The New Orleans-based health system is seeing improved clinical outcomes in a pilot Medicaid program targeted at patients living with hypertension and type 2 diabetes.
Ochsner Health is reporting strong results from a pilot remote patient monitoring program targeting Medicaid patients living with type 2 diabetes and hypertension.
Billed as one of the first in the country, the program, coordinated by Ochsner Digital Medicine, saw nearly half of participating patients dealing with uncontrolled hypertension bring their blood pressure under control within 90 days, a 23% improvement over traditional care management. And almost 60% of those with poorly controlled diabetes were able to improve their blood-glucose readings and A1c levels.
“So meaningfully moving the needle among Medicaid patients with type 2 diabetes and hypertension is unprecedented," Denise Basow, MD, the New Orleans-based health system's first and current chief digital officer, said in a press release. “We are confident this program can be scaled to improve the lives of others across the state and around the country to mitigate the impacts of chronic disease.”
The RPM program was launched in June 2020 at Ochsner LSU Health Shreveport, and has enrolled more than 4,400 patients. Health system officials noted the program addresses a serious gap in chronic care management in Louisiana, where roughly 40% live with hypertension and 14% lives with diabetes.
RPM programs hold great potential in bringing care management out of the hospital, clinic and doctor's office and into the home, where providers can monitor a patient's daily health and habits and adjust care (including medication) accordingly. With digital health technology, they can capture relevant data to identify trends and support treatment plans.
Ochsner is one of the top health systems in the country with regard to digital health strategy, and has been gradually building out several programs on a national platform. Data from the RPM program could be used to support arguments to the Centers for Medicare & Medicaid Services (CMS) to improve Medicare and Medicaid reimbursement.
“As clinicians, we are always working to improve patient outcomes and the overall patient experience, and this program shows that we can use home-based technologies to accomplish both," Lauren Beal, MD, Ochsner's medical director of primary care and community clinics for northwest Louisiana, said in the press release.
One of the keys to a sustainable RPM program is sustainable clinical outcomes, and Ochsner officials noted that those living with hypertension continued to show positive results after 18 months. In addition, the program was well-received by patients, with a net promoter score greater than 91.
Ochsner officials said they'll continue to work with payers and employers to improve reimbursement, which would allow the health system to expand the program to other parts of the state and, eventually, other parts of the country.
“Over 30,000 patients have benefited from Ochsner’s Digital Medicine chronic disease programs,” Richard Milani, MD, Ochsner's chief clinical transformation officer and vice-chairman of the Department of Cardiology, said in the press release. “We're offering patients compassionate human care combined with the power of technology, and we’ll continue to expand these programs to help more patient populations.”
Recent wildfires are a fresh reminder of the value of the real-time dashboard, which allows health systems to manage resources and transfer patients as needed.
The wildfires flaring this week are a reminder that Oregon is one of the only states in the country with the technology to provide healthcare officials with a real-time, statewide dashboard of staffed hospital beds, ventilators, and resources such as negative pressure rooms.
For Staci Sparks, vice president of nursing at Asante, a three-hospital system in southern Oregon, the dashboard is a welcome tool. Just two years ago, the evacuation zone for one wildfire included Asante Rogue Regional Medical Center.
"At that point, we were trying to figure out if we need to evacuate people," she says. "There was nowhere else for them to go here. We were in a high-capacity situation, and we're somewhat geographically isolated. This system gave us a state look to see what hospitals had beds and capability, and where to get them to the right place."
Staci Sparks, vice president of nursing, Asante. Photo courtesy Asante.
The system was established in 2020, using GE Healthcare Command Center technology to address hospital capacity issues during the COVID-19 pandemic. With funding from the state, it has not only continued and grown past the peak of the pandemic, but was spun out of its incubator at Oregon Health & Science University to become Apprise Health Insights.
The company continues to seek funding from Oregon and the US Centers for Disease Control and Prevention (CDC), says CEO Andy Van Pelt, who also serves as executive vice president of the Oregon Association of Hospitals and Health Systems (OAHHS), under which Apprise Health Insights is operated as a for-profit subsidiary and data arm of the organization.
The real-time dashboard facilitates the quick transfer of patients to appropriate facilities as needed, and is gradually replacing the state's older tech platform. So far, Van Pelt says, the new system has automated 85% of the 300 data fields in the legacy system.
That migration speeds up all reporting, while freeing up staff previously dedicated to the manual reporting processes in the older system, he adds.
"The governance committee is made of health system patient coordination and patient flow folks that represent the seven trauma regions around the state of Oregon," Van Pelt says. "They meet regularly with the state, we come up with policies and procedures and workflows, and how and when the data can be used, and for what purposes."
Apprise Health Insights hosts the system and online dashboard, monitors all data feeds, and conducts all education and onboarding of users of the dashboard, he says.
