The wind may be even stronger at the back of telehealth this year–but not without a bit of chill

Late last year, this Editor noted that ‘the wind may finally be at the back of telehealth distribution and payment’. The expansion of telehealth access for privately issued Medicare Advantage (MA) plans, state-run Medicaid and CHIP (Children’s Health Insurance Plan) plan members, and this year’s Medicare Physician Fee Schedule, along with a limited expansion of telemedicine in the Value-Based Insurance Design (VBID) model for MA announced earlier this year by CMS, is a leading indicator that government is encouraging private insurers to pay doctors for these services, who in term will pay vendors for providing them.

The Veterans Health Administration (VA) has historically been the largest user in the US of telehealth services (home telehealth, clinical video telehealth, store-and-forward). They are also a closed and relatively inflexible system (disclosure–this Editor worked for Viterion, a former RPM supplier to the VA). In 2017, under then Secretary David Shulkin (who left under a cloud, and not an IT one), there were hopes raised through the Anywhere to Anywhere VA Health Care Initiative. So the news released at the start of HIMSS’ annual meeting that veterans will be able to access their health data through Apple’s Health Records app on the iPhone, perhaps as early as this summer, was certainly an encouraging development. According to mHealth Intelligence, the key in enabling this integration and with other apps in the future is the Veterans Health Application Programming Interface (API), unveiled last year.

Anywhere to Anywhere is also making headway in veteran telemedicine usage. Of their 2.3 million telehealth episodes in their FY 2018, over 1 million were video telehealth visits with veterans, up 19 percent from 2017. 105,000 of those video visits were through VA Video Connect to veterans’ personal devices. The remainder were real-time interactive video conferences at a VA clinic. The other half were assessment of data between VA facilities or data sent from home (the underused Home Telehealth).  Health Data Management

Virginia also moved to make remote patient monitoring part of covered telehealth services for commercial health plans and the state Medicaid program. The combined bills HB 1970 and SB 1221 will be sent for signature to Governor Ralph Northam, to whom the adjective ‘beleaguered’ certainly applies. National Law Review

But service providers face compliance hurdles when dealing with governmental entities, and they’re complex. There are Federal fraud, waste, and abuse statutes such as on referrals (Anti-Kickback, Stark Law on self-referral), state Corporate Practice of Medicine Doctrine statutes, and medical licensure requirements for telehealth practices. Telehealth: The Beginner’s Guide to Legal Pitfalls is a short essay on what can face a medical practice in telehealth.

News roundup: Current Health’s Class II, Healthware Italy’s €10 million boost, the low state of Latin America telemedicine, weekend reading on digital health in health systems

Scottish startup gains FDA Class II clearance, pilots with Mount Sinai Brooklyn. Edinburgh’s Current Health has received FDA Class II clearance for its AI-enabled remote patient monitoring wearable monitors. The single arm-worn wearable sends data every two seconds on oxygen saturation, respiration rate, pulse rate, temperature, activity, and posture. Algorithms analyze the data and alert clinicians to patient status and deterioration. The Mount Sinai pilot follows on Dartford and Gravesham NHS Trust for a post-discharge monitoring program, with a 22 percent reduction in home visits plus fewer hospital readmissions and emergency department visits. Current Health is the renamed snap40. Mobihealthnews, BusinessWire release

Healthware, a Salerno, Italy-based consultancy group primarily concentrated in marketing and sales, has received a €10 million investment from Fondo Italiano d’Investimento SGR (FII Tech Growth). The investment will be used over the next two years has received to expand Healthware’s business transformation for life sciences companies and product development and services for digital health start-ups which improve health outcomes through new technologies. Release.  Hat tip to Healthware’s Antonietta Pannella

Telemedicine adoption in hospitals ranges from 65 to below 30 percent in Latin America. A study published this week in Health Affairs Global Health Policy (paywalled) looks at the different rates of hospital-based telemedicine adoption in nine Latin America countries. Leading is Chile with the aforementioned 65 percent; Argentina, Costa Rica, Mexico and Peru with less than a 30 percent. In the middle: Panama (35 percent), Uruguay and Guatemala in the 40 percent range. Despite supportive official policies in many of these countries, “Efforts to implement telemedicine are isolated and scattered, often left to the public sector or taking the form of insulated projects that are not sustained” or scaled up nationally and regionally. Mobihealthnews

For weekend reading. Intersecting with the Latin America story above is this. This Editor missed the October issue of Global Health: Science and Practice published out of Johns Hopkins, but here it is. The focus of the six articles is digital health integration into health systems in the US and internationally. Hat tip to Alain B. Labrique via Twitter

Digital health versus eHealth: ‘here we go again’ with the confusion and the differences. Plus Women in eHealth (JISfTeH)

Editor Donna (and Editor Steve before her) always likes a good dust-up about terminology. One of the former’s pet peeves is the imprecise usage of telemedicine (virtual visits) versus telehealth (remote patient monitoring of vital signs); she will concede that the differences have been so trampled on that telemedicine has nearly faded from use.

