models of care post COVID world (COVID graphic)
Photo source: iStock

The 2020 HLTH VRTL conference focused on how the COVID-19 crisis is accelerating trends that are transforming healthcare. In this article, I will describe the picture painted by the speakers of what the soon-to-be post-COVID health care world will look like.

I viewed the conference through my multifocal lens as a financial analyst, consultant, and patient and in keeping with my mission at Your Autoimmunity Connection, I kept one question in mind:

How could these accelerating post-COVID trends help patients with the subset of chronic inflammatory diseases with which the organization is most concerned: autoimmune and autoinflammatory disorders?

Recap and link to Part 1

In Part 1 of this story, I described how COVID-19 has accelerated the use of telemedicine and remote patient monitoring. At the same time, it has speeded the migration from FFS by showing that a VBC reimbursement model can be a more reliable revenue stream for practices in disruptive times. These disruptor-driven trends have also spurred new primary care delivery models and consumer competition for the digital front door as described below. Companies highlighted in Part 1 were Amwell, Oscar Health, Massachusetts General Physicians Organization, and Aledade.

Emerging trends: new models of care

Novel, experimental primary care delivery models are emerging from inside and outside the current system. Not only big players (payers, providers, practice systems, and innovative employers), but also DTC online and walk-in acute care, “doc-in-a-box” online providers, drugstore, retail, and tech giants are all competing to be healthcare digital front doors.

New Models of Care
Submitted by author

1. Modifying existing integrated delivery systems

Geisinger Health System

Geisinger Health System (GHS) is a regional health care provider to central, south-central, and northeastern Pennsylvania as well as southern New Jersey. Headquartered in Danville, Pennsylvania, Geisinger’s footprint includes:

        • over 3 million patients in 45 counties 
        • 9 hospitals,
        • a 550,000-member health plan,
        • two research centers
        • Geisinger Commonwealth School of Medicine.

It has been widely recognized for delivering high-quality healthcare at a low cost through an integrated delivery system model.

Jaewon Ryu, the President and CEO of Geisinger, said,

“Primary Care is the front door and it is how we drive affordability. We have been on a journey during the last three years on which we have been redesigning primary care. We believe there is an opportunity to introduce different flavors for those with multiple chronic conditions.”

What does this mean for autoimmune and autoinflammatory care?

As a large integrated delivery system, Geisinger has already developed products and services that could potentially help autoimmune patients, such as:

      1. The “myGeisinger” patient portal: 24/7 appointments, message your care team, and more.
      2. Geisinger at-home program. Here is their list of the chronic conditions included:
        • cancer
        • dementia,
        • heart disease
        • kidney disease.

These are obvious targets for geriatric populations, but what about other chronic conditions that could benefit from home visits? That includes more severe autoimmune and autoinflammatory conditions, including chronic fatigue and post-viral (led by post-COVID) syndromes.

2. New models of primary care

One Medical

One Medical is a membership-based, technology-powered primary care model-of-care. It offers seamless digital health and inviting in-office care. The offices are convenient to where people work, shop, live, and go online. Their vision is to delight millions of members with better health and better care while reducing costs. Its mission is to transform health care for all through a human-centered, technology-powered model.

Their suite of services goes beyond the traditional primary care to include

        • 24/7 virtual care
        • same or next-day appointments
        • on-site lab services
        • longer appointments.

These types of services give patients more convenient access.

Amir Dan Rubin, CEO of One Medical, explained,

“We are trying to transform healthcare through our modernized primary care approach and simultaneously address the needs of key stakeholders.”

  He continued,

“We have created a staff model, HMO-like approach hidden in concierge sheep’s clothing. We have all salaried primary care providers. We have built our own software using machine learning to route the messages to virtual team members. In addition, we get reimbursed at an organizational level through conventional insurance. But we have also built the underlying incentives to deliver value-based, coordinated care.”

But will this improve autoimmune care?

Improvements in care collaboration and coordination, along with a more preventive mindset related to value-based care (VBC), could benefit autoimmune patients. However, care delivery models must to choose to focus on them.

