Movie studios used to make films, release them and hope you liked them. Blockbuster then brought films to your living room. Netflix now uses the information it has about you to predict what you will like. A similar shift is happening in health care as delivery moves from the hospital to the home.
The initial shift from hospital to home — i.e., the Blockbuster stage — is a long-term trend that has been sharply accelerated by Covid-19. Many patients have avoided hospitals and doctor’s offices for fear of getting the virus. The main exit route has been provided by telemedicine, which virtualizes the existing paradigm of patient-physician consultation. Teladoc, the leading U.S. provider, saw its share price nearly triple in the first half of 2020 before merging with Livongo.
This has brought convenience and efficiency for millions of patients. But it’s important to note that a physician’s capability is diminished during a telemedicine consultation compared to an in-person consultation. The doctor cannot check a patient’s pulse, examine their chest or perform an EKG. In short, it is difficult for them to assess and manage the majority of chronic disease patients. Remote care technology must evolve to help physicians and to truly transform health care.
Firstly, the technology must provide the clinician with useful data (vital signs, glucose, EKG) alongside video consultation. It must do this in a patient-friendly way. Secondly, in the Netflix stage, we must responsibly build predictive algorithms on top of those datasets to anticipate the deteriorating patient in their own home (perhaps more analogous to the movie Minority Report). The latter could improve patient outcomes, reduce hospital admissions and, crucially, reduce cost.
But telemedicine already exists and so does the ability to remotely monitor a patient. So, why does this approach not already exist? Remote monitoring of patient data has a checkered history. Firstly, randomized control trials looking at whether remote monitoring of things like blood pressure can prevent hospital admissions have had mixed results. Secondly, in a fee-for-service world, there has been no profit to be gained in keeping patients out of the hospital. Thirdly, even if doctors wanted to implement remote monitoring, it was difficult to deploy and they did not have the bandwidth to monitor thousands of patients at home. Finally, the data has not been high enough quality to build predictive models. So, as ever in medicine, the technology must fit in with the business model and the care delivery model — which has finally started to happen.
My company, Current Health, has developed technology capable of capturing a broader set of human health data and, in turn, is delivering greater insight. Continuous, passive monitoring using modern wearables is replacing clunky, intermittent manual solutions. Critically, we’ve seen how patients are more willing to use the devices, which require little effort from them, and the continuous datasets generated provide greater insight. For example, a partner of ours, Dexcom boasts a continuous glucose monitor that reveals more about the patient’s diabetes than a traditional glucometer. It empowers the patient, as well as the doctor, which drives their engagement. Secondly, continuous datasets can be used to develop predictive algorithms, which was not previously possible.
The care model is being reimagined by health care providers and technology companies. In the cult novel The House of God, junior doctors are told that if they do not take a temperature, they cannot find a fever. In overburdened and under-resourced health systems, that attitude persists. Hospitals are now beginning to adopt virtual wards at scale, and they expect their technology partners to help them triage their patients. In the long-term, machine learning can tackle the problem of identifying the signal in the noise of fluctuating vital signs, biomarkers and patient-reported symptoms. In the short-term, technology vendors can provide monitoring-as-service using registered nurses to tackle this problem.
Finally, the business case is strengthening. Even before the pandemic, Centers for Medicare and Medicaid Services published specific current procedural terminology codes, also known as CPT codes, for remote vital sign monitoring in January 2019 in an effort to incentivize adoption. In November, CMS announced its Acute Hospital Care At Home program. The waiver allows hospitals to treat acute patients in their own home and to be reimbursed at the same rates as in-hospital treatment. So, United States health-care providers can now generate a significant revenue stream from monitoring patients outside the hospital. This is particularly interesting considering that hospital revenue has been hammered during Covid-19. Reimbursement is not the whole answer, but it has reduced the financial return-on-investment barrier. It is the carrot designed to work in tandem with the stick of financial penalties incurred for patient readmissions brought in under Medicare’s Hospital Readmissions Reduction Program. CMS wants to keep patients out of the hospital and believes that remote monitoring is one way to achieve that.
The market for remote care platforms is nascent and growing. Pre-pandemic, the market was expected to grow at a 13.5% compound annual growth rate to $1.8 billion by 2026. However, the pre-COVID-19 market size and growth estimates are most likely now an underestimate. Market demand for remote solutions, particularly via employee health plans, has accelerated as evidenced by Teladoc’s value accrual in the public markets. The merger with Livongo, a digital chronic care-management company, moves the company beyond pure telemedicine and gives the clinician access to quantitative patient data. Direct-to-consumer health companies, like Apple, continue to build out their quantified self-offering while B2B remote care platforms work with hospital systems to integrate into care pathways. These players are likely to coexist in the medium term as they serve different patient niches. Ultimately, they may begin to compete to become the core infrastructure for remote care. The winners will provide a rich clinical picture of the patient, detect deterioration and integrate it into care pathways.
“Health care has left the building,” the venture capital firm Andreessen Horowitz optimistically proclaimed last summer. If anything, health care is now being forced to leave the building. Remote care management will be a key enabler, but the use of telemedicine is just the tip of the iceberg. Expect to see the Netflix of health care emerge in the next few years.