‘Warning flare’ study: will pandemic-induced digital health solutions get renewed by hospitals in 2023-4, or will they churn?

June 15, 2023 | by

Hospitals and health systems in 2020 and 2021 were desperate for virtual solutions. But comes the reckoning now that they have returned to 1) business as (mostly) usual and 2) even more financial shortfalls. Technology and software contracts typically run three to five years, with new vendor contracts usually three or four. Did these solutions work as implemented? Probably on a spectrum of very well to ‘kinda’. But did they return the desired results in care quality, financially on investment or simply add to the fixed costs which aren’t affordable anymore?

Panda Health, a company that consults with hospitals on digital health adoption, did research via Sage Growth Partners in March 2023 surveying 100 hospital C-suite executives and leaders to assess whether they were satisfied with their current digital health solutions acquired in the pandemic period, whether they would renew with the same vendors, or search for new vendors. While this survey size is small and hedged, the directional prediction is that there will be considerable churn–turnover–among vendors in 2023-25, but not in every one of the 11 areas surveyed have the same risk.

Not unexpectedly, the highest churn risk is projected to be among telemedicine/e-visits and remote patient monitoring (RPM)–the two areas most kickstarted by the pandemic. Lower risk was found in functional areas such as self-service patient scheduling, digital care coordination, patient acquisition/activation, and IT areas such as data lakes and data fabric. Five categories are in the middle.

Telemedicine/E-Visits: 97% of surveyed health executives stated that the pandemic crisis played a role in their acquisition decision. 47% were ‘moderately’ to ‘not satisfied’ with their choices. 30% of these contracts will expire this year and next. In projecting this against a US total of 6,414 hospitals, 1,693 may be changing solutions by the end of 2024.

Remote Patient Monitoring: The pandemic kickstarted RPM adoption by hospitals. 82% of hospitals deployed their solutions since the pandemic began with 19% within the past 12 months. 53% reported that they were ‘moderately’ to ‘not satisfied’ with their choices. With 33% of contracts expiring by 2024, the study estimates that 1,058 hospitals may be changing their solutions.

A different picture–Digital Care Navigator/Website Chatbot: Only 14% of respondents adopted these solutions, all within the past two years. Only 25% of contracts come due during 2024, with 55% coming due in 2025 and the remainder presumably in 2026 and beyond. Yet of all 11 categories, 63% of executives reported some level of dissatisfaction, with 38% ‘not satisfied’–the highest percentage in the study. 197 hospitals are projected to consider changing solutions by the end of 2024. 

Even low/moderate and low churn solution categories have moderate (‘moderately’ to ‘not satisfied’) levels of dissatisfaction that edge close to 50%. Exceptions are the last two categories, Data Lakes and Patient Acquisition. Fair warning to all companies who are selling digital health into hospitals–it’s time for your customer success teams to get busy, find out where their pain points are, and who’s feeling them.

The Great Shakeup (free report, PDF download). Panda release.  Hat tip to HIStalk 14 June

ISfTeH Student Contest and Award 2023, Friday 16 June

June 8, 2023 | by

The International Society for Telemedicine and eHealth (ISfTeH) will be presenting the second session of this annual contest. Four students in this cohort will be presenting their work in the field of telemedicine and digital health via Zoom on Friday, 16 June, 2:00pm CEST (UTC+2, US Eastern Daylight Time 8:00am, BST 1:00pm).

The use of 3D technology in Medical Education: an experience report
Iasmin Lourenço Ribeiro, Rio de Janeiro State University, Brazil
 
Integration Between Medical Graduation and Professional Master’s Degree in Telemedicine and Telehealth at a Brazilian Public University
Juliana Magalhães Aguiar Cardoso, Rio de Janeiro State University, Brazil
 
Captar-Libras: Video Communication System for the deaf applied to pre-medical care
Lucca Fagundes Ramos de Oliveira, Universidade Federal de Ouro Preto, Brazil
 
Social Media as a Tool to Enhance Training and Patient Recruitment in a Large Trial With Patients With Hypertension and Diabetes in Minas Gerais – Brazil
Taiza dos Santos Azevedo, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Brazil

The first session was in April. From the earlier presentations and these, a jury will assess and score the presentations. Gold, silver, and bronze medals (with a cash prize) will be awarded to the three best presentations.

The ISfTeH Student Contest and Award and the prize for the winners are supported by ISfTeH member Medgate.

If you are working at a school or university and would like your students to be involved in future editions of the contest, or if you want your students to become members of the ISfTeH, contact our ISfTeH Student Membership coordinator, Dr. Simone Farah.

Perspectives: How AI and ML can accelerate the growth of telemedicine across the globe

May 31, 2023 | by

TTA has an open invitation to industry leaders to contribute to our Perspectives non-promotional opinion area. Today’s Perspectives is from Deepak Singh, a thought leader in AI and telehealth. In his work, he builds AI-powered healthtech and telehealth solutions that can reach from big cities to remote areas of the world. With double master’s degrees in business and information systems, he has 10 years of experience in product development, management, and design ranging from telecom to multimedia and from IT solutions to enterprise healthcare platforms. This article discusses how artificial intelligence (AI) and machine learning (ML) can accelerate the global growth of telemedicine, including a consideration of risks and possible solutions.