One Medical’s chronic disease list, as usual, omits mention of autoimmune, autoinflammatory, and immune-related chronic inflammatory conditions. Until such conditions are more than an afterthought, these primary care innovations are unlikely to improve autoimmune/autoinflammatory care. Even though improved care for these types of patients could be a competitive edge for new companies if they seize the opportunity.

Firefly Health

Firefly Health is a virtual-first, primary care, behavioral health, and system navigation service. Their care teams include the following:

        • a health guide,
        • a nurse practitioner,
        • a behavioral health specialist, and
        • a primary care physician.

Their service offerings include same-day appointments, video visits, quick prescription refills, and more time with providers.

Fay Rotenberg, CEO of Firefly Health sees primary care as “bonding, steering, and health care fiduciary.”  She says,

“We are transforming from a reactive, transactional, doctor-centered model, towards a proactive, personalized, digitally-enabled approach that supports healthy behaviors to drive better outcomes and lower costs. Our mission is to provide half-priced healthcare that is twice as good clinically and emotionally.”

Firefly Health was designed with the consumer in mind so it is easy to use. First, download the app, then connect with your care team who can help you in person, virtually, and via chat.

Their tech-enabled digital care platform, Lucian™, is built to track users’ care over time. For diagnostic testing, Firefly has an extensive, curated network of partners, some of which offer in-home testing. In addition, their teams can manage chronic diseases such as diabetes and high blood pressure. For more serious conditions, they partner with specialists.

How might Firefly Health advance autoimmune care?

The Firefly Health tech-enabled digital care platform and coordinated care teams offer elements that could be directed to help autoimmune and other chronic immune disorder patients better manage their daily health issues. 

I can imagine how Firefly Health’s proactive personalized app could expand its functionality to help autoimmune patients with lifestyle modifications that could lower stress levels and reduce flares. But there’s no mention of chronic fatigue or autoimmune/inflammatory on their website. Instead, it’s just the usual mention of anxiety, diabetes, and high blood pressure as examples of chronic conditions.

They already have behavioral health specialists on care teams, and as we know, mental health issues, especially anxiety, loom large in autoimmune patients. Maybe mental health is the wedge to get Firefly Health to focus on immuno-inflammatory disease patients, too.  

Competition for the Digital Front Door 

Will community pharmacies be the next neighborhood healthcare destination, an increasingly digital front door to more than prescription and OTC products?

New Models of Care
Submitted by author

1. Walgreens – from pharmacy to retail clinics   

Walgreens is part of the Retail Pharmacy USA Division of Walgreens Boots Alliance, Inc., a global leader in retail and wholesale pharmacy. They operate more than 9,000 retail locations across America, Puerto Rico, and the U.S. Virgin Islands. Walgreens is considered a neighborhood health destination serving approximately 8 million customers each day.

Walgreens pharmacists provide a wide range of pharmacy and healthcare services. To best meet the needs of customers and patients, Walgreens offers a true omnichannel experience, Their platforms bring together physical and digital health care delivery mechanisms. They are supported by the latest technology to deliver high-quality products and services in local communities nationwide.

Alex Gourlay, the Co-Chief Operating Officer at Walgreens, thinks that

“Putting together the family doctor and the local pharmacist with HIPAA-compliant health information and providing really local solutions for patients and customers both physically and digitally will open the front door of health care.”

In the future, he believes that the local pharmacy will focus on health (prescriptions, counseling, and polypharmacy management), well-being (vaccines, blood pressure, and lipids monitoring) as well as some acute illnesses. He hopes that making the pharmacy an important part of the digital front door will increase preventive health by making it more available at lower costs, especially to people of lower socioeconomic resources.

Will this be a new front door for chronic autoimmune patients?

Walgreen is partnering with Village MD to open co-located doctorled primary care clinics. They explicitly mention targeting chronic disease patients, but we suspect that, as usual, they have diabesity, heart, lung, and kidney disease in their sights, not autoimmune/inflammatory.

