This article examines the future of healthcare in a post-COVID-19 world as gleaned from the HLTH VRTL 2020 online mega-conference. It also explores the impact of the future state on the care of chronic inflammatory diseases, my area of focus. As I engaged in virtual sessions and networking, I viewed them through my lenses as a financial analyst, business consultant, and patient.

In keeping with my mission at Your Autoimmunity Connection, I constantly kept one question in mind. How could these post-COVID changes help patients with autoimmune and autoinflammatory conditions?

How did HLTH VRTL work out?

I love going to conferences, from the anticipation of adventure with my well-worn suitcase and beloved travel clothes. Plus the excitement of meeting new people in the most unlikely locations: bathrooms, hallways, and elevators. For me, conferences have been intermittent opportunities to take the pulse of digital health.

In the past, HLTH has been one of the best such adventures. In 2019, I shared a room with Mette Dyhrberg, founder of Mymee, a great way to collaborate on our joint missions to improve research, diagnosis, and care for autoimmune patients.

This year, 2020, the Year of the COVID-19 pandemic, is different. With safe travel options limited, we are all adjusting to virtual conferences.

I am happy to report that the HLTH VRTL platform execution was superb. During an entire week of online presentations and one-on-one virtual meetings, the platform never crashed. In fact, that dreaded circular buffering icon never once appeared. Kudos to the HLTH VRTL tech team for creating a seamless virtual conference experience.

First impressions of HLTH VRTL 2020

First impressions are key. HLTH did a great job setting the stage. They started with an inspirational video and followed with an informative statistics video.

Among the myriad of tracks, I found the daily recaps with Andy Slavitt, Leona Wen, and John Brownstein to be useful and informative. These helped me to quickly identify the healthcare delivery trends that I think might be important to chronic autoimmune and autoinflammatory patients.

Below are highlights of selected sessions, framed by my analysis and commentary on how disruptive post-COVID drivers of change might help create a new normal that will better meet the current and future needs of autoimmune patients.

The disruptor: COVID-19 forced rapid growth in telemedicine and remote patient monitoring.

In the “Future of Telehealth,” section of the HLTH Counterpoint Series, Tina Reed, Executive Editor of Fierce Healthcare, moderated contrasting perspectives on the future of telehealth from Roy Schoenberg, President, and CEO of Amwell (NYSE: AMWL), and Mario Schlosser, CEO of Oscar Health.

• Amwell – telehealth platform for all

Amwell is a leading telehealth platform provider in the United States and globally. It connects and enables stakeholders to deliver greater access to more affordable, higher quality care. These include:

• • • providers,
    • insurers,
    • patients,
    • innovators.

With over a decade of experience, Amwell powers telehealth solutions for over 2,000 hospitals and 55 health plan partners with over 36,000 employers, covering over 80 million lives.

Roy Schoenberg, CEO of Amwell, said,

“The coronavirus has shown people that delivering healthcare with technology has a role to play. We have a strong voice for the payer and provider, maybe we are beginning to see the arrival of the patient voice…If we can create a gratifying experience for the people that we serve over the long term that is a winning strategy.”

He continued,

“There is an important question as to whether these technologies are part of the delivery or the payer side of care.”

He sees a future where group practices are enabled by technology to be more easily accessible to patients while providing great customer service and communication. Rather than viewing telehealth as just another “tool”, he believes that a “home run” would be when:

”Telehealth is a care setting in which traditional medicine is delivered and the home front will be the most coveted care setting.”

How does this apply to autoimmune care?

Chronic disease patients, especially autoimmune and autoinflammatory disorders patients, need ongoing support between regularly scheduled appointments. The expanding use of telehealth may benefit them.

Telehealth can enable more frequent, convenient, yet less costly encounters from patients’ homes. This is even more true if telehealth is not just replacing PCP encounters but augmenting them with coaching and other staff. Coordinating with specialists is another important feature for chronic and autoimmune disease patients, but that doesn’t seem to be as far advanced.

