able to add benefits—ranging from healthier food to transportation services—if it might help keep a member out of the hospital. The witnesses cautioned the following:

  • Quality measures should reflect these updated benefits. One expert witness suggested that quality measures should be updated to ensure that consumers can compare MA plans based on simple metrics.
  • The online platform—Medicare Plan Finder—should be simplified and reorganized. A second expert witness stated that, in general, consumers consider the Plan Finder to be difficult to navigate. In allowing these additional benefits, it could be even more challenging for consumers to compare and contrast MA plans and compare MA to traditional Medicare.

Also last week, CMS stated intentions to update the Medicare Plan Finder to add consumer-friendly changes. Some of the changes include adding an out-of-pocket prescription drug cost calculator and a web chat feature and simplifying the login process for the tool. These changes are likely due, in part, to a report issued by the Clear Choices Campaign and the National Council on Aging.

Related: Deloitte’s research into understanding the next wave of Medicare enrollees found that retiring Baby Boomers will likely have different needs from the Baby Boomer population already enrolled in Medicare. For one, their experience with employer-sponsored health coverage and networked products (e.g., health maintenance organizations [HMOs] and preferred provider organizations [PPOs]) could make them more attracted to MA products. Moreover, these “trailing-edge” Boomers already use health technology more than their older counterparts, which could lead them to demand more out of tools like the Medicare Plan Finder. In addition, the research found that this new wave of older adults is more likely to want to age in their homes than the previous Baby Boomers. This could make supplemental benefits like these more attractive to the future population.

CMS insights into making health care more accessible to rural communities

CMS is trying to improve access to high-quality, affordable care for rural Americans, the agency announced on May 8. Rural communities tend to have high rates of poverty, chronic conditions, and uninsurance. CMS wants to bring its programs to rural areas to address these problems. For example, the agency says it will expand access to telehealth by making it easier for providers to bill Medicare for a wider range of virtual services.

Related: Deloitte’s Realizing the Potential of Telehealth describes several ways telehealth can help to reduce costs and improve health outcomes, as well as the surrounding policy landscape. Although some barriers exist, policymakers and consumers appear interested in more widespread access to these services.

CMS administrator discusses timeline for ACO risk contracts

Accountable care organizations (ACOs) should save more money, agency Administrator Seema Verma said in an address to the American Hospital Association (AHA) on May 7.

Verma noted that, while a subset of ACOs have transitioned to a “two-sided” risk model—meaning they assume downside risk, or share financial responsibility for losses with Medicare—the majority of ACOs remain in “upside-only” tracks. According to Verma, two-sided ACOs have shown significant savings to the Medicare program, but the one-sided ACOs increase Medicare spending.

In a recent web survey, 70 percent of ACOs participating in Track 1 of the Medicare Shared Savings Program (MSSP) indicated that they would “likely” leave the MSSP if they have to assume risk for losses, citing concerns about the amount of risk, unpredictability of rules, and a desire for more stable financial projections as their main rationale (see the May 8, 2018 Health Care Current).

Beginning in 2019, these ACOs must transition into a two-sided risk model. The National Association of Accountable Care Organizations (NAACOS), which administered and published results of the survey, previously advocated for CMS to allow ACOs that meet specific performance criteria to continue in Track 1.

CMS responds to two Medicaid waivers

On May 7, CMS approved its fourth state waiver to allow Medicaid work requirements. New Hampshire’s waiver, which applies only to its Medicaid expansion population, requires able-bodied beneficiaries to work, attend school, volunteer, or actively search for work to receive benefits. The waiver exempts caregivers and people who are in a state-certified drug court program.

At AHA’s meeting that same day, CMS Administrator Seema Verma announced that the agency would not allow Kansas to impose a three-year lifetime limit on Medicaid benefits. In her remarks, she noted the distinction between lifetime limits and the temporary lock-out provisions included in work-requirement waivers. Four other states—Arizona, Maine, Utah, and Wisconsin—have also sought waivers to impose lifetime Medicaid limits.