Introduction

The ongoing technological advancements have led the way towards greater opportunities for the growth of the global health business, particularly telemedicine through increased connections via the internet, robotics, data analytics, and cloud technology that will further drive innovation over the next ten years. It is obvious that artificial intelligence (AI) usage plays a noteworthy part in the maneuvering and execution of medical technologies when considering the bulky amount of data handling needed by healthcare, the requirement for consistent accuracy in complex procedures, and the rising demand for healthcare services.

Telemedicine is the practice of performing consultations, medical tests and procedures, and remote medical professional collaborations through interactive digital communication. Telemedicine is an open science that is constantly growing as it embraces new technological developments and reacts to and adapts to the shifting social circumstances and health demands. The primary goals of telemedicine are to close the accessibility and communication gaps in four fields: teleconsultation, which is having all kinds of physical and mental health consultations without an in-person visit to a medical facility; teleradiology, which uses information and communication technologies (ICT) to transmit digital radiological images (such as X-ray images) from one place to another; telepathology, which uses ICT to transmit digitized pathological results; and teledermatology, which uses ICT to transmit medical information about skin conditions.

AI has been progressively implied in the field of telemedicine. AI deals with machine learning (ML) that discloses complex connections that are hard to figure out in an equation. In a way that is similar to the human brain and neural networks that encrypt data using an enormous number of interconnected neurons, ML systems can approach difficult problem-solving in the same way that a doctor might do by carefully analyzing the available data and drawing valid judgments.

A growing understanding of artificial intelligence and data analytics can help to broaden its reach and capabilities. Telemedicine’s goal is to boost productivity and organize experience, information, and manpower based on need and urgency and it can be augmented by the use of AI and ML.

Evolving application of AI and ML in Telemedicine

In order to enable clinicians to make more data-driven, immediate decisions that could enhance the patient experience and health outcomes, AI is being employed in telemedicine more and more. The use of AI in healthcare is a potential approach for telemedicine applications in the future.

Al and ML were able to bring about the necessary revolution in so many sectors due to their competence, increased productivity, and flawless execution of tasks. AI is now surpassing the boundaries of being a mere theory and stepping into a practical domain where the need for human supervision for the execution of jobs by machines will be minimized all due to the presence of enormous datasets along with an increment in the processing power of that data. A computer-based algorithm that uses AI has the ability to analyze any form of input data such as ‘training sets’ using pattern recognition which eventually predicts as well as categorize the output, all of that is beyond the scope of human processing or analytical powers that uses traditional statistical approaches. In the field of telemedicine, the adoption of AI and ML still has to go a long way till its vital concepts are understood and applied likewise, nevertheless, the current scenario gives a promising picture where many research projects have applied AI to predict the risk of future disease incidence, decrypting cutting-edge imaging, evaluating patient-reported results, recording value-based metrics, and improving telehealth. The perspective to mechanize tasks and improve data-driven discernments may be comprehended by profoundly improving patient care with obligation, attentiveness, and proficiency in prompting AI.

Drawbacks of artificial intelligence in telemedicine (more…)

Some thoughts on Teladoc and the Week That Was in telehealth

May 4, 2022 | by

Yes, your Editor has, for the past few weeks, felt like Pepper the Robot, moving at two speeds–crazed and off. (‘Off ‘ to the left. Now cart me off.) Home renovations, with strangers tramping through your abode, noise, dust, and the corresponding moving of furniture, packing and unpacking, pre- and post-cleaning, then trying to put things right and get your life back will do that. Add to that an unexpected gushy kitchen sink that took three ‘fixes’ to get actually fixed. Then there were technical problems with our email sender that Editor and Administrator Emeritus Steve had to work through. One becomes more appreciative of order, routine, and Peace and Quiet.

Speaking of Peace and Quiet, there is little to be found in telehealth. Instead, there is a lot of Feeling Off. The Big News of late last week, of course, was Teladoc’s troubles. In the words of Seeking Alpha, they had one horrific quarter. The horror show started with writing off the Livongo acquisition– a noncash goodwill impairment charge of $6.6 billion, for a massive loss of $41.11 per share for a total of $41.58 per share. To compare, last year’s Q1 loss was $1.31 per share. While revenues were up almost to projection (25%), it was still a $3 million miss and in context, it was the cherry on a very nasty sundae. After rosy projections last year, Teladoc lowered their 2022 revenue guidance from $2.6 billion to $2.45 billion.  

Moving forward from the questionable Livongo acquisition at the absolute peak of the market, CEO Jason Gorevic admitted some hard truths to investors that deepened the hole: much more competition, particularly in telemental health; the rising cost of paid search advertising and the keywords driving towards direct-to-consumer telehealth driving up the cost of acquisition; and difficulty closing B2B deals. This creates, in the terms of analyst SVB Leerink’s Stephanie Davis quoted in FierceHealthIT, “a direct-to-consumer air pocket that business-to-business sales (and their inherently longer cycles) are too slow to fill” at least, in her view, until the end of the year.

Teladoc’s difficulties, as this Editor has noted, started after a peak in early 2021 as the pandemic started its protracted wind-down and telehealth volumes plunged to well below 5% of claims as practices reopened. The stock value is down over 90% from last February, not helped by a volatile market triggered by war and inflation. Similar difficulties are plaguing Amwell (down 92% since February 2021), Talkspace (down to a paltry 16 cents and in court for misleading investors), SOC Telemed (taken private at a 70% drop in value, TTA 8 Feb), and other health tech companies. For our Readers, this is no surprise: the telehealth bender is ovah.