And that's been a relief for Asante.
"Getting through the pandemic was a little bit easier than post pandemic, because there was this burning platform," says Sparks. The end of the staffed bed crunch "gave us some time afterwards to go back and say, how would we do this differently from a local perspective and also from a state perspective? And learn those lessons and apply them to other scenarios that could occur."
Part of that is understanding what a system driven by data uploads from electronic medical records can offer, and what its limitations are.
"Electronic medical records don't always have the best reputation in the industry," Sparks says. "In the future, we need to view technology as a tool, which is what it is. The intent is to make it easy to do the right thing for patient care, and to make it easy to do the right thing for our employees' workloads."
"This is really an exercise in trust building," Van Pelt says. "It creates an actionable data set that at the end of the day really impacts a patient's care [to make it] quicker, more efficient, and more appropriate. … During the Labor Day fires in September of 2020, we had to evacuate five hospitals in a 24-hour period. We were grateful to have the first version of this."
Andy Van Pelt, vice president, Oregon Association of Hospitals and Health Systems, and CEO, Apprise Health. Photo courtesy Apprise Health.
Apprise Health Insights is talking to about a dozen states about adopting this technology. In addition, Van Pelt says, Oregon Senator Jeff Merkley has introduced legislation to modernize real-time data for hospital data and emergency response nationwide.
Alaska's chief medical officer Ann Zink "is a good friend of ours and is looking at potential legislation to modernize capacity-type data around the country," Van Pelt says.
As for Sparks, the dashboard helps her grow into her new role as vice president of nursing at Asante, the first such vice president over the entire system.
"My learning curve has been steep for the first four months," she says. "It's doing more listening and observing than acting or decision making. In six or 12 months, that will shift. You need to understand what you're working with before you can ask people to make changes or before you can make decisions that really impact their work."
Jennifer Bollinger says healthcare organizations are paying too much attention to technology and not enough on the people and processes that make virtual care work.
To Jennifer Bollinger, the patient experience shouldn't be defined by technology, but by the value of interactions with the care team. For that reason, she's ditching the term "digital health" in favor of "connected health."
"Digital really isn't our strategy," says the senior vice president and chief consumer officer at Ochsner Health. "It is one of the key levers for transformative care, but it's just one part of [an equation] that includes people and processes. Connecting them and making those connections seamless and personal is our goal."
Bollinger's work in digital consumerism with the New Orleans-based health system highlights another underlying challenge as well: connecting with the consumer, rather than the patient. As healthcare organizations move toward value-based care, they need to look beyond the idea of connecting with patients of the health system and focus more on connecting with consumers of healthcare services.
That ecosystem is much larger and more complex, encompassing not only the individual moments that require healthcare interactions but the whole journey.
Jennifer Bollinger, senior vice president and chief consumer officer at Ochsner Health. Photo courtesy Ochsner Health.
"Consumers really don't know how to figure out that they don't want a lot of choices," she points out. "They want ease and guidance. They want someone to guide them."
In the midst of this shift from periodic to value-based care, healthcare providers have been undergoing a change of perspective as well. The emergence of telehealth and digital health tools and strategies has given the consumer more control over healthcare choices, which in turn has flooded the market with new healthcare locations and opportunities. Healthcare organizations can no longer sit back and expect the consumer to come to them; they need to reach out and market their capabilities, competing with other hospitals and health systems, health plans and telehealth vendors with their own providers, retail health clinics, and large companies like Amazon.
In this atmosphere, health systems have to see the consumer, or everyone within reach of their healthcare services, rather than the patient, or someone who has used their services. And the strategy is shifting from 'You're going to need healthcare services and here we are,' to 'We're better at this than the others.'
And part of being better is using technology to make healthcare more intuitive.
"The pandemic was certainly an enforcing factor" in identifying the value of virtual care, says Bollinger, noting the nationwide shift to telehealth and digital health tools to facilitate easier healthcare access at a time when in-person care was risky. And now that the pandemic is waning, she says, health systems are asking themselves, "Are we going to be able to cash the check that we wrote?"
At Ochsner, which has forged a path in digital health that goes back long before the pandemic, the key isn't highlighting these new tools and platforms, but showing their value. An RPM program works if it improves medication adherence and reduces trips to the doctor's office; a messaging program works if it boosts scheduled wellness visits or vaccinations or reduces no-shows for appointments; and a patient portal is effective if it channels patients to the right place without the need for extra clicks or a phone call.
On some of those occasions, "if I have to pick up the phone and talk to someone, something has broken down," Bollinger says. "Now there are times when talking to someone is a positive, but not when you're just trying to do something quickly."
In many cases, consumers already know about patient portals, messaging platforms, and virtual care, Bollinger notes, but they haven't seen how it can help them. The health system has to connect the dots.