It’s quite easy to see how this model could be helpful for autoimmune patients, e.g., early detection of rheumatoid arthritis and thyroid disease, but we will need to see if their plans even focus on this population.

New Models of Care
Submitted by author

2. CVS/Aetna – from retail Rx to a broader approach to healthcare

CVS/Aetna connects consumers with the health resources of CVS Health in communities across the country as well as among Aetna’s network of providers. The goal is to remove barriers to high-quality care and build lasting relationships with consumers. They hope to make it easier for them to access the information, resources, and services they need to achieve their best health.

CVS Health footprint includes the following:

        • 9,800 retail locations
        • approximately 1,100 walk-in medical clinics
        • a pharmacy benefits manager with approximately 93 million plan members
        • a dedicated senior pharmacy care business serving more than one million patients per year
        • expanding specialty pharmacy services
        • a leading stand-alone Medicare Part D prescription drug plan.

CVS Health also serves an estimated 39 million people through traditional, voluntary, and consumer-directed health insurance products and related services, including a rapidly expanding Medicare Advantage offering.

Larry Merlo, President, and CEO of CVS Health reflected that

“As a company, we are 20 months into transforming the business with CVS and Aetna coming together. The pandemic became an opportunity to reprioritize elements of the transformation journey to deliver health services, create new solutions, and make them accessible in nontraditional settings.”

He sees a future where they can play a role in fostering reliable public health information. Given the amount of dis- and misinformation around vaccines, the coming massive COVID vaccine rollouts are an opportunity for CVS as a major cold-chain distributor and vaccine dispenser to play a positive role.

Karen Lynch, EVP CVS Health and President of  Aetna commented

“We were continually innovating around new products and services while consumer behavior was changing rapidly as the virus was raging. People want to access healthcare digitally. Delivery of more health care in the home than before means we will continue to see transformational changes in healthcare post-pandemic.”

How could this help autoimmune care?

For autoimmune and autoinflammatory patients, making the corner pharmacy more accessible will only be marginally helpful for some routine care (e.g., vaccinations, regular prescriptions). However, home delivery of prescription and OTC products can be a life-saver for autoimmune patients in voluntary or involuntary isolation. 

However, if companies like Walgreens and CVS could figure out a more consumer-friendly way to distribute and administer infusion biologic drugs, that could be a game-changer. Getting access to biologics could be part of putting clinics inside the pharmacy that focus on the needs of autoimmune patients by streamlining some of the more routine and repetitive aspects of their care.

As I reflected on pharmacies becoming the digital front door, I wondered if dental offices, which currently see many consumers twice a year for their regular cleanings, will also try to expand their offerings. Dental practices are already screening patients for oral cancer, sleep apnea, and periodontal disease (which can trigger autoimmune disease and flares). Perhaps they can expand this list to offer thyroid screening, nutrition coaching, and other services that relate to the mouth as a gateway to the rest of the body, including to the immune system.

New delivery models focus on women’s, family, and behavioral health

In addition to the expanding role of the pharmacy in care delivery, there are other new competitors. Some examples follow from women’s, family, and behavioral health. Online clinics are experimenting with novel delivery models, using women’s health needs as the digital front door.

New Models of Care
Submitted by author

Maven – virtual women’s and family health

Maven is the world’s largest virtual clinic in women’s and family health. They offer on-demand access to over 1,000 women’s and family healthcare providers. They also connect their clients with dedicated care coordinators who personally help users navigate their benefits.

According to Katherine Ryder, the Founder, and CEO of Maven, 

“At Maven we owe better care to the next generation and this starts with a focus on family health.”

She continued,

“one of the silver linings of COVID is that digital health companies with new virtual models to support more holistic and patient-centered care will have a more urgent place in our system today.”  In addition, “we are integrating care for parents with care for kids to support the well-being of the entire family.”

Implications for autoimmune care

Women of childbearing age are at higher risk of autoimmune, autoinflammatory and conditions like chronic fatigue syndrome than any other demographic. With Maven’s focus on family health, they could easily offer screening for autoimmune disorders, including genomic testing (which they are likely doing already for fertility and family planning purposes) to identify those who are at higher risk.