One industry leader in a post-ATA conversation with this Editor cited a less obvious factor–that hospitals and other health providers are now putting together their own telehealth/triage packages tied into population health and case management software, with and without ‘white label’ providers such as Bluestream Health and Zipnosis (acquired by insurtech/payvider Bright Health a year ago). Teladoc is a late entry to this provider/payer market with Primary360, where they also compete with Babylon Health [TTA 7 Oct 22]. And health retailers have joined the primary care telehealth game. Walmart last week announced a virtual health diabetes care program for employers through their recently acquired MeMD.

Big Telehealth’s troubles may depress investment in related earlier stage companies–or help those in niches such as telemental and population health, or remote patient monitoring (RPM) systems that have telehealth features (e.g. TytoCare), as VC investment seeks a brighter home. Right now, this Editor’s Magic 8 Ball is saying ‘outlook, cloudy”. 

American Telemedicine Association sets up ATA Action for policy advocacy

January 22, 2022 | by

The American Telemedicine Association (ATA), which has been known for its advocacy of telemedicine and telehealth since 1993 (!), is doubling down with setting up a separate “affiliated trade organization”, ATA Action, for policy advocacy. This is centered on making permanent pandemic-expanded telehealth access for Americans, state and federal telehealth coverage, and appropriate payment policies. ATA Action will be led by Kyle Zebley, ATA vice president, public policy, as executive director. There is a long list of ‘founding members’ and ‘Advocacy Council Members’ listed in the ATA release.

Key policy advocacy is centering on nine major points, including: 

  • Removing the in-person telemental health requirement
  • Increased broadband access
  • Coverage through federal programs such as Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), the Indian Health Service, TRICARE, and the Veterans Health Administration
  • Telehealth across state lines while maintaining state authority to regulate the clinical practice
  • Remove regulatory roadblocks to decentralized clinical trials
  • Align Medicare coverage of remote patient monitoring with how it is practiced

ATA is also confirming that their 2022 annual meeting will be in-person at the Boston Convention & Exhibition Center 1-3 May. Information and registration are here.

Rock Health/Stanford U Digital Health Adoption Report: high gear for telemedicine, digital health, but little broadening of demographics

March 3, 2021 | by

It’s good news–and an antidote to the bubble at the same time. Rock Health and Stanford University Medicine-Center for Digital Health’s just-released report found that, unsurprisingly, that telemedicine/telehealth use rocketed during the pandemic and gained ground that would not have been true for years otherwise, as of September 2020. However, the growth was not largely from new demographics, but largely among the adopters of telehealth in 2019 and prior. It also rolled back to about 6 percent of visits. Wearable use also boosted, especially for better sleep, as did self-tracking. But overall healthcare utilization cratered from March onward, barely reviving in the late summer, and telemedicine use declined to a steady state of about 6 percent of all visits–far more than the near-zero it was pre-pandemic. Here’s our rundown of the highlights.

Telemedicine user demographics haven’t changed significantly. It accelerated among those in the 2019 and prior (through 2015) profile: higher-income earners ($150K+), middle-aged adults aged 35-54, highly educated (masters degree and higher), urban residents, slightly male skewed (74 percent men/66 percent women/67 percent non-binary)and those with one or more chronic conditions (78 percent) and high utilizers (87 percent with 6+ visits/year). This profile apparently sustains across racial and ethnicity lines. (page 15) The non-user profile tends to be female, over 55, lower-income, rural, not on a prescription, and Hispanic. (page 23)

More usage of live virtual video visits than before–11 points up from 32 to 43 percent. These reduced reliance on non-video communications: telephonic, text, asynchronous pictures/video, and email. (page 12) And respondents largely accessed live video and phone visits through their doctor, indicating a pivot on practices’ parts: 70 percent of live video telemedicine users and 60 percent of live phone telemedicine users. (page 17) But the reasons why were more acute than this Editor expected: 33 percent for medical emergency, then minor illness (25 percent), then chronic condition (19 percent). (page 16)

Barriers to use remain significant in telemedicine and have not changed year to year except for awareness of options. (page 22-23)

  • Prefer to discuss health in-person (52 percent)
  • Not aware of options (much less this year)
  • Provider didn’t recommend
  • Cost
  • Poor cellular or broadband connection is minimal (3 percent). There is also no barrier of ‘inability to use’, though this may be skewed by the survey group being online (see methodology).

Wearables and digital information tracking accelerated, but ‘churn’ continued. 54 percent of respondents adopted wearables, up 10 points, while information tracking increased by 12 points.  (page 11) Unpacking this:

  • The populations with the highest rate of digital tracking were those with heart disease, diabetes, and obesity as chronic conditions
  • The leading reasons for wearables remained fitness training and weight loss. However, right behind these were major year-to-year spikes in better sleep (27 to 52 percent), managing a diagnosed condition (28 to 51 percent), and managing stress (24 to 44 percent).
  • The surprise uses of wearables? Managing fertility tracking and menstrual cycle.
  • Yet wearables churn continues. From the study: 55 percent of respondents who owned a wearable in 2020 stopped using it for one or more purposes (though they may continue using it for another purpose). The demographics tend to mirror telemedicine users for adoption and stopping use. (pages 24-28)

Healthcare utilization overall, telemedicine or not, has barely revived versus the March baseline, using the Commonwealth Fund data TTA profiled here. The report usefully digs into the groups that delayed care: 50 percent of 35-54-year-olds, women, Northeast residents, chronic conditions, and mental health. (page 34)