FDA approves second use for CAR-T therapy

On May 1, the FDA approved a Chimeric Antigen Receptor T-cell (CAR-T) therapy for a second time.

CAR-T therapy is a process that involves genetically engineering a patient’s own T-cells to bind to certain cancer cells (see the May 8, 2018 Health Care Current). In 2017, the FDA approved two CAR-T therapy drugs: Gilead Sciences launched a CAR-T drug to treat adult patients who have large B-cell lymphoma, and a second company launched a drug to treat pediatric acute lymphoblastic leukemia in patients up to age 25. Last week, the FDA approved the leukemia drug manufacturer’s CAR-T therapy for a second indication, to treat large B-cell lymphoma, at a different price.

Indication-specific pricing is a technique that factors a drug’s use in treatment when determining its cost. Under this pricing model, a drug could have a higher cost when used for a specific treatment in a small patient group and a lower cost when used in a larger patient group for a different indication. Though pharmaceutical companies market different uses of the same drug under different brand names, each with their own price, this CAR-T therapy—for both pediatric leukemia and large B-cell lymphoma—is the only example of indication-specific pricing of the same cancer drug in the US. Some pharmacy benefit management (PBM) organizations, such as Express Scripts, have indication-specific pricing arrangements for certain cancer drugs and treatments for inflammatory diseases.

Breaking Boundaries

Is the US ready to reap the benefits of precision medicine?

Last week, the National Institutes of Health (NIH) launched its precision medicine initiative, All of Us, after three years of planning. The All of Us initiative aims to compile health data from a representative sample of 1 million Americans. Tapping into such diverse data will help researchers better understand the mechanisms of disease and potentially be able to advance the field of precision medicine. Anyone over the age of 18 who lives in the US can enroll in the study. About 45,000 participants enrolled in the pilot testing phase, which started a year ago.

All of Us is collecting data from multiple sources, including electronic medical records and surveys about participants’ behaviors and environments. Eventually it will gather genetic reports and information from wearable fitness devices. The first sequencing will begin later this year.

As Deloitte’s Margaret Anderson describes in a recent blog, before All of Us, this type of work started with the Framingham Heart Study, an ongoing study that NIH launched 70 years ago. It has provided vast amounts of data that have helped researchers identify patterns in cardiovascular disease. Although some of the methods used to collect data—and the technologies used to study it—have changed since Framingham, both initiatives rely on volunteer participants who agree to take part and donate their data. The data from All of Us, combined with advanced analytic capabilities, could yield novel, powerful insights that could lead to new clinical applications for patients with different diseases.

In related news, precision medicine is the theme of this month’s issue of Health Affairs. To launch the issue, the trade journal held an event in Washington, D.C. on May 8. Several authors were on hand to discuss their articles.

  • Alessandro Blasimme from the Department of Health Sciences and Technology at the Swiss Federal Institute of Technology in Zurich, reported on the results of his team’s analysis of data-sharing guidelines, which have been issued over the past two decades by multiple organizations. The team found that the data-sharing policies across specific organizations, and the data types, are fragmented. This fragmentation might have contributed to the current stalemate in data sharing. To move toward a more efficient data-sharing ecosystem for precision medicine, Blasimme’s team suggests that policy makers consider innovative ways to improve privacy, consent, and data quality. Guidance should focus on interoperability, attribution, and public engagement, and it should promote data-sharing policies that can be adapted to multiple data types.
  • A team from the University of San Francisco reported on their study focused on genetic test spend and market growth since the mapping of the human genome in 2003. The study shows there are approximately 75,000 genetic tests on the market, with ten new tests arriving each day. Given the number of tests available, it can be challenging for clinicians to incorporate the results into practice, and difficult for health plans to determine which tests offer enough value to cover. 
  • Research from the Personalized Medicine Coalition demonstrated significant underrepresentation of African, Latin American, and Asian populations in genomic studies.

Other speakers at the event described how precision medicine and genetic information are being used to diagnose and treat patients more effectively. They also described real-world examples of how precision medicine is working to help patients.

(Source: Health Affairs, May 2018)

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