• Oscar Health – Beyond insurance

Oscar Health is a hybrid insurance company, telemedicine platform, and primary care provider, based in the Pacific Northwest. Founded in 2012, Oscar Health was the first direct-to-consumer (DTC) health insurer. It facilitates member engagement with their own full-stack technology platform that handles both the insurance side and the care delivery side of the business. This includes:

• • • claims processing workflows,
    • benefits adjudication,
    • prior authorizations,
    • features to support telemedicine, remote patient monitoring, and care collaboration and coordination.

Oscar is one of many companies building variations on care teams to improve coordination, delivery, and customer service while controlling costs. These teams, which Oscar calls concierge care guides, can help patients do the following:

• • • find a physician or specialist,
    • coordinate their care,
    • navigate billing and benefits.

This approach: digitally supported personalized care teams led by nurses, coordinated by guides (aka coaches), and physicians. The personalized care teams provide a range of care, including chronic disease plans, which is similar to ideas we’ve proposed from 2014 on to help CID patients navigate their complex ongoing care.

Mario Schlosser, CEO of Oscar Health, told HLTH that the COVID boost to telehealth is a

“huge opportunity to bend the cost curve and increase the number of touchpoints (visits) and therefore reduce the variation in care.”

For autoimmune and autoinflammatory disorders patients, more telehealth visits and remote monitoring of symptoms, medications, etc. between appointments could help them reduce flares, better manage side effects, and avoid costly emergency care and hospitalizations.

Schlosser sees a future where there will be more remotely enabled physician practices that take on the financial risk themselves so that

“the number of physician visits go up, but the price goes down.”

Implications for autoimmune patients

In conclusion, telemedicine and remote patient monitoring are enabling technologies, much needed. However, they have not yet directly focused on autoimmune or autoinflammatory disease care.

Using telehealth to expand access, speed, and the number of encounters, along with the expanded use of care-based team models that include specialists, could potentially benefit autoimmune patients.

Likewise, remote patient monitoring can enable better chronic autoimmune disease care. However, this will only occur if payers, providers, and platform companies finally focus on this invisible opportunity, as costly and complex as cancer.

The driver: faster migration from FFS to VBC enables new payment & reimbursement models

Value-based care (VBC) offers a new financial foundation for healthcare delivery business model experiments. From the perspective of autoimmune patients, I wonder if the VBC payment models better support the long-term, multiple-modality care coordination that such patients need, but have generally not received from FFS delivery models?

Bryony Winn did a great job setting the stage, asking why this is a good time to discuss “A Push Into Value-Based Care”, as she asserted that:

1. 1. The COVID pandemic shows that perverse incentives make FFS unsustainable for providers. However, VBC’s steady revenue models may better align payers, providers, and patients.
   2. We now have evidence from programs that were launched and tested mainly by the government over a decade ago, that VBC can work to reduce costs and improve outcomes.
   3. An open question: what kind of provider networks work best under VBC?

From my perspective, FFS has not been a good model for chronic disease management, let alone, chronic antiinflammatory, and autoimmune diseases. The key question is, will VBC payment models support providers and practices to provide better care for lifelong chronic inflammatory patients?

• Hospital-led ACO – Mass General Physicians Organization

The Massachusetts General Physicians Organization (MGPO) is the largest multi-specialty medical group in New England and one of the largest in the U.S.

Dr. Timothy Ferris- CEO of Mass General Physician Organization, said,

“I do not see [hospital-led ACOs vs independent physician practice-led ACOs]as an either-or? [Hospital-led ACOs] have capital that can be redeployed in ways that generate benefits for the system and patients…The key thing is investing in the infrastructure and services that the FFS model does not pay for.”

These include:

• • • high-risk care managers,
    • tracking hypertension patients,
    • embedded mental health services.
    • other proactive preventive strategies.

How can big ACOs compete with new, inexpensive retail FFS offerings? For example, DTC apps such as HIMS, HERS, Keeps, etc. offer one-stop, doc-in-a-box shopping for popular prescription drugs. Other competitors include big point-of-care retailers, like CVS and Walgreens, for acute care, vaccinations, prescriptions, etc.

Ferris continued,

“I think that integrated delivery systems of the future will have to find a model to deliver low-end services.” (flu shots, etc.) as cheaply as their new competitors. “But most of our spend is not on low-value care, but rather on folks who are very sick.”