Yet trust in health information remains with the person’s physician, family, hospital, payer, and pharmacy. Overall, there is a reluctance to share data with entities beyond these. Health tech and tech companies aren’t trusted sources, along with social media, and lag to less than 25 percent, along with less willingness to share data with them. COVID-19 data is broken out in sharing, generally following these trends except for more willingness to share this data with governmental entities and research. (pages 29-31) 

The report recommends that for telemedicine to go deeper into adoption, refocusing is in order: (page 21)

  • Shift from a transactional model to a continuous virtual care or ‘full-stack’ model
  • Seek a different kind of customer. One-third of telemedicine visits were for emergencies. A more sustainable model would concentrate on chronic condition management and lower-acuity care.
  • Accept that new care models are disintermediating the patient-provider relationship especially in the younger age groups

The methodology of the survey: N=7,980 US adults, matched to US demographics; dates conducted 4 September-2 October 2020; online survey in English only. Rock Health summary, link to free survey report download, Mobihealthnews article.

The shape of telemedicine during the first half-year of the pandemic: significant but wildly uneven usage

February 5, 2021 | by

There has been a plethora of tracking studies starting last year on how telemedicine stepped in for in-person visits during the early months of the COVID-19 pandemic. Telehealth visits peaked, then tapered off as medical offices reopened. Reviewing our articles:

  • Commonwealth/Phreesia: tracking the latter’s practices, they dropped from a high of 13.9 percent on 18 April to 6.3 percent by early October. Where telemedicine use stayed high was behavioral health–psychiatry–which remained at 41 percent.
  • Epic Health Research Network’s data, which concentrated on hospitals and clinics, showed a similar drop from the mid-April high of 69 percent but ended August at 21 percent. Regionally, the South had the least takeup of telehealth even in the critical period. 
  • FAIR Health, using insurer claims data, tracked with Commonwealth/Phreesia from 13 percent in April to 6 percent by August.

The latest study has been just published in Health Affairs (abstract free, paid access full study). Using data from 16.7 million commercially insured and Medicare Advantage enrollees from January to June 2020, the steep rise from a negligible base was the same but the percentages were between the Commonwealth and Epic studies. 30.1 percent of all visits were provided via telemedicine (including telephonic) and the weekly number of visits increased twenty-three-fold compared with the prepandemic period. The database also permitted a deeper analysis of usage.

  • Telemedicine use was lower in communities with higher rates of poverty (31.9 percent versus 27.9 percent for the lowest and highest quartiles of poverty rate, respectively). Unfortunately for comparison, not included in the information was the actual rate in wealthy counties.
  • Overall visits (in-person and virtual) plummeted by 35 percent, a backlog in deferred care still being made up
  • Rural telemedicine use was lower than urban–24 percent versus 31 percent by county
  • How specialties incorporated telehealth varied widely. As previously reported, psychiatry had a high uptake of telemedicine and reported the least drop in overall visits. Surprisingly, endocrinology (68 percent) and neurology also had high utilization. Only 9 percent of ophthalmologists reported telehealth use, because the physical exam requires highly specialized equipment. 
  • Management of chronic conditions was in between those two extremes. Conditions like hypertension and diabetes had a big drop in care volume that was mitigated by a large increase in telemedicine use.

Healthcare Dive 

COVID-19 and telehealth–promise or peril? And the perils of digital health in conflict countries and India.

January 14, 2021 | by

The Journal of the International Society for Telemedicine and eHealth (JISfTeH) has published its latest issue today (13 Jan). JISfTeH is one of the few journals which shine a bright spot on digital health in developing countries. This month concentrates on conflict countries and COVID in India: 

  • Scaling Up Digital Health In Conflict Countries discusses the lack of any form of digital health and coordination in Afghanistan, Somalia, Sudan, and, with some exception, Nigeria. It compounds the extreme lack of healthcare services–for instance, 23 percent of Afghanis have poor access to healthcare, resulting in a high mortality rate. It can change. Rwanda, once synonymous with war, has one of the best healthcare systems in Africa due to the use of digital health services. India is using digital health in combating the TB explosion of 300,000 cases in one year. The exception in Nigeria is the liftoff of 54Gene, a genomic studies company in the world’s most genetically-diverse continent, which has secured $4.5 million in seed funding.
  • Speaking of India, telehealth has been kickstarted there due to COVID-19. The Indian Government is prioritizing the use of telehealth in the population and both public and private institutions have rolled out initiatives. India’s challenges are how patients pay for it (70% of healthcare expenses out of pocket) and how it reaches the two-thirds of population in rural areas where there is inadequate telecom and broadband for services. The irony, of course, is that India is a huge exporter of software and telecom services to the world. COVID-19 As A Catalyst for Telehealth Growth In India: Some Insights.

The editorial by Richard E. Scott of Canada and Prof. Maurice Mars of South Africa, COVID-19 and eHealth: A Promise or Peril Paradox?, cautions on the floodgates opening for telehealth in COVID’s wake. Spontaneous telehealth, where “healthcare providers themselves saw the value of an eHealth solution and implemented it independently and without traditional steps or approval” is quite separate from evidence- and needs-based telehealth. There is a lot of pressure at the national level, by the WHO, and by vendors to ‘make hay while the sun shines’. “Enthusiasm must be tempered with thoughtful guidance” on multiple and quite variable factors.

Telemedicine office visits versus in-person recede to 6%, concentrating in behavioral health. Will the gains hold?