The Journal of the International Society for Telemedicine and eHealth (JISfTeH) makes a grand attempt to parse the differing definitions of digital health and eHealth in their opening editorial of this month’s (24 Jan) issueeHealth has fallen so far from use that the few times one does see it is in associations such as ISfTeH and the New York eHealth Collaborative. Even the World Health Organization, which has always been a fair arbiter for the industry, defined eHealth back in the salad days of 2005 as “the use of Information and Communication Technologies (ICT) for health”–broad, but workable. After a witty aside in defining digital health as “an area of healthcare focused entirely on fingers and toes” (plus), and examining the overly broad definitions of Eric Topol and Paul Sonnier, the authors Richard E. Scott and Maurice Mars seem to settle on this: that while digital health is given a  much broader but nebulous definition (to the point of linguistic absurdity cited in Mesko et al.), and may incorporate related technologies like genomics (another poorly defined term) and ‘big data’, it would not work without that ICT. And that at least there’s a settled definition for eHealth, as stated above, for which this Editor assumes we should be happy. In the author’s closing, “Will we be sufficiently motivated to rise to such a challenge-globally agreed universal definitions? If not ……here we go again …..”

This month’s journal theme is also Women in eHealth, with articles on Brazilian eHealth distance education, digital technology in midwifery practice, and how online social networks can work for drug abuse treatment referral. There’s also a change in format, with article links opening to full PDFs of each article.

The telehealth ‘entrepreneur’ whose $5 million funding bought stays at the Ritz and portfolios at Bottega Veneta

This curious and cautionary tale should be better known. A young entrepreneur named Keisha L. Williams from Ashburn, Virginia had an attractive proposition. She needed immediate funding to bring to the US an Austrian telehealth system described as “software that would allow doctors to remotely examine and talk with patients.” Ms. Williams had degrees in both law and electrical engineering, so credibility. She also had a story. The software was in ‘escrow’ in Austria. There were taxes and fees that had to be paid immediately. And she had family situations, financial and medical emergencies. In other words, she had a ‘great line of ‘stuff’ on the technology, urgency, and personally, a few tugs on the heartstrings.

Ms. Williams told this story enough times over four years, and to enough people who believed her–more than 50, who invested over $5.4 million.

What happened? 95% of the money was spent on over the top vacations to Bora Bora, Italy, the Bahamas, and Jamaica, plus the occasional yacht with ‘hand and foot services’ and shopping at top-end retail such as Bottega Veneta and Vuitton. $500,000 alone was spent on her girlfriend. About $300,000 was spent on the software.

The rest of the story involves 14 Federal fraud charges, four accomplices, and unwitting, likely vulnerable people who were talked into giving over their savings. Late in January, she was sentenced to 15.5 years in Federal prison.

Many of our Readers have started companies or worked with entrepreneurs who have a great story and need money. The stories touch our hearts–and sometimes our checkbooks. Apparently, Ms. Williams raised the money without exposing herself to anyone in the industry or private investors who would ask remotely leading questions. To us, this technology sounds hardly sexy–it’s telemedicine virtual visit software with maybe some remote patient monitoring thrown in. Yet to 50 people, who are now poorer or who were involved with the fraudulent scheme — it sounded really special. (The name is also common–there are quite a few people on LinkedIn with the same name, which may make life difficult for them.)

With the rising tide of telehealth, if your cousin or uncle has heard of a great way to visit your doctor over the phone and asks you if you’ve heard about it, you might want to ask Uncle to pass the pie as you switch the conversation to being on guard for fraudulent schemes. Washington Post (read the comments), Daily Mail, Seattle Post-Intelligencer, press releases 17 Oct and 18 Jan from the US Attorney’s office, Eastern District of Virginia

Short takes: Livongo buys myStrength, Apple Watch cozies with insurers, Lively hears telehealth and $16 million

Livongo gets behaviorally stronger with myStrength. Extending from their base in diabetes and chronic disease management into behavioral health, Livongo made a logical extension with early-stage behavioral health company myStrength. A large percentage of those with chronic conditions are also struggling with a behavioral health issue–Livongo cites 20 percent but in this Editor’s opinion, the estimate is low. Both Livongo and myStrength have been very successful in the payment game, with both companies achieving payment and reimbursement by employers, insurers, health systems, and state/Federal payers. The other factor is that employers and payers want single, integrated platforms for wellness and disease management. Livongo last year bought Retrofit for its weight management program. Competitor Omada Health recently acquired the behavioral health technology of defunct Lantern. MedCityNews, Fortune, Livongo release

Apple Watch wastes no time in partnering with insurers. Or vice versa! Confirming that Apple Watch’s growth strategy hinges heavily on health via its new features are fresh agreements with Aetna/CVS Health and a rumored reach into three Medicare Advantage plans. The Aetna partnership is with an app called Attain, which blends Apple Watch activity tracking data with users’ health history to create personalized programs. The program is limited to about 250,000 slots plus additional slots for employer plans, and will debut this spring. Late last year, United HealthCare announced Apple Watches would be added to existing wellness program called Motion and their Rally platform. Both Aetna and United have tiered payment programs for the watches, with United adding a HSA reward. For Medicare Advantage plans, Apple is rumored that they will subsidize the watch for use as a health tracker and coach. FierceMobileHealthcare 30 Jan (Aetna), 14 Nov 18 (UHC), and 29 Jan (Medicare Advantage).

