Techquity: Getting Healthy Through Equity-by-Design

The U.S. spends more on health care than any other nation in the world. Yet Americans’ health outcomes rank relatively low compared with other wealthy peer nations on Planet Earth, manifesting a low return-on-investment for this huge financial spend. Nowhere is this more evident than in America’s place in equity compared with nine countries, shown in the graph on health care system performance from The Commonwealth Fund’s perennial study, Mirror, Mirror – the latest version of which was subtitled, “reflecting poorly” on health care in the U.S.             Equity is an over-arching concept that the health care ecosystem has begun to embrace as a key metric for what looks good (or not) in U.S. health care. This week at the VIVE 2023 conference, the HLTH Foundation, collaborating with Ipsos, published a report on Techquity in 2023, analyzing survey data collected from 212 respondents from 200 health care organizations. For context in using this dataset, the folks responding to the study came from the HLTH and CHIME email lists; those on these lists may already be well aware of the concept of “techquity,” and certainly health equity. As a benchmarking survey conducted among a community of folks somewhat more clued-into the concepts being discussed, it offers us important insights into what this group of health industry leaders is thinking about — ahead of the mainstream, but directionally instructive for our understanding of the overall issues and where we are on the adoption curve of equity and its many layers — equity overall, health equity, and “techquity.”             Start with the definition set forth in the report: that techquity is the “intentional design and deployment of technology both to advance health equity and to avoid depending existing systemic inequities and health disparities.” Importantly and pragmatically, this definition includes both the technology deployed and the data practices implemented when using technologies. The concept of techquity is built on four pillars in this research: Trust in the technology Access to the technology Initial use or adoption of the technology, and Sustained engagement with the technology.             The term “techquity” was new to one-half of the respondents. Once the term was explained in the survey interviews, the majority of people understood the concept. However, as the first bar chart illustrates, techquity fell below other priorities on leaders’ minds — namely the high cost of care and the move to value, 4 in 5 people calling as “urgent” (net moderately + extremely). Second in priority for this audience was the slow adoption of information technology (among 71%), followed by cybersecurity threats which tied with health equity and techquity among about 2 in 3 respondents — still urgent, along with clinician shortage and burnout challenges which ranked a very close 5th place for urgency.                   Among those folks who have embraced techquity in their organizations, they tend to support a  specific group of people or a community – most notably, Medicare, Medicaid, rural geographies, and BIPOC communities. Key focuses of the techquity “pioneers” initiatives have addressed community partnerships, the user-friendliness of health technology, addressing literacy, educating via awareness campaigns, and ensuring data privacy and security. You can see other initiatives listed in the bar chart here. It is too early to assess the effectiveness of these initiatives. But we should be mindful in the current economic uncertain environment that investments in techquity may be constrained, an opinion held by over one-half of the survey respondents.           Health Populi’s Hot Points:  Trust is the first pillar of techquity: trust is also the precursor for patients’ health engagement, we’ve learned from the earliest research into patient engagement and activation, from the first Edelman Health Engagement Barometer to the research of Judith Hibbard and most recently, the Edelman Trust Barometer. Weaving together the data in the last chart from the Techquity report makes clear the value of equity-by-design. As I introduced the report above, I noted that VIVE and Ipsos bundle both the technology and data practices into the techquity-concept. This was embraced by about one-half of respondents who agreed with the survey question that “equity is integrated into our data strategy.” Human-centered design was also part of the thinking among two-thirds of respondents in this study. We have a lot of work to do on this: as the study was conducted among more of the techquity/health equity cognoscenti, equity-by-design and its tactical calls-to-action must be baked into the plans of those charged with delivering on the promise of health equity — from data strategy and capture to analysis and usability design. Thanks to the HLTH Foundation, #VIVE2023, and Team Ipsos for bringing these insights into the benchmarking research.