In part because many very sick patients present with multiple comorbidities, any provider’s ability to reduce the spending on these sick folks is limited.

“We can show that large integrated delivery systems were able to reduce overall system costs by 2%”.

How could big hospital systems apply this to autoimmune patients?

Dedicated care managers (similar to those tracking hypertension patients) could help autoimmune patients with treatment support needs between regular appointments. They could also help foster more proactive flare-prevention strategies.

Autoimmune and autoinflammatory conditions are costly to manage and not just because of specialty medications. However, avoiding flares and thus even more expensive episodes of emergency care and hospitalization strike me as low-hanging fruit, high-return investments for big hospital systems.

Yet this unmet need is an opportunity that seems generally to have been overlooked. Maybe the emergence of post-COVID syndromes, which look very much like autoimmune reactions, will force big provider systems to come to grips with the unseen epidemic of immunological and inflammatory diseases.

More Content by the author: 
HLTH: Uncovering Innovations to Help Patients with Immune-Mediated Diseases

• Physician-led ACO – Aledade

Aledade is a platform company that partners with primary care physicians to help them build and lead their own Accountable Care Organizations (ACOs).

Farzad Mostashari, the co-founder and CEO of Aledade, told us that 6 years ago they bet that independent PCP ACOs would win over hospital-led ACOs. The independents were not burdened with the large financial overhead of hospital systems. Therefore, Aledade saw an opportunity to

“Go with those with the most to gain and the least to lose from VBC.”

As of 2020, Aledade serves 550 practices and 7000 clinicians with $10 billion under management.

“It is working and it’s growing.”

Aledade provides regulatory expertise, technology, data analytics, business transformation services, and upfront capital. In addition to all the other elements, independent practitioners need to succeed in value-based care.

Patients are not seeing reduced care. Mostashari said we can offer “more screening, more immunizations, better blood pressure control.”  Patients are getting primary care that is “more accessible, more informed, and more engaged.”

Overall, they claim an 8-13% reduction in the total cost of care. Savings vary by state.

Will this improve autoimmune care?

Providing affordable, easy to integrate, off-the-shelf IT infrastructure and other business process support tools as well as data management for primary care docs could enable them to better compete with large hospital systems. This might also enable them to offer more timely, accessible care to chronic disease patients, including autoimmune patients.

This leaves open the question of how specialists, much utilized by autoimmune and chronic inflammatory patients, fit in. Specialist practices have thrived under supply-restricted, high-demand FFS models.  And so far have not been eager to participate in digitally-enabled care team practices.

Once more, maybe the pandemic disruption to cash cows like colonoscopy will accelerate the previously sluggish migration of specialists to VBC models.

Conclusion of Part 1 of Healthcare in a Post-COVID-19 World

Telemedicine and remote patient monitoring are two necessary but not sufficient enabling technologies for better autoimmune care delivery. Making care more accessible from patients’ homes through telemedicine, apps and the expanded use of care-based team models could potentially benefit those with chronic immune conditions, who need more frequent touchpoints on their care journeys.

The changing reimbursement landscape, from fragmented, uncoordinated FFS to patient-centered (or at least capitation or episode-of-care coverage) VBC may also better financially support care delivery for autoimmune patients. Especially those patients on specialty meds who need monitoring, management, and support between regular physician and specialist visits.

Such care should also include non-pharmacological modes like physical therapy, exercise coaching, diet management, sleep, and mental health support. Some of these pieces are being incorporated into some of the new care delivery models. However, the chronic disease focus has been on cancer, diabetes, and cardiopulmonary disease, not inflammatory, immunological, autoimmune or autoinflammatory conditions.

The conference focused on bringing virtual primary care into the home or at least to the smartphone. However, I have unanswered questions concerning the role of specialists in these new models. How will team-based care coordination integrate the multiple specialists (e.g. rheumatologist, gastroenterologist, dermatologist, neurologist) many autoimmune patients need to guide chronic care?

Part 2 focuses on new delivery models and the competition for the digital front door from inside and outside traditional healthcare.