"We've done a lot of 'one-size-fits-all solutions," she says. "Now it has to be made personal."
Bollinger points out that consumers have seen how technology improves the experience in other businesses, like banking, travel, and shopping. But how does that translate to healthcare? Making a bank deposit, planning a vacation, or buying a jacket isn't the same as conferring with a doctor about a health concern.
"It's sometimes hard to get them to articulate their expectations for healthcare," she says.
That's where connected health comes in, and where consumer strategy is important. Health systems need to focus not on the technology but on the people and processes that make it work. Instead of talking about the digital ecosystem of consumer tools, talk about the connections that these services offer with providers and care teams, and the opportunities those connections offer to improve health and wellness.
"We aren't paying enough attention to the up-and-coming generations," Bollinger says. "The pandemic offered them a lot of choices, and they’re taking advantage of that."
The Delaware-based health system's Helen F. Graham Cancer Center & Research Institute has received an award from the Association of Community Cancer Centers (ACCC) for a program that integrates cancer care with primary care.
ChristianaCare's cancer care program has earned national recognition for a unique program that integrates primary and cancer care.
It also addresses a gap in cancer care management spotted by the health system.
"We conducted an informal survey that found as many as 15% of our patients did not have their own primary care provider,” Cancer Program Clinical Director Cindy Waddington, MSN, RN, AOCN, said in a press release, which includes a link to a recent podcast on the program. “Having a primary care provider onsite working closely with the entire cancer care team helps ensure that essential patient care beyond cancer treatment is not delayed."
The health system pointed out that patients undergoing cancer treatment are often dealing with other health concerns, especially chronic issues like diabetes, heart problems, COPD, and high blood pressure, and that cancer treatment can exacerbate those issues. To facilitate comprehensive care, the program enables oncologists to refer their patients to primary care services for any non-cancer concerns.
"Primary care in oncology has been a long-standing challenge for cancer patients and cancer programs,” Family Nurse Practitioner Debra Delaney, RN, MSN, ACNS-BC, FNP-BC, who provides primary care services at the Graham Cancer Center, said in the press release. “Thankfully, we’ve been able to solve that challenge by addressing the whole person and promoting healthy living for the long-term.”
As part of the process, Delaney helps patients who finish their cancer treatments transition to a primary care provider for ongoing care management.
"Earning the prestigious ACCC Innovator Award for our primary care practice is an accomplishment that belongs to our entire cancer care team, which has worked long and hard to develop this unique program designed to improve our patients’ long-term health,” Nicholas Petrelli, MD, the Bank of America endowed medical director of the Helen F. Graham Cancer Center & Research Institute, said in the press release.
EHNAC and CARIN have collaborated on a guide for healthcare providers, insurers, developers, and app developers.
Two influential developers of healthcare data standards have created a common code of conduct to help consumers control the exchange of their health data.
The CARIN Code of Conduct Accreditation Program (CCCAP) brings CARIN's code of conduct together with the criteria review process of EHNAC to accelerate health data exchange activities of health plans, health systems, EHR vendors, implementers of HL7 FHIR-based application programming interfaces (APIs), and third-party app developers.
The collaboration is intended to support additional levels of trust related to consumer access to health data.
The CARIN Alliance works with more than 80 stakeholders to enable consumers to obtain, use, and share their digital health information as they desire. The Electronic Healthcare Network Accreditation Committee (EHNAC) is a standards development organization that develops criteria for standards and accredits organizations that exchange healthcare data via electronic means.
“We envision a future where any consumer can choose an application of their choice to retrieve both their complete health record and their complete claims information from any provider or plan in the country using HL7 FHIR APIs, and the CARIN Code of Conduct has been instrumental in helping to advance these efforts,” Ryan Howells, program manager for the CARIN Alliance and principal at Leavitt Partners, CARIN's convener, said in a press release.
This past July, the Centers for Medicare & Medicaid Services (CMS) commenced enforcement of key components of the Interoperability and Patient Access final rule – a key federal initiative intended to accelerate the ability for individuals to access their personal health information via an application of choice leveraging HL7 FHIR APIs. As part of the rule, CMS gave payers the option to implement an attestation framework asking developers to describe the data practices and privacy provisions of the applications that are connecting to the HL7 FHIR APIs.
This new voluntary certification program builds on the CARIN code of conduct self-attestation approach, but is not required by CMS or CARIN, the organizations said.
“Since the CARIN Alliance launched MyHealthApplication.com, which provides the ability for applications to self-attest to the CARIN code of conduct, it’s been important to continue to collaborate on implementing and fostering adoption of an industry-wide consumer-facing application attestation and certification framework," said Lee Barrett, executive director and CEO of EHNAC. "This includes focusing on providing the highest level of stakeholder trust for all healthcare stakeholders – patients, providers, health plans, third-party app developers, and many others."