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The New Deaths of Despair in America – Among U.S. Children

The phenomenon of Deaths of Despair is the short-hand name for rising mortality among certainly people living in the U.S. due to overdose, accidents, and suicide. Angus Deaton and Anne Case published their first of many research papers on Deaths of Despair in 2015. Their research uncovered the risks of dying a Death of Despair to be higher among men, especially those between the ages of 25 and 64. But mortality isn’t only going in the wrong direction for those people most closely associated with the Deaths of Despair demographic: there’s another life-span line graph moving in the wrong direction, and it’s for young Americans under 19 years of age. s         NPR broadcast a Morning Edition story titled “Live Free and Die” on March 25th. Subtitled “the sad state of U.S. life expectancy,” The declining curve here represents U.S. life expectancy for all residents of all ages of 76.1, some 6+ years lower than comparable country averages the OECD has collected for Australia, Austria, Belgium, Canada,, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the U.K. For more on the Deaths of Despair in the U.S., you can search through the Health Populi blog for my various takes — starting with the milestone research of Deaton and Case discussed in this post. Now we turn to a JAMA viewpoint published on March 13 titled The New Crisis of Increasing All-Cause Mortality in US Children and Adolescents. Dr. Steven Wolf and colleagues write about, quote, “A nation that begins losing its most cherished population — its children — faces a crisis like no other.”             Here is the line graph Dr. Woolf et al. featured in their essay. This chart graphs the mortality rates per 100,000 people between ages 1 and 19 years old by five causes: COVID-19, transport accidents (i.e., death by car, bus, train, etc.), homicide, suicide, and poisoning. Death rates for young Americans increased across all five categories. Today I’m pointing to homicide, the solid aqua blue line, in the graph. Note that these data go to 2021, so do not include the life expectancy data for young Americans from 2022 or first quarter of 2023.     The increase in pediatric injury deaths was not caused by COVID-19 but due to injuries, the authors note. But the pandemic “may have poured fuel on the fire,” they observe. “Much of this surge involved homicides, which increased by 39.1%, and deaths from drug overdoses, which increased by 113.5%.”             Gains in kids’ life expectancy (say, for pediatric cancer and congenital disorders) improved young peoples’ mortality rates; we can see the graph’s declining mortality rates here, by cause. The mortality rates for people ages 1 to 19 continued to fall from 1999 until about 2013, when deaths due to injury took a turn up and to the right — especially among young males. “Firearms play a central role in this crisis,” one of the concluding paragraphs asserts. “They are the leading cause of death among youths aged 1 to 19 years old and accounted for nearly half of the increase in all-cause mortality in 2020.” Bullets, drugs, and automobiles are now causing a youth death toll sufficient to elevate all-cause mortality rates, they conclude. Health Populi’s Hot Points:  “Without bold action to reverse the trend, children’s risk of not reaching adulthood may increase.” That’s Dr. Woolf’s and colleagues’ last sentence of the succinct 2-page JAMA viewpoint. The piece was published on March 13, two weeks before yesterday’s Nashville mass shooting at the Covenant Presbyterian Church School killing three children and older victims.           Last week, I received a mailing from my local hospital system, Main Line Health. I cut out a phrase from the marketing piece that resonated with me — “Human care means seeing our neighbors.” This came to front of mind now as I wrestle and think about the data from the CDC, OECD, and the JAMA viewpoint on “losing our most cherished population:” our children. Human care really does mean seeing our neighbors. So does public policy and legislation. We are all health citizens, every day.