October 29, 2020 | by

Has the telehealth wave receded to a ‘new normal’ tide? An updated Commonwealth Fund/Phreesia/Harvard University study, including data through 4 October, confirms that we are far past the point of telemedicine dominance of the office visit. Office visits to providers have largely returned to the 1-7 March baseline and even slightly above for ages 6 and above. But telemedicine visits, from their high in this study of 13.9 percent on 18 April during the peak of the COVID-19 pandemic, have continuously dropped and have leveled off to 6.3 percent. (Telemedicine here includes both video and telephonic visits; the sample is 50,000 providers that are Phreesia clients.)

To put this in proper perspective, the pre-pandemic baseline of telemedicine in practice use was an infinitesimal .1 percent.

Larger organizations use more telemedicine than smaller ones. Primary care practices with 6 or more physicians in the group account for 9.4 percent of telemedicine visits, while practices of 1 to 5 physicians account for 4.3 percent.

Even so, by September, only 9 percent of practices were heavy users (20 percent +) of telehealth, compared to 35 percent in April. Minimal use (5 percent or less) moved up to 39 percent. One-third never used telemedicine at all–did they shut down completely?

For those seeking to segment the overall telehealth market, the chart detailing telemedicine in visits to medical specialists is of interest. It confirms the anecdotal information this Editor has heard that telehealth remains highly popular and used in behavioral health (psychiatry)–41 percent of visits. By comparison, the next most popular are rheumatology and endocrinology at 14 percent of visits. The pandemic apparently has forever changed the mental health visit and acceptance of non-face-to-face delivery, with interesting (isolating?) consequences for both patients and doctors.

crystal-ballCan telehealth hold this gain, and develop from this base? What will it look like for the average practice? Pay the lady with the crystal ball! CMS will eventually roll back the waivers on usage of non-HIPAA platforms such as Facetime (appropriately so for security and privacy reasons). Reimbursement by Medicare and commercial plans will be a major hot button. A recent survey of health system executives presented at the HLTH virtual conference indicated yawning uncertainty at the top level:

  • 30 percent of respondents said they were unsure what their plans are if telehealth reimbursements return to pre-COVID levels
  • 13 percent said they’d return to face-to-face visits
  • 20 percent said they’d continue doing virtual visits regardless
  • 17 percent said they’d analyze the financial viability of continued use

(Nokia-UPMC Center for Connected Medicine and Klas Research, Healthcare Dive)

More on this: The hazy post-pandemic future of telehealth and From back-to-work to telehealth to retail rebranding: HLTH 2020 takeaways   

Previously: As practices reopen, telemedicine visits continue to plunge from 69% to 21%: Epic (September), COVID effect on US practices: in-person visits down 37%, telehealth peaks at 14% (Commonwealth Fund through July)

Digital health investment smashes the ceiling: $9.4 bn invested through 3rd Q

October 8, 2020 | by

$9.4 bn is a whole lot of bubbly! To no one’s surprise in the industry, kick-started by telehealth, Rock Health’s tracking of US digital health company investment through 3rd Q smashed through 2018’s full-year high point ($8.2 bn) with a cannonball of a total. Adding $4.0 bn to first half’s $5.4 bn, it represents 311 deals and is 27 percent above last year’s oddly fading-in-the-stretch $7.4 bn [TTA 7 Feb]. Rock Health projects the year total to be about $12 million and 400 deals. 

  • Average deal size topped $30.2 million, 150 percent greater than the $19.7 million average in 2019.
  • Driving this total were “mega deals” of $100 million or more, accounting for 41 percent of all deals (compared with 30 percent for year 2019). Even with the inclusion of fitness companies that this Editor does not consider true health tech, such as Zwift (interactive fitness entertainment), ClassPass (online fitness), and Tonal (more online fitness), the 20+ remaining companies indicate a concentration of Big Capital into Big Deals. The Big Deals concentrate in three sectors: on-demand virtual care delivery, R&D process enablement, and fitness/wellness.
  • Not surprisingly, telehealth and telemedicine are soaring: $1.6 bn in funding compared to $662 million same period 2019
  • Also pointing to concentration: 64 percent of this year’s investors have previously made investments in digital health, which exceeds any prior year. Institutional venture firms have the largest share of transactions (62 percent), with corporate venture capital accounting for 15 percent of transactions.
  • Given COVID and election year craziness, IPO action has moved right along and matched 2019’s six. Accolade and GoHealth in July; Amwell, Outset Medical, and GoodRx in September. Hims Inc. is merging with a blank-check company as SOC Telemed did in August. MDLive may be going public in early 2021.
  • What is down so far this year is merger and acquisition activity. Through September, there are only 63 acquisitions, which will likely trail by year’s end 2019’s 113. Teladoc is the 9,000 Elephant in M&A, with InTouch Health closing in August ($1 bn final due to the stock value soaring) and Livongo at $18.5 bn dwarfs the remainder. Optum-AbleTo has been reported in ‘advanced talks’ but there’s no confirmation of closing; it was reported to be at $470 million. 

Note: Rock Health only counts US deals in excess of $2 million, so international activity by companies like Doro are not included.

Also Mobihealthews.

DOJ ‘takedown’ charges 86 defendants with $4.5 bn in fraudulent telemedicine claims in largest ever action

October 2, 2020 | by

We unpack the 2020 National Health Care Fraud and Opioid Takedown. Closing out September was the largest simultaneous group of Department of Justice (DOJ) and Federal agency coordinated actions concerning fraudulent medical claims. The indictments charged 345 defendants, including 100 medical professionals, across 51 federal districts, for submitting fraudulent claims against Medicare and private insurance programs totaling over $6 bn.