Stakeholders who attain CARIN code of conduct accreditation will be listed on the CARIN My Health Application site and the EHNAC Accredited Companies page. Already, multiple consumer-facing applications who have attested to the CARIN Code of Conduct are listed on the MyHealthApplication.com website
In the second of a two-part interview, Brian Clear MD, chief medical officer of Bicycle Health, talks about treatment details and regulatory challenges.
Editor's note: This is the second of a two-part interview. The first part was posted on Wednesday, October 12.
Brian Clear, MD, has been chief medical officer of Bicycle Health since March 2021. In part 1 of this conversation with HealthLeaders, he discussed his journey from residency to his current role, why the company's opioid treatment method is underutilized, how the program works, the role telemedicine plays, and the support it has received by medical societies.
HealthLeaders: What does a typical Bicycle Health session involve?
Clear: Patients see our provider for an hour on the first day where they're establishing the diagnosis, talking through treatment options, making sure that the patient is on board with the telehealth-based treatment option, and then starting treatment the same day. There's a quick check-in with the patient the very next day to make sure they're doing well. Follow-ups are either 20 or 30 minutes.
Providers check in with the patient at least every week until we know that they're stable on early treatment, meaning they're comfortable on the correct dose of buprenorphine and they're able to give us a drug screen that supports that the medication is effective, meaning no illicit opioids and presence of buprenorphine.
It's a once-daily medication taken at home. Quite simple. We make sure every patient has a stock of at-home urine drug screens, and we use a random text messaging system to prompt the patient when to complete one of these screens, kind of like uploading photos of a check to your bank for deposit. Our app walks the patient through the process of completing a sample, then taking a series of photographs so that our provider can interpret the results of the drug screen.
Brian Clear, MD, Chief Medical Officer of Bicycle Health.
We're also testing for fentanyl, specifically, for patients who can become pregnant. We're also doing home pregnancy tests. We can also do saliva-based testing where, if needed, we can directly observe sample collection and watch the whole test on camera if we have reason to believe a patient might be using someone else's sample. But we've done a genetic matching study on our urine tests and find that less than 3% of our patients in the study provided a false or tampered sample. So, we have high confidence in the urine test for most patients.
HL: Can they overdose at home on buprenorphine?
Clear: It's a problem more of the patient worrying about accidentally having taken too much or accidentally missing the dose. Buprenorphine as a medication is very, very forgiving of accidental mis-dosing. It has what's called a ceiling effect where, beyond a certain point, the medication actually stops having any additional effect because it saturates all the opioid receptors in the body. Once all the receptors are saturated, more medication doesn't have any receptor to bind to.
So it's essentially impossible for an adult who has a tolerance to opioids to overdose on buprenorphine. Similarly, patients can miss one or two days of dosing usually without experiencing considerable withdrawal. If they miss three more days, that's when opioid withdrawal starts to set it.
HL: What total population are you affecting at this point?
Clear: We have treated over 20,000 patients. When I say treated past tense, that's not the goal; treatment needs to be ongoing for the benefits of treatment to be ongoing. This medication reduces death and disability rates from opioid use disorder for as long as it continues. But just like if you stop your blood pressure medication, your blood pressure goes back up, we find that for most patients who stopped, they're likely to return to illicit opioid use within a year or two. So we have currently active in our program about 8,000 patients.
HL: And they're all being seen via telehealth through Bicycle Health doctors?
Clear: Yes, every one of our physicians is double-boarded in either family medicine or internal medicine and in addiction medicine. We also work with advanced practice clinicians. Those are nurse practitioners and physician assistants who have at least two years full time experience working with patients with opioid use disorder.
HL: How does this integrate with their other care, such as a local primary care provider?
Clear: About half of patients who come to us are established with a local primary care provider, and of those, about half of those patients are willing to give us permission to coordinate care with that local primary provider. We strongly encourage all patients to establish with a primary care doc if they don't have one already, and strongly encourage all patients to let us coordinate.
We'll send visit notes to that primary care doc. If they have questions or concerns, we'll make time to get on the phone with that primary care doc or their mental health home and make sure that that doctor is informed of the treatment that we're offering and also why, and the benefits that it offers to patients.
A lot of our patients do struggle with fear of informing their primary care doctor or their mental health professional of their opioid use disorder treatment, and it's a rational fear. We still running into issues where doctors who are not fully informed about correct opioid use disorder treatment will stigmatize patients when they become aware that they're receiving this treatment. In some extreme cases doctors will decline to continue working with the patient, which frankly is unconscionable. We do still run into that. But we believe that through communicating very proactively, we can help primary care docs and mental health docs understand that this is beneficial treatment for their patients.
HL: How does what you have learned compare to the new JAMA study?