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Patients Have AI-Disconnect When it Comes to Their Health Care – Pew Research Center Insights

Most U.S. health citizens think AI is being adopted in American health care too quickly, feeling “significant discomfort…with the idea of AI being used in their own health care,” according to consumer studies from the Pew Research Center.                  The top-line is that 60% of Americans would be uncomfortable with [their health] provider relying on AI in their own care, found in a consumer poll fielded in December 2022 among over11,000 U.S. adults. Most consumers who are aware of common uses of AI know about wearable fitness trackers that can analyze exercise and sleep patterns, as a top health/wellness application for the technology. Other commonly-known examples of AI in daily living included chatbots that respond to consumers’ questions, product recommendations based on previous purchases, and security cameras that send alerts when they “see” an unrecognized person at the door.                   Pew Research Center has published several analyses based on the data collected in the December 2022 consumer survey. I’ll focus on a few of the health/care data points here, but I recommend your reviewing the entire set of reports to get to know how U.S. consumers are looking at AI in daily life. Among U.S. consumers who are aware of AI applications, over one-half view robots that can perform surgery as well as AI tools that can detect skin cancer represent major advances in medical care. For pain management and chatbots for mental health? Not so much major advancements as minor ones which one-third of consumers perceive. For mental health, 46% of consumers thought AI chatbots should only be used by people that are also seeing a therapist. This opinion was held by roughly the same proportion of people who had heard about AI chatbots for mental health as those who did not know about the use of AI chatbots for mental health.                   Less than half of people expect AI in health and medicine to improve patient outcomes. Note that one-third of people expect AI to lead to worse health outcomes. Medical errors continue to challenge American health care. About 4 in 10 people view the potential for AI to reduce the number of mistakes made by health care providers as well as the opportunity for AI to address health care biases and health equity. This is an important opportunity for AI applications to address in U.S. healthcare: two in three Black adults say bias based on patients’ race or ethnicity continues to be a major problem in health and medicine, with an additional one-quarter citing bias as a minor problem, found in the Pew study.               Health Populi’s Hot Points:  As industry continues to move faster and faster toward AI, and currently the hockey-stick S-curve of ChatGPT adoption, mass media are covering the issue to help consumers keep up with the technology. USA Today published a well-balanced and -researched piece titled “ChatGPT is poised to upend medical information. For better and worse.” In her coverage, Karen Weintraub reminds us: “ChatGPT launched its research preview on a Monday in December [2022]. By that Wednesday, it reportedly already had 1 million users. In February, both Microsoft and Google announced plans to include AI programs similar to ChatGPT in their search engines.” Dr. Ateev Mehrotra of Harvard and Beth Israel Deaconess, always a force of good data and evidence-based healthcare, added, “The best thing we can do for patients and the general public is (say), ‘hey, this may be a useful resource, it has a lot of useful information — but it often will make a mistake and don’t act on this information only in your decision-making process.” And Dr. John Halamka, now heading up the Mayo Clinic Platform, concluded that, while AI and ChatGPT won’t replace them, “doctors who use AI will probably replace doctors who don’t use AI.” Dr. Halamka also recently discussed AI and ChatGPT developments in health care on this AMA Update webcast. From the patient’s point of view, check out Michael L. Millenson’s column in Forbes discussing how in cancer, AI can empower patients and change their relationships with physicians and the care system. A recent essay in The Conversation, co-written by a medical ethicist, explored a range of ethical issues that Chat-GPT’s adoption in health care could present. Privacy breaches of patient data, erosion of patient trust, how to accurately generate evidence of the technology’s usefulness, and assuring safety in heath care delivery are among the risks the authors call out, as well as the potential of further entrenching a digital divide and health disparities. Vox published a piece this week arguing for slowing down the adoption of AI. Sigal Samuel asserted, “Pumping the brakes on artificial intelligence could be the best thing we ever do for humanity.” He argues that, “Progress in artificial intelligence has been moving so unbelievably fast lately that the question is becoming unavoidable: How long until AI dominates our world to the point where we’re answering to it rather than it answering to us?” Sigal de-bunks three objections AI proponents raise in this bullish, go-go nascent phase of adoption: Objection 1: “Technological progress is inevitable, and trying to slow it down is futile” Objection 2: “We don’t want to lose an AI arms race with China,” and, Objection 3: “We need to play with advanced AI to figure out how to make advanced AI safe.” Yesterday, Microsoft and Nuance announced their automated clinical documentation tool embedded with GPT-4 and the “conversational” (i.e., chat) model. Given the fast-paced adoption of AI in medical care, and ChatGPT as a use case, we will all be impacted by this technology as patients and caregivers, and workers in the health/care ecosystem. It behooves us all to stay current, stay honest and transparent, and stay open to learning what works and what doesn’t. And to ensure trust between patients, clinicians and the larger health care system, we must operate with a sense of privacy- and equity-by-design, respecting peoples’ sense of values and value, and act with transparency and respect for all. In hopeful mode, Dr. John Halamka concluded his conversation on the AMA Update with this optimistic view: “So how about this—if in my generation, we can take out 50% of the burden, the next generation will have a joy in practice.” Concluding this discussion for now, wishing you joy for your work- and life-flows!