Lively adds telehealth to hearing assistance. Lively’s mobile-connected, direct to consumer hearing aids are adding more telehealth features such as remote tuning, virtual video consults with an audiologist, and an online hearing assessment/uploading audiogram for assessment. The NYC-based company also announced closing on a $16 million seed/Series A fundraising round led by Declaration Capital with participation from Tiger Management. There are an estimated 35 million Americans with hearing loss in a $10bn annual market. Hearing aids are rapidly adding digital and DTC features–others in the field are Eargo and ReSound. Lively releaseAlleyWatch, Mobihealthnews. (Lively is not to be confused with Lively!, acquired by GreatCall two years ago)

Tunstall Americas sold to Connect America

Connect America, a PERS and telehealth/remote patient monitoring company based in suburban Philadelphia, Pennsylvania, has acquired Tunstall Americas, the US division of Tunstall Healthcare Group. Financial terms were not disclosed.

The Tunstall brand name will ‘sunset’ and transition to Connect America, according to the 29 January release. Tunstall employees and offices will, at least for now, be operating from their current locations. The combined company will have 1,000 employees, more than 300,000 shared subscribers, and over 1,000 healthcare network partners. 

Connect America is a private company, founded in 1977, and is estimated to have between 250 and 500 employees (Crunchbase); both companies are roughly equal in size. Their website states that they are the largest independent provider of PERS in the US. They market traditional and mobile PERS under the brands Medical Alert, Alert 911, Alert365, AlertMax365 for Men, and Caregiver365. The RPM devices are marketed under ConnectVitals. Richard Brooks, the president of the healthcare sales division, was formerly the president of Health Watch, which was the second largest PERS company in the US at the time of its sale to Philips.

Oscar Meyer, the president of Tunstall Americas, is quoted in the 24-7 Press Release headlined on the Tunstall Americas website, but it is not stated what position he will have in the merged company.

Tunstall Healthcare Group and its main investor, Charterhouse Capital Partners, have been quietly shopping the company for some years. In early 2017, Charterhouse and other shareholders were forced to relinquish nearly half the equity in the company to senior lenders and management amid a stunning £1.7bn debt burden at the end of September 2016 [TTA 7 Aug 2017]. The overall picture has improved somewhat, but is uneven especially in the home markets of UK and Ireland. A report in healthcare market intel company LaingBuisson News on 15 May 2018 reported on Tunstall’s financials for the FY closing 30 Sept 2017. While global revenue improved by 9.1 percent to £240.6m, UK and Ireland revenue fell 11 percent to £82.7m. A welcome sign was that losses narrowed to £46m to £391m, not breakeven but a substantial positive change. Reports on Companies House are not available yet for the 2018 closing.

Despite acquiring AMAC, the third-largest PERS company in the US back in 2011, Tunstall Americas never made much of a dent in the well-established US PERS market nor the difficult telehealth/RPM market, and had gone through many management changes in the past decade. A sale of the US operation, in this context, makes complete sense. Cision-PR Newswire Release. (Interestingly, the US sale release is not on the Tunstall corporate website as of today.)

Where’s the evidence? Healthcare unicorns lack the proof and credibility of peer-reviewed studies.

Another sign that too many healthcare unicorns are decoupled from the rock-solid fundamental reality–that they work. Healthcare unicorns–those startups valued over $1 bn–are unicorns because they have patents, processes, or a line of business that has immense potential to be profitable. The standard in healthcare, unlike other tech, is the peer-reviewed study. Is this process or device effective based upon the study? Does this drug looks like it will work? Is this study validating, encouraging? Peer-reviewed research takes place before a drug or device goes into clinical trials — a precursor. It ensures a certain level of disclosure, validation, and transparency at an early stage.

Instead, these unicorns largely rely on ‘stealth research’–a term coined by Dr. John P.A. Ioannidis, the co-director of the Meta-Research Innovation Center at Stanford University (METRICS). He summed it up in his latest peer-reviewed paper, “Stealth research: lack of peer-reviewed evidence from healthcare unicorns” (co-authored with Ioana A. Cristea and Eli M. Cahan), published in the European Journal of Clinical Investigation 28 Jan: 

In 2014, one of us (JPAI) wrote a viewpoint article coining the term “stealth research” for touted biomedical innovation happening outside the peer-reviewed literature in a confusing mix of “possibly brilliant ideas, aggressive corporate announcements, and mass media hype.”