Clear: What they found is very consistent with my experience of developing a telehealth-based program for opioid use disorder. We would have been happy if we could have done just as well as in-person programs, but what we've achieved are much better outcomes than we know is the norm in in-patient programs.
What the JAMA study looked at, and what is probably the most important thing to look at in determining how successful a program is with treating opioid use disorder, is how many patients stay engaged after a certain amount of time. The JAMA study looked at a year and a half, which is great. Most programs measure three months of engagement and don't look too far beyond that.
JAMA found that when you're looking at a group of patients before telehealth-based care for opioid use disorder existed and compare them to a group of patients after telehealth-based care for opioid use disorder existed, for patients who had telehealth as an option, and about 20% of them actually use telehealth, we find that their overdose rates go down considerably compared to patients engaged only in in-person care, and also their engagement rates and treatment after a year and a half go up considerably, by about a third compared to in-person treatment only.
And that's what we find in our program, too. We find that 70% of patients who start with us are still engaged with us after a year. That compares to my experience in in-person programs where if you've got more than 45% of patients engaged after a year, you're doing a really good job. 70% is kind of unfathomable.
HL: What's your biggest challenge?
Clear: The biggest challenge is regulatory. It's working to offer this care in states that currently ban it. And there are quite a few states that still ban it because, as I mentioned earlier, buprenorphine is not separated out from other opioids in the law, like it should be. The DEA has changed that at the federal level, but some states have been slower to follow suit and still have restrictions either on use of buprenorphine or on use of telehealth in general.
HL: What's the largest such state that still is problematic?
Clear: We were practicing in Alabama until about six months ago, and they enacted a new law banning the use of telehealth to provide treatment for opioid use disorder. We had to leave Alabama. And that was one of our states of greatest need.
HL: Are the payers on board for the long-term nature of this care?
Clear: Payers are very much on board. A couple of years ago, when I first started presenting to payers, it was common to have to lay out and explain the evidence for why we strongly recommend continuation of opioid use disorder treatment long-term. But now, I think that evidence is prevalent enough to where payers understand.
I rarely must have that conversation of convincing them of why ongoing treatment is recommended. The task is just to demonstrate that we can and that we do a good job of offering ongoing treatment for opioid use disorder.
The Center for Connected Medicine has released a new report identifying the 15 health systems who are investing in biotech and therapeutic startups and spinning out their own companies.
Large health systems are fueling healthcare innovation by making their own investments in biotech and therapeutics startups and supporting intriguing new startups.
A new report from the Center for Connected Medicine has turned the spotlight on this little-known and often secretive trend. Titled "A New Player in Biotech Investing," it highlights a growing movement in healthcare to support companies and technologies that could someday change the way clinical care is delivered.
“There’s a notion across the industry that we’re just seeing the tip of the iceberg when it comes to what medicine is capable of achieving to treat disease,” Matthias Kleinz, senior vice president of UPMC Enterprises, the innovation and venture capital division of UPMC and one of the 15 organizations included in the report, said in a press release. “Organizations like ours bring unique resources and expertise to efforts that seek to turn groundbreaking scientific research into life-changing therapies for patients around the world.”
According to the study, the increase in health systems support mirrors the increased activity that has been seen in digital health and telehealth in general, some of its sparked by the surge in telehealth use during the pandemic.
The study identifies four characteristics of a health system that's investing in new biotech and therapeutic startups:
They're large enough to dedicate resources to venture startups;
They have relationships with academic researchers;
They include dedicated venture capital organizations; and
They focus on internal spinouts.
"There is also near-term benefit to health systems beyond the potential return on their investments," the report notes. "By working to ensure more personalized and custom therapies, such as stem cells, CAR-T, and others, are accelerated from laboratory to patient bedside, health systems not only greatly improve patient care but also have the potential to capture commercial upside through new service revenue."
At the same time, investments don't guarantee success, and a successful investment includes support from the top down, significant guidance and coaching from healthcare experts, and an understanding that risk is involved.
“Can you build the support within your organization and invest for the long term?" Kleinz noted in the report. "It’s hard to take a long view when you have more immediate short-term needs.”
The health systems included in the report are:
Cleveland Clinic Ventures;
Intermountain Ventures;
Jefferson Innovation;
Johns Hopkins Technology Ventures;
Kaiser Permanente Ventures;
Mass General Brigham Ventures;
Mayo Clinic Ventures;
Michigan Biomedical Venture Fund;
Mount Sinai Innovation Partners;
NYU Langone Health Technology Opportunities and Ventures;
With the end of the COVID-19 public health emergency on the horizon, some healthcare organizations are struggling to come to grips with the impending loss of telehealth freedoms.
For healthcare providers treating some of the most underserved populations and communities, the end of the COVID-19 public health emergency is pretty bleak. Federal waivers expanding access to and coverage of telehealth will end with the PHE, forcing them to curtail or even end programs that had seen quite a bit of success over the past few years.