The vast bulk–$4.5 bn–of the fraudulent claims were classified as ‘telemedicine’ and were perpetrated by more than 86 criminal defendants in 19 judicial districts. The remainder of the charges rounding to the $6 bn were for substance abuse treatment and opioid distribution fraud: more than $845 million connected to substance abuse treatment facilities, or “sober homes,” and more than $806 million connected to other health care fraud and illegal opioid distribution schemes across the country. 

These ‘telemedicine’ claims included unnecessary durable medical equipment (DME), genetic or diagnostic testing, and prescription drugs. The typical scam worked like this:

  • Telemedicine company executives paid doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and medications, often for pain, for patients
  • The patient for whom it was ordered had either no contact with the doctor or nurse practitioner or only a brief telephonic conversation. The person may not have been a patient of the practice.
  • DME companies, genetic testing laboratories, and pharmacies then purchased those orders in exchange for illegal kickbacks and bribes, then submitted false and fraudulent claims to Medicare, state Medicaid, and private insurers which are Medicare Advantage plan sponsors

Most of the Federal charges in the indictments here cite Federal anti-kickback statutes in both criminal and civil law.

The nationwide charges were executed by an alphabet soup of agencies at the Federal level:

  • Enforcement actions were by the Criminal Division, Fraud Section’s Health Care Fraud Unit, in conjunction with its Health Care Fraud and Appalachian Regional Prescription Opioid (ARPO) Strike Force program, and its core partners, the US Attorneys’ Offices, Department of Health and Human Services Office of Inspector General (HHS-OIG), the FBI, and the Drug Enforcement Agency (DEA)
  • Prosecution is by Health Care Fraud and ARPO Strike Force teams from the DOJ’s Criminal Division’s Fraud Section, 43 US Attorneys’ Offices nationwide, and agents from HHS-OIG, FBI, DEA, and other various Federal and state law enforcement agencies. 

Unpacking the actions which reveal some dizzying schemes, some of the more interesting individual cases against fraudulent ‘telemedicine’ in the 2020 National Health Care Fraud and Opioid Takedown took place in Florida and Illinois:

  • Middle District of Florida: a telemarketing operation collected the personal information of Medicare beneficiaries, purchased doctor’s orders for orthotic braces, and then submitted more than $25 million in claims to Medicare
  • Southern District of Florida: three telemedicine executives and three owners of durable medical equipment companies were charged and pled guilty in connection with more than $175 million in fraud loss
    • Editor’s note: none of the principals of QuivvyTech have been identified by this Editor in the ‘Takedown’ indictments and corresponding information documents listed for the Southern District. Humana’s civil suit against QuivvyTech is here [TTA 27 August]. 
  • Northern District of Illinois: seven defendants were charged with defrauding insurance programs of more than $205 million. One is a very busy doctor who, according to the indictment, was the top prescriber in the United States for multiple genetic testing billing codes. He worked for more than 10 telemedicine companies, was licensed in 17 states, and allegedly paid five of his friends and relatives to sign telemedicine orders in his name for medically unnecessary genetic testing and durable medical equipment. “In total, the scheme allegedly resulted in $145 million in false and fraudulent claims billed to Medicare and approximately $54.6 million paid by Medicare for claims associated with this doctor’s name.” 
  • Your Editor cannot resist the twist that ‘telemedicine’ fraud took in her home state of New Jersey. Two cases involving telemarketing, senior health fairs, and door-to-door sales (!) of genetic testing, including genetic cancer screening, had a total fraud value of nearly $1bn. A multi-jurisdictional case involving the District of New Jersey, the Middle District of Florida, and the Southern District of California also involved the ordering of orthotic braces signed off by ‘telemedicine’ doctors who didn’t speak or only briefly spoke to Medicare beneficiaries/members. $871 million purchased a great deal of real estate, personal luxury items, and nightlife events for the two owners of the DME companies involved, who incidentally entered guilty pleas.

A biotech extra. In the list of multi-jurisdictional actions is a scheme to mislead investors, manipulate a biotechnology company’s stock price, and defraud payers for COVID-19 and allergy testing. The company named in the complaint is Arrayit Corporation, a publicly-traded company (OTC) located in Sunnyvale, California. This was jointly prosecuted by the National Rapid Response Strike Force, the Market Integrity and Major Fraud Unit of DOJ’s Fraud Section, and the US Attorney’s Office for the Northern District of California. The separate Securities and Exchange Commission (SEC) charges on the veracity of their COVID-19 test is here. For those with a speculative bent, the current value of the stock is zero.

DOJ press release. Also FierceHealthcare’s overview.

Editor’s note: ‘Telemedicine’ has been placed in quotes to differentiate these scams from legitimate provider-patient telemedicine video/audio consults or telephonic medical visits which may involve patient diagnosis and prescribing. These are now more frequently called telehealth. The differentiation is already well understood by our professional Readers and is made for the benefit of our non-professional Readers who may view this article on Twitter and LinkedIn feeds, or via Google search. 

As practices reopen, telemedicine visits continue to plunge from 69% to 21%: Epic (US)

September 2, 2020 | by

The extreme high tide has receded–but still way up than before the pandemic.  The Epic Health Research Network (yes, that Epic EHR), updated its earlier study through 8 May [TTA 22 July] to compare in-office to telehealth visits through 12 July. The trend that EHRN spotted (as well as Commonwealth Fund/Phreesia/Harvard) continued with telemedicine visits declining as practices reopened. As of mid-July, telehealth visits, as a  percentage of national ambulatory visits, declined to 21.2 percent compared to 78.8 percent in-office. 