The term ‘stealth research’ was prompted to the author by the practices of Theranos–ironically, a company that started and was funded in the Stanford nexus. By the time Dr. Ioannidis’ viewpoint paper was published in JAMA in Feb 2015, Theranos had ballooned to a $9 bn valuation. His paper was the first to question Theranos’ science–and Theranos aggressively pushed back against Dr. Ioannidis, including their general counsel attempting to convince the author to recant his own writing. Three years later, we know the outcome.

This latest study concludes that there is a real dearth of peer-reviewed research among healthcare unicorns–and that it’s detrimental. It measured whether these unicorns published peer-reviewed articles and whether they publish highly-cited (in other publications) articles; compared them against companies with lower valuations; and whether founders or board members themselves impacted the scientific literature through their own citations.

The meta-study looked at 18 current and 29 exited healthcare unicorns. Highlights:

  • Two companies–23andMe and Adaptive Biotechnologies published almost half of all unicorn papers–196 combined
  • Three unicorns (Outcome Health, GuaHao and Oscar Health) had no published papers, and two more (Clover Health, Zocdoc) had published just one
  • Seven of the exited unicorns had zero to one papers
  • In fact, ‘there was a negative, non-statistically significant association between company valuation and number of published or highly-cited papers’

As our Readers know, Outcome Health had a little problem around artificially inflated advertising placement wrapped in health ed and placed in doctors’ offices [TTA 29 Jan 18]. Oscar and Clover Health are insurers. Zocdoc…well, we know their business model is to get as many doctors to sign up in their scheduling app and pay as much as possible. But it’s the drug and device companies that are especially worrisome in a stealth research model. The paper points out among other examples StemCentrx, bought for $10.2 bn in 2016 by AbbVie for its Rova T targeted antibody drug for cancer treatment, was halted at Phase III because it was not effective. Acerta Pharma, also focused on cancer treatments, was bought by AstraZeneca for $7.3 bn; two years ago, AstraZeneca had to withdraw the Acerta data and admit that Acerta falsified preclinical data for its drug.

The conclusions are that healthcare unicorns contribute minimally to relevant, high-impact published research, and that greater scrutiny by the scientific community through peer-reviewed research is needed to ensure credibility for the underlying work by these startups. “There is no need for numerous papers. Discrete pivotal, high-impact articles would suffice.”

This Editor returns to #5 on Rock Health’s Bubble Meter: high valuations decoupled from fundamentals. Based on this, the lack of publishing represents risk–to investors and to patients who would benefit from better vetted treatments. To these companies, however, the risk is in having their technology or researched poached–as well as the investment in time and money research represents.

The study authors point out several ways to minimize the risk, including collaborating with academic centers in research, validation without disclosing all technical details, secure patents, and contributing their technology to other research. A higher-risk way is to “withhold significant publications until successful validation from agencies such as the Food and Drug Administration (FDA) or the European Medicines Agency (EMA)” but usually investors won’t wait that long. ‘Stealth Research’ paper, TechCrunch review Hat tip to David Albert, MD, of AliveCor via Twitter

News roundup: Virginia includes RPM in telehealth, Chichester Careline changes, Sensyne AI allies with Oxford, Tunstall partners in Scotland, teledermatology in São Paolo

Virginia closes in on including remote patient monitoring in telehealth law. Two bills in the Virginia legislature, House Bill 1970 and Senate Bill 1221, include remote patient monitoring (RPM) within their present telehealth and telemedicine guidelines and payment in state commercial insurance and the commonwealth’s Medicaid program. It is currently moving forward in House and Senate committees with amendments and. RPM is defined as “the delivery of home health services using telecommunications technology to enhance the delivery of home health care, including monitoring of clinical patient data….” Both were filed on 9 January. Virginia was an early adopter of parity payment of telemedicine with in-person visits. The University of Virginia has been a pioneer in telehealth research and is the home for the Mid-Atlantic Telehealth Resource Center. mHealth Intelligence

Chichester Careline switches to PPP Taking Care. Chichester Careline is currently a 24/7 care line services provided by Chichester District Council. Starting 1 March, PPP Taking Care, part of AXA PPP Healthcare, will manage the service. According to the Chichester release, costs will remain the same, technology will be upgraded, and telecare services will be added. Over the past 35 years, Chichester Careline has assisted over 1 million people across Britain. 

Sensyne collaborates with University of Oxford’s Big Data Institute (BDI) on chronic disease. The three-year program will use Sensyne’s artificial intelligence for research on chronic kidney disease and cardiovascular disease. Sensyne analyzes large databases of anonymized patient data in collaboration with NHS Trusts. BDI’s expertise is in population health, clinical informatics and machine learning. Their joint research will concentrate on two major elements within long-term chronic disease to derive new datasets: automating physician notes into a structure which can be analyzed by AI and integrating it into remote patient monitoring.  Release.