"It's going to be a challenge," said Chris Grasso, MPH, chief information officer for Fenway Health, a Boston-based federally qualified health center (FQHC) serving more than 35,000 patients annually, many of them part of the LGBTQ+ community. "It's a lot to untangle and figure out."
Grasso, who keynoted a recent telehealth summit in Massachusetts hosted by the Northeast Regional Telehealth Resource Center (NETRC), said these all-in-one healthcare centers serve patients who fall through the cracks because of those barriers.
"Now that the COVID restrictions are coming back, it's going to be harder to do our work," she says. "But we need to keep the lights on and the doors open."
NETRC is one of 12 regional and two national resource centers in the federally funded National Consortium of Telehealth Resource Centers. Based in Augusta, Maine, it serves as the clearinghouse for telehealth policy and information for all of New England and New York.
Healthcare organizations of all sizes across the country often rely on the consortium and individual TRCs for the latest news in telehealth policy and regulations, and these regional summits serve as focal points for catching up on the latest.
At the NETRC event in Southbridge, Massachusetts, Christina Quinlan, an executive consultant and advisor to the NETRC who'd previously worked as the chief operations officer for an FQHC on an island off the Maine coast, noted FQHCs and RHCs have long balanced the need to use new technology to reach patients with ROI.
"Telehealth and innovative technology wasn't anything new to us," she pointed out. "We just never got paid for it."
That changed with the pandemic, which thrust these types of healthcare providers into the spotlight as an important resource for both primary and specialty healthcare services at a time when hospitals were overcrowded and people were avoiding them and the doctor's office for fear of infection. Among the federal and state waivers to expand telehealth adoption were measures specifically focused on FQHCs and RHCs.
Quinlan noted that despite the positive results seen from the increased use of telehealth, CMS has only made permanent six CPT codes for telehealth services related to behavioral healthcare.
"It's primarily for psychotherapy," she said. "What they've expanded isn't nearly enough."
Grasso said Fenway Health, which sees more than 2,000 patients seeking HIV care, embraced virtual visits early on during the pandemic to provide a safe means of accessing care for those at heightened risk. As time has passed, they've seen patients from more than 40 states and 1,000 zip codes, as well as transgender patients from states who've taken action to restrict healthcare services.
"There have been lots of opportunities for us to be innovative," she said.
And they have to. According to Grasso, a 2015 study indicated one-third of all LGBTQ+ patients have reported a negative healthcare experience, and 23% have avoided seeking healthcare because of fears of mistreatment. This puts the pressure on providers to find new methods for providing discreet care, such as through digital health messages and virtual visits.
"Our patients are some of the biggest disruptors in healthcare right now," she pointed out.
FQHCs and RHCs are also facing stiff competition, she noted—not only from hospitals and health systems ramping up their efforts to address social determinants of health and connect with underserved patients, but from free-standing and retail health clinics offered by the likes of CVS and Walgreens, telehealth providers and health plans with their own provider resources, and direct care platforms launched by Amazon, Google and others.
"We have to continue to be creative to compete in this market," she says, mentioning a plan to explore the use of kiosks in locations around Boston and surrounding cities.
Part of the problem may be that FQHCs and RHCs haven't been vocal enough about the lack of permanent telehealth coverage.
"For them [CMS], it's like, if we're not complaining about it enough, it's not an issue," said Quinlan, who's urging advocates to give federal officials an earful so that CMS might address the issue in its proposed 2024 Physician Fee Schedule, which is slated to come out next July.
They're also hoping that Congress may step in and enact new legislation making those telehealth waivers permanent. Danielle Louder, the NETRC's program director for technology-based initiatives, noted there are more than 100 telehealth-related bills now before Congress, alongside lobbying efforts from a broad range of stakeholders to take action.
For now, FQHCs like Fenway Health are continuing to look for new ways to reach and deliver care to underserved communities—Grasso said they've "had to do a lot of MacGyvering" along the way—and keeping an eye on the end of the PHE, which is still a moving target. The latest news puts that date in 2023, and Congress has ensured that the CMS waivers will remain in effect six months after that.
"It's their job to continue doing what they're doing," Quinlan says. "But it will be much harder."
In the first of a two-part interview, Brian Clear, MD, chief medical officer of Bicycle Health, describes an approach supported by the AMA, the American Society of Addiction Medicine, and other experts.
The cutting edge of digital health and home testing is bumping up against norms in society and medicine as the healthcare industry tackles a substance abuse epidemic. An organization that epitomizes this challenge is Bicycle Health, a Boston-based provider treating more than 8,000 patients in 29 states for opioid use disorder.