The new EHRN study used a broader sampling than previously. They surveyed healthcare providers of data: 37 healthcare organizations representing 203 hospitals and 3,513 clinics in 50 states. The decline in telehealth visits noted in early May continued, with May finishing with a national 50/50 split.

But in context, telehealth visits immediately before the COVID-19 pandemic were a whopping .01 percent. 

Regionally, the Northeast leads in July telehealth visits with 25 percent. The South has the least adoption of telehealth with only 13 percent. In terms of total office visits, neither the South nor West have rebounded to pre-pandemic levels, whereas the Northeast and Midwest have.

The key to the future of the telehealth bubble bath is if telehealth usage versus in-person stabilizes for several months. But there’s another factor which has come about through higher telehealth usage. Noted in our July article was speculation on the reasons why the sudden decline, other than practices reopening, most of which pointed to practice training, reimbursement, and older/sicker patients falling into the smartphone/digital divide. The STAT article has statements from telehealth providers which are quite bubbly and quotable, with the CEO of MDLive stating that new bookings are up 300 percent and mental health hasn’t declined. But a problem now surfacing is providing patients with the right care at the right time–and fitting it into the office schedule. What visits can best be handled as telehealth and which require an in-person visit? This Editor recalls that Zipnosis, a white-labeled telehealth system we haven’t heard from in a while, incorporated for health system applications a triage intake which would direct the patient to the right level of care. Can this be rolled out in a similar way to the practice level?

Is the NHS ready to adopt telemedicine through and through–and is telemedicine ready?

August 27, 2020 | by

This analysis by Dominic Tyer in Pharmaphorum discusses the rapid adoption of telehealth during the COVID pandemic, both telephonic and online, to keep people in touch with their doctors. Health Secretary Matt Hancock quantified the changes wrought as “I’ve lost count of the number of times someone said to me: ‘what would have taken months took minutes’.” The article goes on to quote him as saying that COVID-19 has “catalysed deep structural shifts in healthcare that were already underway”, citing as examples data-driven decision-making, working as a system, and telemedicine. In fact, to Secretary Hancock, “From now on, all consultations should be teleconsultations unless there’s a clinical reason not to.”

For all the advances, Mr. Tyer points out flaws such as safeguarding sensitive health issues, particularly for young people, use by rare disease patients and those with a genetic condition, and reaching the 10 percent of the population who do not use the internet. All of these are significant. He concludes that “in the UK there’s clearly the political will and healthcare backing for wider use of telemedicine by the NHS, despite some, as-yet not entirely resolved, technological and safety issues.”

Will the UK revert to ‘underuse’, as the US has rolled back as well as practices have reopened? (What is ‘underuse’ defined as anyway?) Will these issues be resolved or ignored in a push forward for telehealth? And teleconsultations as a norm, with in-person an exception, is perhaps at this time, and in improving health outcomes, an overreach? Hat tips to Roy Lilley of the nhsManagers.net newsletter and Steve Hards

While telehealth virtual office visits flatten, overall up 300-fold; FCC finalizes COVID-19 telehealth funding program (US)

July 22, 2020 | by

As expected, the trend of telehealth visits versus in-person is flattening as primary care offices and urgent care clinics reopen. Yet the overall trend is up through May–a dizzying 300-fold, as tracked by the new Epic Health Research Network (EHRN–yes, that Epic). Their analysis compares 15 March-8 May 2020 to the same dates in 2019 using data from 22 health systems in 17 states which cover seven million patients. It also constructs a visit diagnosis profile comparison, which leads with hypertension, hyperlipidemia, pain, and diabetes–with the 2020 addition of — unsurprisingly — anxiety.

POLITICO Future Pulse analyzed EHRN data into July (which was not located in a cross-check by this Editor) and came up with its usual ‘the cup has a hole in it’ observation: “TELEHEALTH BOOM BUST”. But that is absolutely in line with the Commonwealth Fund/Phreesia/Harvard study which as we noted tailed off as a percentage of total visits by 46 percent [TTA 1 July]. But even POLITICO’s gloomy headline can’t conceal that telehealth in the 37 healthcare systems surveyed was a flatline up to March and leveled off to slightly below the 2 million visit peak around 15 April. 

Where POLITICO’s gloom ‘n’ doom is useful is in the caution of why telehealth has fallen off, other than the obvious of offices reopening. There’s the post-mortem experience of smaller practices which paints an unflattering picture of unreadiness, rocky starts, and unaffordability:

  • Skype and FaceTime are not permanent solutions, as not HIPAA-compliant
  • New telehealth software can cost money. However, this Editor also knows from her business experience that population health software often has a HIPAA-compliant telehealth module which is relatively simple to use and is usually free.
  • It’s the training that costs, more in time than money. If the practice is in a value-based care model, that is done by market staff either from the management services organization (MSO) or the software provider.
  • Reimbursement. Even with CMS loosening requirements and coding, it moved so quickly that providers haven’t been reimbursed properly.
  • Equipment and broadband access. Patients, especially older patients, don’t all have smartphones or tablets. Not everyone has Wi-Fi or enough data–or that patient lives in a 2-bar area. Some practices aren’t on EHRs either.
  • Without RPM, accurate device integration, and an integrated tracking platform, F2F telehealth can only be a virtual visit without monitoring data.