This could be integrated with their intergenerational approach, looking to detect or even prevent chronic immuno-inflammatory conditions in their patients’ children. They could help connect autoimmune patients with specialists or even coach them in lifestyle modification approaches that may reduce their chances of developing disease or at least get them earlier diagnosis and treatment.

New Models of Care
Submitted by author

kindbody – fertility and reproductive health

kindbody is expanding access to fertility and reproductive health with virtual or in-clinic care for fertility, gynecology, and wellness. With transparent pricing, their website includes pricing information for services such as IVF, egg freezing, and embryo banking, as well as nutrition counseling. Care teams can include an ob-gyn, endocrinologist, physician assistant, and a variety of counselors and coaches.

According to Gina Bartasi, the Founder and CEO of kindbody-

“kindbody is on a mission to increase access to fertility and family-building care for all. 50% of our corporate team identifies as non-caucasian, 45% of our patients are women of color and 15% are GBTQ+ so when we think about creating change, we are really being mindful of today’s social inequity.”

Implications for autoimmune care

For autoimmune patients, many of whom are women of color with low incomes (a group that faces slower diagnosis and less aggressive care), a logical extension of kindbody’s current offerings could include autoimmune screening as part of genetic testing used for family planning as well as routine thyroid screening for autoimmune thyroiditis, the most common autoimmune diseases among women.

Furthermore, kindbody could help connect autoimmune patients with specialists or even coach them in lifestyle modification approaches that may reduce flares or their chances of developing a disease or at least get them earlier diagnosis and treatment.

New Models of Care
Submitted by author

brightline – Behavioral health for children, teens, and families

brightline is reinventing behavioral health care for children, teens, and their families.They deliver integrated care through innovative technology, virtual behavioral health services, and a collaborative care team focused on supporting children across developmental stages and their families.

Given the ongoing explosion of mental and behavioral health issues among children, teens, and young adults, especially under the stress of COVID-19 lockdowns, the current environment is ripe for a solution like brightline.

According to Naomi Allen, CEO and Co-Founder of brightline, we are

“providing uncommon support to the most common family challenges in behavioral health”

As shown below, brightline offers the broadest multidisciplinary care teams of any of the companies (not just the female/family offerings) profiled in these posts. This represents more silo-busting coordination of specialists than any of the other platforms. As an advocate for autoimmune patients, I am happy to see this innovative approach being used. I’ve provided screenshots to show this competitive advantage.

brightline provides access to a wide variety of providers, including:

        • behavioral health therapists,
        • occupational therapists,
        • speech therapists,
        • coaches, and others,

Amongst other services, they offer tailored content, telehealth visits, treatment plan tracking, and digital exercises at home. 

Screenshots from Brightline app
Graphic provided by the author

Particularly noteworthy is their approach to prevention, which includes a yearly pediatric well visit as shown below.

Screen shot from Brightline app describing pediatric health well visit
Graphic provided by the author

Could brightline work for autoimmune patients too?

Brightline is an example of diverse multidisciplinary care teams being scaled through digital technology to help children with a wide variety of therapy programs. Better care coordination and specialist collaboration is needed by autoimmune patients, too. What’s more, autoimmune patients, an increasing number of them children, almost always have comorbid mental health issues, primarily depression and anxiety.

It would be a logical extension of the Brightline approach to reach out to their mood disorder patients to see how many in their families suffer from chronic diseases, especially autoimmune, maybe even undiagnosed immuno-inflammatory disorders.

Taking this even further, a platform like this could work for chronic GI conditions with immunological aspects such as the IBDs (inflammatory bowel diseases: Crohn’s and ulcerative colitis). Given what we now know about the gut-brain axis, GI diseases almost always involve a big mental health component.

Specifically, brightline could offer IBD patients access to care teams that include gastroenterologists as well as dieticians, health coaches, and psychologists that could help them better manage their daily lives between regular appointments. Such an approach could help IBD patients avoid flares and complications requiring costly hospitalizations or emergency visits.