The company, which srarted as a single clinic in Redwood, City, California, uses digital health and home urine testing, alongside an approved medication for treatment called buprenorphine, the main ingredient in the commercial brand Suboxone. The success of that type of treatment plan was highlighted in a recent JAMA Psychiatry study which found that the expanded use of telehealth to treat opioid use disorder during the pandemic reduced the risk of opioid overdoses.
HealthLeaders: How did you arrive at your current role at Bicycle Health?
Brian Clear: It started 10 years ago, right through residency training. Anyone who's paying attention, especially in the hospital system, notices that substance use disorders are the underlying cause for a lot of the pathology that comes into the hospital, but they're not commonly addressed. I hope this has changed by now in my own residency program, but when I was training, I thought my attendings were excellent, and I got an excellent quality of training in all regards except substance use disorders, where it was pushed off, like it's not a medical problem.
Brian Clear, MD, chief medical officer for Bicycle Health. Photo courtesy Bicycle Health.
This is a social problem. This is a criminal justice system problem. Patients who are referred to abstinence-based recovery programs, often costing tens of thousands of dollars, get a month of time, essentially in a hotel, and then they go back to where they were, and return to their old habits, with nothing fixed.
The funny thing is there's a compelling, highly effective solution to it, that just because of an abundance of regulation, a lot of stigmas, and general medical provider reluctance to engage in the care of patients with substance use disorders, it's not used.
How often do you find an opportunity like that in healthcare, where you have a national health emergency and you have a solution for it that is ready-made and available but being underutilized? It's just a huge opportunity to improve public health.
I ended up working in an opioid treatment program in Tallahassee, Florida, after residency, did my buprenorphine and opioid use disorder training program through them, and started my own small kind of micro practice in the neighborhood. Then I got an opportunity to move out to San Francisco and work in a large opioid treatment program with integrated primary care and behavioral health. That got me plugged into public health systems in San Francisco, a lot of incredible doctors doing great work in the care of patients with opioid use disorder. And then I got introduced to Ankit Gupta, founder of Bicycle Health, through the California hub and spoke program.
I stepped into this role, and it's grown way beyond what I thought it was going to be, where I was expecting to direct a program in California, and then we expanded to Florida, which made me a little bit nervous having two licenses on opposite ends of the country. But then you learn how much need there is outside of California. And once you get used to the diligence process, you can safely operate in other states. And lo and behold, two and a half years later, we're in 29 states and continuing to grow and seeing amazing outcomes for our patients, which is pretty cool.
HL: What are the components of this program?
Clear: There are three medications that are shown to reduce death and disability from opioid use disorder. The one that can be prescribed and taken daily as a medication in a patient's home safely and effectively is buprenorphine. Methadone is another effective medication, which is less safe, and it's given through a really tightly regulated opioid treatment program structure. The other medication that's effective, but much less effective than either buprenorphine or methadone, is naltrexone, which goes by the brand name Vivitrol. We focus on buprenorphine, because that's the tool that's available as a first-line treatment. For patients with opioid use disorder, it has an equivalent rate of reducing death and disability compared to methadone, but a much better safety profile.
HL: Why is it so underutilized?
Clear: Stigma is one element. Historically, the medical system has not looked at substance use disorders as a chronic disease or as a medical problem. This dates back all the way to the post-World War I era, when the American Medical Association essentially took the stance that substance use disorders were not within the umbrella of medical practice, that it should be regulated by the Department of Justice rather than physicians. It's taken a very long time to reverse that stance and convince doctors that there is a highly effective medical treatment for opioid use disorder specifically.
Also, it's very tightly regulated. There's a lot of fear of enforcement action by the DEA [US Drug Enforcement Administration], fear of medical boards taking action against licenses. Buprenorphine is an opioid, a medication that at a very low level stimulates and blocks opioid receptors. But it's not separated out in the Controlled Substances Act as being different from other opioids, even though it is. Providers are afraid that as the DEA expanded enforcement action against overprescribing of oxycodone and hydrocodone, it's going to be a red flag practice to be prescribing buprenorphine, which is ironic and kind of horrible, because that is precisely the solution to the problem that was caused by overprescribing of oxycodone and hydrocodone, and more recently, the fentanyl epidemic.
HL: Where are the American Medical Association and the Food and Drug Administration today on their position on this?
Clear: We've got more evidence for the efficacy of buprenorphine than we have for any other medication in the history of medicine. There are multiple Cochrane Reviews establishing the efficacy of buprenorphine at this point. No reputable society can ignore that. Buprenorphine use for opioid use disorder is universally embraced. It just takes a very long time to change attitudes of individual physicians and expand that practice to a whole network of medical practices nationwide. But the societies are all on board, including the AMA and the ASAM [American Society of Addiction Medicine].
But there's a real lack of understanding amongst regulators, in some states, especially of the key difference between problematic opioids and buprenorphine. A waiver system was created where providers have to get special training, and do attestations every year to maintain that. It's a lot to navigate.