Tunstall partners with Digital Health & Care Institute Scotland. The partnership is in the Next Generation Solutions for Healthy Ageing cluster. Digital Health & Care supports the Scottish Government’s TEC Programme and the Digital Telecare Workstream. The program’s goals are to help Scots live longer, healthier lives and also create jobs.  Building Better Healthcare UK

Teledermatology powered by machine learning helps to solve a specialist shortage in São Paolo. Brazil has nationalized healthcare which has nowhere near enough specialists. São is a city with 20 million inhabitants, so large and spread out that when the aircraft crew announces that they are on approach to the airport, it takes two hours to touch the runway. The dermatology waitlist was up to 60,000 patients, each waiting 18 months to see a doctor. The solution: call every patient and instruct them to go to a doctor or nurse to take a picture of the skin condition. The photo is then analyzed and prioritized by an algorithm, with a check by dermatologists, to determine level of treatment. Thirty percent needed to see a dermatologist, only 3 percent needed a biopsy. Accuracy level is about 80 percent, and plans are in progress to scale it to the rest of Brazil. Mobihealthnews.

The King’s Fund ‘Digital Health and Care Explained’ 27 March

https://www.kingsfund.org.uk/events/digital-health-and-care-explained?utm_source=Telehealth&utm_campaign=J1083#topicsAs briefly mentioned earlier this month, The King’s Fund in London will be previewing digital health with ‘Digital Health and Care Explained: demystifying the tech revolution in health and care”, a full day meeting on Wednesday 27 March at The King’s Fund. The ‘demystification’ will include policy challenges, operational innovations, research breakthroughs–and the practical aspects of making a ‘radical transformation’ real. Registration and session information is at the link above and here. Follow the event on Twitter at #KFexplain

And put on your calendar the Digital Health and Care Congress Wednesday-Thursday 22-23 May in London. Our Readers are eligible for a 10% discount using the link above or in the sidebar, plus the code Telehealth_10.

Bayer’s G4A accelerator awards agreements with KinAptic, Agamon, Cyclica (DE)

KinAptic (US), Agamon (Israel/UK), and Cyclica (Canada) are the three winners of Bayer’s 100 day G4A accelerator program. They now move to collaboration agreements with Bayer to further develop their products and services.

The final three were picked from six who were awarded a 100-day intensive in Berlin from the end of August. They in turn were selected from over 1,800 competitors from 100 countries. All six represent an interesting spread of innovative companies that have developed specialized applications that can positively impact everyday patient health.

KinAptic specializes in biometric wearables, including VR and sensor-based electrical stimulation, for several medical applications: stroke rehabilitation, pain mitigation, muscle re-education, fitness tracking, strength training, and tremor mitigation. KinAptic was one of the winners of MedStartr Momentum 2017 in NYC, which was co-sponsored by Bayer G4A. (TTA is a sponsor and supporter of MedStartr, including Momentum 2017).

Agamon is a healthcare intelligence platform that collects, structures, and evaluates data to support clinical trial candidate identification out of unstructured medical reports. With Bayer, they plan to deploy their platform into two to three hospitals as a testing ground.

Cyclica uses AI and biophysics to accelerate drug development. Specifically, they are developing algorithms based on biophysics to gain new insights into the polypharmacological profiles of small molecules and to expedite discovery of new medicines through structural pharmacogenomics.

The three runners up were OME (personalized health coaching–UK), S-There Technologies (health data via urinalysis–ES), and Zencorlabs (AI for heart failure–DE). We look for more news from all six in the future. Hat tip to Joseph Curcio of KinAptic via LinkedIn. Bayer G4A announcements: winners and the accelerator program.

NHS England digital head Bauer exits for Swedish medical app Kry, but not without controversy

Juliet Bauer, who is departing NHS England’s chief digital officer post after 2 1/2 years for the sunnier shores of Appdom, has apparently also taken a splash in hot water on her way there. She is joining Sweden’s Kry (Livi in the UK), a GP telemedicine app available in Europe and the UK in an undisclosed product executive role. Livi offers NHS and private services for video consults, including a current contract with GPs in Surrey. 

The event that has sparked the controversy was Ms. Bauer’s article on digital health in the Times (paywalled) on 14 Jan praising Kry/Livi without disclosing publicly that she is joining the company in April. She stated that data provided by Kry/Livi showed “higher levels of patient and GP satisfaction while at the same time delivering higher patient safety and medical quality as well as crucial improvements in lowering prescription of antibiotics.” To add to it, the claim was not backed up with details nor, in reports, did the article cite other medical companies.