Perhaps not wanting to paint a totally doomy picture (advertising sponsorship, perhaps?), the interview with Ed Lee, the head of Kaiser Permanente’s telehealth program, confirmed that the past few months were extraordinary for them, even with a decent telehealth base. “We were seeing somewhere around 18 percent of telehealth [visits] pre-covid. Around the height of it, we’re seeing 80 percent.” They also have pilots in place to put technology in the homes of those who need it, and realize its limitations.

Speaking of limitations, the Federal Communications Commission (FCC) COVID-19 Telehealth Program, authorized by the CARES Act, is over and out. The final tranche consisted of 25 applications for the remaining $10.73 million, with a final total of 539 funding applications up to the authorized $200 million. Applicants came from 47 states, Washington, DC, and Guam. FCC release. To no one’s surprise, 40 Congresscritters want to extend it as a ‘bold step’ but are first demanding that Chair Ajit Pai do handsprings and provide all sorts of information on the reimbursement program which does not provide upfront money but reimburses eligible expenditures. That will take a few months. You’d think they’d read a few things on the FCC website first. mHealth Intelligence

ATA’s annual conference now 22-26 June–and fully virtual; announces three awards and Fellows

June 12, 2020 | by

The American Telemedicine Association has reimagined their annual conference and gone fully virtual–including an exhibit hall and poster displays. This year’s theme is “Moving at the Speed of Innovation…. Accelerating Telehealth Adoption”–if it hasn’t accelerated enough during the COVID pandemic, there’s always consolidating the gains.

Perhaps due to the complete cancellation of HIMSS and the addition of Joe Kvedar, MD, incoming ATA President, this year’s ATA has a five-day menu of healthcare leaders and over 300 speakers in 100+ sessions. Here’s a sample from the keynotes:

  • Ken Abrams, MD, Chief Medical Officer, Deloitte Consulting
  • Rachel Dunscombe, CEO, NHS Digital Academy; Tektology
  • Jesse Ehrenfeld, MD, Chair, AMA Board of Trustees
  • Thomas Goetz, Chief of Research, GoodRx
  • Jennifer Goldsack, Executive Director, Digital Medicine Society
  • Victoria Guyatt, Head of Ethnography, IPSOS
  • Joe Kvedar, MD, Professor, Harvard Medical School; Senior Advisor, Mass General Brigham (Partners HealthCare); Incoming President, the ATA
  • Ali Parsa, Founder and CEO, Babylon Health
  • Suchi Saria, Assoc. Professor, Machine Learning & Data Intensive Computing Group, Johns Hopkins University and Bayesian Health
  • Jennifer Schneider, MD, President, Livongo
  • Michelle Segar, Director, Univ. of Michigan Sport, Health and Activity Research & Policy Center
  • Jeroen Tas, Chief Innovation & Strategy Officer, Philips Healthcare

Registration is priced gently at $450. Full information, schedule, and registration here.

ATA 2020 Awards

The ATA Champion award this year is to the Veterans Health Administration, US Department of Veterans Affairs. The VA has been a leader in telehealth and store-forward technologies since, well, 2002 or so. VA Video Connect last year had 1.3 million appointments. (Sadly, your Editor’s former company, Viterion, which pioneered with VA in a RPM platform, is not currently a telehealth/RPM vendor–VA’s sole vendor is Medtronic.)

The President’s Award for the Transformation of Healthcare Delivery went to The Children’s Health Virtual Care Program at Children’s Health in Dallas. They have pioneered telemedicine programs for children.

The ATA’s Woman of the Year is  Tania S. Malik, J.D., an entrepreneur and a lawyer focused on healthcare, and specifically, telehealth solutions that facilitate online patient-provider interactions for primary care, mental health treatment, and naturopathic and integrated medicine.

Six Fellows were also named to ATA’s College of Fellows. Release.

 

Telehealth and the response to COVID-19 in Australia, UK, and US: video

May 7, 2020 | by

Malcolm Fisk, whom our Readers know as Senior Researcher at the De Montfort University in Leicester, was kind enough to forward information on a recent video interview with André Martinuzzi of the Living Innovation Project, a Europe-wide innovation group with 14 partners ‘co-creating the way we will live in 2030’.

This 17:30-minute video covers a lot of ground on the UK response to the coronavirus (the uncertainty as of mid-April), how the UK, US, and Australia have used telehealth in response, and how telehealth can ‘stick’ after the crisis, but only if we design an inclusive infrastructure. You can view the video on the Living Innovation page by clicking on ‘View Video’ on the upper right hand side, or go directly to YouTube.

There’s a brief preview in the video of Dr. Fisk’s paper (awaiting publication, co-authored with Anne Livingstone and Sabrina Pit) on ‘Telehealth in the Context of COVID-19: Changing Perspectives in Australia, the United Kingdom and the United States’. Telehealth was very rapidly put into use for diagnosis, monitoring, and home treatment of COVID patients. Restrictions were lifted and investments made in communicating the availability of telehealth. However, the infrastructure for telehealth is strained, especially in the US with a mixed, primarily private model dependent on payers or individuals paying per virtual visit. In the UK, health trusts have encouraged the use of telephonic and audio/video models. In Australia, telehealth, particularly in remote areas, is well established. TTA will keep Readers posted on the publication of this paper. A big hat tip to Malcolm Fisk.