HL: How does Bicycle Health use telehealth to make this therapy available and effective?
Clear: As of 2018, a full 40% of counties in the United States didn't have a single provider who is able to treat opioid use disorder with buprenorphine. In my experience working in Florida and also San Francisco, patients often have to commute insane distances. In my Florida practice, the average patient commute to get to the program each day was almost an hour. We had patients coming over 100 miles every single day to come to the program, just because care is very sparse. So that selects for patients who [live] in dense urban areas close to programs, also patients of means, patients who have access to transportation. In rural areas, especially patients who are of lower means often have no ability to access care whatsoever, because they can't travel that far. If they're working, they can't take that time off work every morning to come into the program.
The most obvious advantage of telehealth is that it transcends that geographic barrier if they have internet access.
Editor's note: Part 2 of this HealthLeaders interview with Bicycle Health Chief Medical Officer Brian Clear, MD, will be posted on Thursday, October 13.
Stanford Health Care's Alpa Vyas is part of a new wave of healthcare executives looking to forge more meaningful and lasting connections between patients and their care teams.
For Alpa Vyas, the concept of patient experience has changed significantly in healthcare. Once considered a luxury to the C-suite, it's now an important part of clinical care delivery and a key to measuring the value of the organization.
"It's really become about the whole journey that a patient experiences with a [care provider] or an organization," says the vice president and chief patient experience offices for Stanford Health Care. "How care is delivered … has fundamentally changed due to the pandemic."
Patient experience is an integral part of patient-centered care, an idea that's been gaining steam for at least two decades, as healthcare organizations look to shift from episodic to value-based care and make the patient the center of the equation rather than a peripheral. And it means a lot more than simply handing out a survey or asking patient to rate their healthcare experience.
"It's a connected experience now," says Vyas, who's been with Stanford Health Care since 2015 and previously worked with the Medical University of South Carolina (MUSC) and Deloitte Consulting. "And the care team has to understand the value and need [for that connection]."
Alpa Vyas, vice president and chief patient experience officer at Stanford Halth Care. Photo courtesy Stanford Health Care.
Stanford Health Care is one of many organizations to elevate the role of chief patient experience officer, part of a "patient experience journey" that Vyas says has been ongoing for several years. With health systems dependent on publicly reported data and benchmarks, Joint Commission reviews and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, leadership has to know how to connect with patients (both current and future), meet their needs, and address concerns before they become complaints.
Due in part to COVID-19 and the elevation of virtual care, the patient experience space is also seeing a good deal of innovation. Healthcare organizations are using a wide array of digital health technology, from online portals to self-scheduling platforms to telehealth and remote patient monitoring tools, that are designed to improve the patient experience.
"We've moved to the next generation [of] omni-channel communication," says Vyas. "Patients can now choose [how they want to connect with their care providers.] When that ability to choose is there, it's up to us to create differentiators."
That means, to use a phrase repeated quite often these days, connecting with patients when, where, and how they want to connect, be it through e-mails, text messages, phone calls, or snail mail. And it's not only about how to connect with them, but how often.
"We're about to connect with and collect data from a patient in new ways, but how do we actually bring this data together in a meaningful way … that personalizes the connection but isn't intrusive?" Vyas asks. "The information that the patient provides has to lead to a broader, more complete picture."
Vyas says she and her team at Stanford Health Care conduct a lot of research, on topics that include human-centered design and empathy, to understand how the healthcare experience from the patient's point of view. They include family and other caregivers in the equation, with the understanding that patient care doesn't begin when the patient enters the hospital or end when he/she is discharged.
There is also an understanding that the benefits of new technology go both ways. While patients can enjoy the luxury of communicating with their care providers on a variety of channels, those providers also have new opportunities to reach their patients with important messages, information, and links to resources, and they can use that technology to measure how those messages are received and acted upon.
"The value is only demonstrated when we can actually do something with it," says Vyas. That might mean an uptick in cancer screenings brought about by an e-mail or text message campaign, or an improvement in patient discharge times caused by a digital platform that smooths out the rough edges of scheduling and provider check-offs, or maybe a single message to a grumpy teenager that leads him or her to improve their diabetes care management routines.
That's the gist of the connected experience, she says: The use of clinical, operational, and interventional data so that the patient experience is completely intertwined with the experience of the care team and physicians.
As the healthcare industry continues its journey toward value-based care, chief patient experience officers like Vyas will be crucial in establishing and maintaining that connection with the patient. And hospitals and health systems will rely on that expertise as they face stiff competition from telehealth companies, health plans and retail giants like Amazon for those healthcare dollars.
"There's still a lot of healthy skepticism about measuring the patient experience," she says. "Over time, we want to use that to design better connections not only for the patient, but also the provider."