‘Brazen,’ ‘jaw-droppingly inappropriate’, and a ‘puff piece’ was how the article was characterized by Meg Hillier, the Labour MP who chairs the Commons public accounts committee. Even Simon Eccles, her soon-to-be-former colleague who is CIO of health and care, chimed in that the article was a mistake by a colleague he called ‘fantastic’ in her advocacy for centering NHS around the individual. Ms. Bauer worked on the recently disclosed 10 year plan, but the key leaders were Dr. Eccles, NHS Digital boss Sarah Wilkinson, West Suffolk Hospitals Foundation Trust head Steve Dunn, and NHS England deputy chief exec Matthew Swindells. Dr. Eccles to the press dismissed any influence by her towards her future imployer.

Ms. Bauer was NHS England’s first chief digital officer, starting in July 2016. She was responsible for patient-focused digital dubbed Empower the Person, including NHS 111, the app library, and the NHS app. According to the internal memo obtained by HSJ revealing her departure, it is with ‘with immediate effect’. Replacing her from 4 February on an interim basis will be Tara Donnelly, the current chief executive of the Health Innovation Network.

The brazenly revolving door of civil servants to companies and vice versa is common on both sides of the Atlantic. Former senators, congressmen, and generals–and those well down the greasy pole–find new employment at lobbyists, companies and industries they used to oversee. Influence and connections, as well as expertise, count for a great deal in the real world. In the private sector, sometimes there are non-solicit or non-compete (the latter unenforceable in many states) agreements, with exceptions for highly regulated and conflict-prone businesses, such as insurers.

Conflict of interest? Too close for comfort to this Editor. In a publicly-funded, contract based healthcare system like the UK’s, the departure of Ms. Bauer for a company contracting with the NHS, without being specifically excluded from dealing with the NHS–in fact, in her departure statement saying quite the opposite–has raised the spectre of conflict of interest. This Editor would also question her judgment in accepting the position without said exclusion–but that was likely the reason she was hired! Will this go away soon? Probably not for at least a week! More in the Financial Times (may be paywalled), The Register 11 Jan and 22 Jan, iNews

Events, Dear Friends, Events: UK Telehealthcare, Mad*Pow HXD, dHealth Summit

UK Telehealthcare is hosting two events at Hammersmith Town Hall, King St. London W6 9JU on 7-8 February. The 7th is a Suppliers’ Forum, the 8th is for Providers. For more information, contact Gerry Allmark, UKTHC’s Managing Director, at gerry@uktelehealthcare.com. UKTHC is also partnering with Naidex on 26th-27th March at NEC, Birmingham. Naidex is Europe’s largest event for the disability and independent living sector with over 250 CPD-accredited seminars and the latest in assistive technology, accessible business advice and more. Registration and more information here.

Two events have moved from NYC to the Boston/Cambridge area, reinforcing that much of entrepreneurial health tech is moving away from the primary cities of New York and San Francisco to secondary–and more affordable (well, slightly!) areas. The first is Mad*Pow’s Health Experience Design (HXD) Conference on 2-3 April at the Royal Sonesta Boston in Cambridge. The conference will be centered on the design and delivery of transformative health services, behavior change interventions, and digital solutions. Information and registration here.

The second is the dHealth Summit on 11 June at State Room Boston.  The University of Rochester in collaboration with West Health organizes this two-day annual conference, now in its fifth year, to foster disruptive technological and process innovations to improve the lives of the nation’s aging population. The pre-conference kickoff on 10 June is themed around caregiving and is at AGENCY CIC Headquarters in Cambridge. Speakers represent a cross-section of care delivery companies, insurers, innovators, and non-profits. What this Editor enjoyed about past conferences was their interactive setup and a fairly select group of attendees. More information and registration is here.

And don’t forget our earlier listings here for Matt Hancock at the RSM 28 Jan, the NOLA Health Innovators Challenge (applications extended to 27 Jan), plus event at the RSM and The King’s Fund (see TTA 9 Jan). In Dallas the Health Wildcatters have their Challenge on 8-9 Feb and there’s more in our 10 Jan roundup.

Telemedicine virtual visits preferred by majority in Massachusetts General Hospital survey

The results are far better than parity with in-person visits for follow up. A group of 254 patients and 61 health care providers were the subject of a survey conducted by researchers at Massachusetts General Hospital, part of Partners HealthCare, and Johns Hopkins. It found that virtual video visits (VVVs) are perceived by the majority of patients as the same as or better than office visits in convenience and cost, at the same level of quality and personal connection. It measured responses from both patients and providers in the MGH TeleHealth (sic) program, in place since 2012, in follow up care from providers in psychiatry, neurology, cardiology, oncology and primary care (the last two added late in the survey).