In addition, applying brightline’s prevention approach to their population of families could allow earlier identification of IBD, especially in children, when early lifestyle modifications (diet triggers, food sensitivities) might prevent the disease altogether.

Summary and conclusions about the 2020 HLTH VRTL conference

The HLTH VRTL conference was an excellent opportunity to capture a glimpse of some of the changes brought about by the COVID-19 pandemic. The sudden, pandemic-triggered  the following changes:

1. An increase in the use of telemedicine and remote monitoring,

2. A shift in payment models to VBC that is accelerating competition for the digital health front door (See above “Competition for the Digital Front Door”).

3. A spurring of a variety of new care delivery models. (See above “New delivery models focus on women’s, family, and behavioral health”).

4. Increasing competition for attracting patients through the digital front door that includes an expanded role of pharmacies, as well as new, digitally enabled, integrated approaches to women’s and family health.

Throughout HLTH VRTL there was almost no mention of autoimmune or other chronic immuno-inflammatory diseases, making it harder to see how these new players might help patients with these conditions.

This omission is telling in terms of where healthcare managers are focusing their efforts. While mental health is now receiving more (well-deserved) attention, autoimmune, autoinflammatory, and conditions like chronic fatigue and post-viral syndromes, easily as costly and as big a cause of human suffering as cancer, are still invisible to most payers and many providers.

Maybe the emergence of post-COVID syndromes (aka long covid) will finally prompt payer and provider interest in chronic immuno-inflammatory disorders in the same way the pandemic & lockdowns have speeded previously slow progress in telehealth and work from home.

There is no one-size-fits-all approach for autoimmune patients and much experimentation is needed, especially since so little has been done outside a handful of small companies that are mostly focused on individual autoimmune diseases.

I hope next year’s HLTH conference will offer more tangible examples of how large and small healthcare companies are using telemedicine, remote patient monitoring, new delivery care models, including VBC reimbursement to better serve the individual daily needs of chronic autoimmune patients. 

Elevating and improving the role of primary care through digitally-enabled platforms and salaried physicians in both established delivery systems and new care models could also benefit immuno-inflammatory disease patients. However, this will only happen if payers and providers focus on this huge unmet need/business opportunity.

We still wonder where immune disease specialists: dermatology, rheumatology, gastroenterology, immunology, endocrinology, fit into these models. Are specialists going to become members of coordinated care teams? Or will they be in satellite practices coordinated through digital platforms that help chronically ill patients get the full spectrum of care they need? How will these new models and digital platforms tackle the complexities of chronic autoimmune and autoinflammatory disease diagnosis and treatment?

Such questions would be good ones for HLTH and its participants to focus on for 2021.

Bonnie Feldman, DDS, MBA

Dr. Feldman is an autoimmune patient advocate and an expert in digital health, the oral and gut microbiomes, and immune-mediated diseases. She is a frequently invited speaker and panelist at national and international conferences including TEDx, SXSW, and Stanford Medicine X.

Currently, she is the Founder and CEO of Your Autoimmunity Connection, a consultancy that through research, consulting, and other professional services, assists clients offer innovative products and services to people with chronic immuno-inflammatory diseases.

Previously, Dr. Feldman was a practicing clinical dentist. As a dentist, she built two dental practices and a consulting business from scratch. Then, armed with an MBA in finance from the UCLA Anderson School of Management, she worked on all sides of the Wall Street equation - sell side, buy side, and investor relations.

Her multimedia work has appeared in numerous online venues such as Forbes, Medium, Tincture, and Thrive Global. She has also been featured in podcasts and documentaries, written various white papers demonstrating deep subject expertise, and created presentations and blog posts that demonstrate her exceptional skills in the art of science storytelling.

Motivated by her desire to help future generations thrive, Dr. Feldman takes her four lenses (dentist, Wall Street analyst, digital health consultant, and patient) to seek out solutions that provide the best of conventional, functional, and digital medicine to improve chronic disease management for all patients.

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