The results were: 

  • The vast majority (94.5%) of patients preferred the travel time (minimal) and time convenience (79.5%) of the VVV
  • Most patients (62.6%) and clinicians (59.0%) reported “no difference” between VVV and office visits on “the overall quality of the visit.”
  • When rating “the personal connection felt during the visit”, over half–but more patients than clinicians–said that there was “no difference” with the VVV (patients, 59.1%; clinicians, 50.8%), although 32.7% of patients and 45.9% of clinicians reported that the “office visit is better”.
  • They were also willing to pay for it–and that increased with distance from the doctor. Among those who traveled more than 90 minutes to an office visit, 51.5% indicated they would pay a co-payment of more than $50 for a VVV compared with 30.4% of those who traveled less than 30 minutes.
  • Results graphs are here

The survey results were published in the American Journal of Managed Care. This month’s issue also examines gamification in healthcare, asynchronous communication between primary and specialty care practitioners at Geisinger, EHRs–and the relationship between data breaches and not surprisingly increased advertising expenditures after the fact to rebuild lost trust. According to this last article, breached hospitals were more likely to be large, teaching, and urban hospitals relative to the control group.

Also UPI and HealthDay.

Medicare Advantage model covering telehealth for certain in-person visits starting in 2020

Another small step for remote monitoring and visits. Late last week, the Center for Medicare & Medicaid Services (CMS) announced a limited expansion of telehealth (remote patient visits) coverage as part of the Value-Based Insurance Design (VBID) model. In 2020, plans can apply to use telehealth as part of their coverage. According to the CMS release, Medicare Advantage (MA) is testing a new series of service delivery approaches, including “increasing access to telehealth services by allowing plans to use access to telehealth services instead of in-person visits, as long as an in-person option remains, to meet a range of network requirements, including certain requirements that could not previously be fulfilled through telehealth.” Other MA additions under the VBID mode include expanded rewards and incentives for beneficiaries for health improvement, and reduced cost sharing and additional benefits to enrollees, including those around chronic conditions or socio-economic status, such as aid around social determinants of health. 

The VBID model is administered under CMS’ Center for Medicare and Medicaid Innovation (Innovation Center, also CMMI), which tests innovative payment and service delivery models to lower costs and improve the quality of care. It began in 2017. The CMS VBID page lists 14 participating plans concentrated in a few states; however, it was open to 25 states this year. The 2020 model expands to 50 states under the Bipartisan Budget Act of 2018 plus will accept other MA plan types such as Special Needs Plans and Regional PPOs. Applications will start later this year. CMS press releasemHealth Intelligence 

It’s not a bubble, really! Or developing? Analysis of Rock Health’s verdict on 2018’s digital health funding.

The doors were blown off funding last quarter, so whither the year? Our first take 10 January on Rock Health’s 2018 report was that digital health was a cheery, seltzery fizzy, not bubbly as in economic bubbles.  Total funding came in at $8.1 billion–a full $2.3 bn or 42 percent–over 2017’s $5.7 bn, as projected in Q3 [TTA 11 Oct]–which indicates confidence and movement in the right direction.

What’s of concern? A continued concentration in funding–and lack of exiting.

  • From Q3, the full year total added $1.3 bn ($6.8 bn YTD Q3, full year $8.1 bn) 
  • The deals continue to be bigger and fewer–368 versus 359 for 2017, barely a rounding error
  • Seed funding declined; A, B, C rounds grew healthily–and D+ ballooned to $59M from $28M in 2017, nearly twice as much as C rounds
  • Length of time between funding rounds is declining at all levels

Exits continue to be anemic, with no IPOs (none since 2016!) and only 110 acquisitions by Rock Health’s count. (Rock only counts US only deals over $2 million, so this does not reflect a global picture.)

It’s not a bubble. Really! Or is it a developing one? Most of the article delivers on conclusions why Rock Health and its advisors do not believe there is a bubble in funding by examining six key attributes of bubbles. Yet even on their Bubble Meter, three out of the six are rated ‘Moderately Bubbly’–#2, #3, and #5–my brief comments follow. 

  1. Hype supersedes business fundamentals (well, we passed this fun cocktail party chatter point about 2013)
  2. High cash burn rates (not out of line for early stage companies)
  3. Unclear exit pathways (no IPOs since ’16 which bring market scrutiny into play. Oddly, Best Buy‘s August acquisition of GreatCall, and the latter’s earlier acquisitions of Lively and Healthsense didn’t rate a mention)
  4. Surge of cash from new investors (rising valuations per #5–and a more prosperous environment for investments of all types)
  5. High valuations decoupled from fundamentals (Rock Health didn’t consider Verily’s billion, which was after all in January)
  6. Fraud or misuse of funds (Theranos, Outcome dismissed by Rock as ‘outliers’, but no mention of Zenefits or HealthTap)

Having observed bubbles since 1980 in three industries– post-deregulation airlines in the 1980s, internet (dot.com) in the 1990s, and healthcare today (Theranos/Outcome), ‘moderately’ doesn’t diminish–it builds to a peak, then bursts. Dot.com’s bursting bubble led to a recession, hand in hand with an event called 9/11.

This Editor is most concerned with the #5 rating as it represents the largest divergence from reality and is the least fixable. While Verily has basically functioned as a ‘skunk works’ (or shell game–see here) for other areas of Google like Google Health, it hardly justifies a billion-dollar investment on that basis alone. $2 bn unicorn Zocdoc reportedly lives on boiler-room style sales to doctors with high churn, still has not fulfilled its long-promised international expansion, and has ceased its endless promises of transforming healthcare. Peleton is a health tech company that plumps out Rock Health’s expansive view of Health Tech Reality–it’s a tricked out internet connected fitness device. (One may as well include every fitness watch made.)

What is the largest divergence from reality? The longer term faltering of health tech/telecare/telehealth companies with real books of business. Two failures readily come to mind: Viterion (founded in 2003–disclosure, a former employer of this Editor) and 3rings (2015). Healthsense (2001) and Lively were bought by GreatCall for their IP, though Healthsense had a LTC business. Withings was bought back by the founder after Nokia failed to make a go of it. Canary Care was sold out of administration and reorganized. Even with larger companies, the well-publicized financial and management problems of publicly traded, highly valued, and dominant US telemed company Teladoc (since 2015 losing $239 million) and worldwide, Tunstall Healthcare’s doldrums (and lack of sale by Charterhouse) feed into this. 

All too many companies apparently cannot get funding or the fresh business guidance to develop. It is rare to see an RPM survivor of the early ’00s like GrandCare (2005). There are other long-term companies reportedly on the verge–names which this Editor cannot mention.

The reasons why are many. Some have lurched back and forth from the abyss or have made strategic errors a/k/a bad bets. Others like 3rings fall into the ‘running out of road and time’ category in a constrained NHS healthcare system. Beyond the Rock Health list and the eternal optimism of new companies, business duration correlates negatively with success. Perhaps it is that healthcare technology acceptance and profitability largely rests on stony, arid ground, no matter what side of the Atlantic. All that money moves on to the next shiny object.(Babylon Health?) There are of course some exceptions like Legrand which has bought several strong UK companies such as Tynetec (a long-time TTA supporter) and Jontek.

Debate welcomed in Comments.

Related: Becker’s Hospital Review has a list of seven highly valued early stage companies that failed in 2018–including the Theranos fraud. Bubble photo by Marc Sendra martorell on Unsplash

It’s Official: CES is now a health tech event (updated)

CES is now, officially, a health tech event. It’s not just the timing before CES of the flashy but apparently cratering JP Morgan annual healthcare investment conference in the absurdly pricey venue of San Francisco (FierceBiotech on the #MoveJPM backlash; the general disillusion with it expressed well here). It’s the fact that whatever mainstreaming health tech has actually accomplished, it’s far better represented in Las Vegas. Always a place of beginnings, endings, fun, gambles taken, lack of sleep, and sore feet, health tech fits right in, big or small.

CES reported that 2019 boasted an increase of 25 percent health-related exhibitors and a 15 percent increase in the amount of floor space dedicated to health tech. One winner was a big gamble by a small company–Living in Digital Times, which organizes and stages the Digital Health SummitTen years later, it turned out to be right place, right time for the founders who work hard to keep it on trend. Lifestyle, robotics, self-care, assistive tech (even exoskeletons), wearables, cosmetic “wellness” devices like P&G’s Opté, and Alexa-type home assistants/robots all now fit into the CES purview. Trial balloons by young companies, AI-powered concept devices from big companies, watches (including the Apple-beater Move ECG from the revitalized Withings TTA 10 Oct 18 and Omron’s HeartGuide), and robots all appeared. Samsung again brought out a brace of concept robots. Last year’s Best of CES ElliQ is finally available for pre-order after three years at a measly $1,500. The humanoid Sophia brought a kid sister, the equally creepy Little Sophia, both of whom failed during this CNET video. Yes, Pepper from Softbank made its appearance and apparently didn’t wilt as it did last year.

Sleep tech was another hot item, with a spin on sleep diagnostics or improvement from many products. A brainwave product, Urgonight from France, claims to be able to train your brain to sleep better. (Send one to Rick Astley who was a poster child for not Sleeping.)  Mental health is a natural crossover into sleep tech and robots, with a $5,000 Japanese robot, Lovot, capable of responsive cuddling and comfort.

Best of the coverage:

  • CNET has probably the best coverage and articles on health which stick to the facts (slim in some cases as they are); anyone who wants to catch up with the feel and flavor of this three-ring circus can start and stay there. Their full show coverage is here.
  • Dr. Jayne at HISTalk also did an excellent health-related product roundup in her Curbside Consult column.
  • Mobihealthnews also has a very long running list of health tech pictures and announcements as part of its limited coverage, including the mea culpas and promised transparency of onetime health ed unicorn Outcome Health [TTA 29 Jan 18].

Beyond the plethora of products encouraging ever more to come forward, what ones will even make it to market, far more be winners? Aside from the Samsungs and P&Gs, which of these young companies planting their stake at CES will be there next year?  As in past CES, the wheel goes round and round, and where it stops, nobody knows–not even the JPM investors.