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Food-as-Medicine Update: How SNAP Members Face Greater Chronic Illness and a “Hunger Cliff”

The pandemic worsened food insecurity for many people in the U.S., putting more people at risk for not only hunger but for chronic diseases that can be managed with access to nutritious, fresh food. In Helping SNAP Consumers During Economic Headwinds from Numerator, we get a current read on food security, the SNAP program, and the challenges of chronic health management that are intimately tied. To set some context on this current challenge to peoples’ health, the U.S. is facing the official end of the pandemic emergency on May 11, 2023. At that point, support for government-sponsored programs that have supported American health citizens’ well-being since the emergency of COVID-19. This included expansion of SNAP and nutrition benefits, among many other services. Exacerbating food insecurity in America, note that food price inflation rose 9.5% in February 2023 versus February 2022; prices will increase by 7.9% in 2023, the U.S. Department of Agriculture expects. People living in low-income households are facing growing stress and insecurity when it comes to food, resulting in a “hunger cliff.” It’s a “cliff,” explained Ellen Vollinger of the Food Research and Action Center, “because this is a very abrupt change in what people are going to have in their food budget,” affecting millions of people in the U.S.             With these data points in mind, we can dig into Numerator’s look into SNAP consumers’ home economics. The first chart shown here from the report profiles enrollees in SNAP programs, the Supplementary Nutrition Assistance Program which is part of the USDA. Numerator, a consumer market research company, profiled SNAP recipients at the end of 2022, finding that 61% of the enrollees were in the bottom 30th percentile of income in America. Nearly one in two SNAP households had children versus 28% of non-SNAP homes. And SNAP households were twice as likely to be Black/African-American or Hispanic/Latino in their race/ethnicity compared with non-SNAP households.             This study looked into the “headwinds” facing SNAP consumers’ home economics, recognizing that the COVID-19 stimulus funds helped to buoy food-insecure householders for many months However, as these funds ran down and out, the inflationary era kicked in the U.S. economy. SNAP households are now more likely to be “overwhelmed” with financial burdens, Numerator observed. These folks heavily over-index with being struggling households, the study found, compared with other U.S. families. One in four are unable to buy enough food to feed their family, and most have low confidence in the economy improving in the next three months. There are four themes for SNAP benefits and enrollees in 2023, explained in the second chart here: brands will need to understand how SNAP recipients are adjusting their shopping baskets, looking for value and lower prices; SNAP consumers are buying more private label products (which are lower-priced); health and wellness are key to SNAP recipients purchasing behaviors, challenged by time constraints in their daily lives; and, brands need to segment consumers looking, in part, at their occupations — heavily indexed toward healthcare and homecare, housekeeping, childcare/daycare, transportation, and other work categories.           Keep in mind these occupational types when considering SNAP enrollees health and wellness goals and challenges. These people are nearly 4 times as likely to be disabled than consumers not enrolled in SNAP benefits: these conditions include respiratory health (COPD, asthma and bronchitis), back pain, and migraines, among other issues. We know folks dealing with one social determinant risk tend to have more than one risk, and in this instance it’s a greater burden of heath expenses over the course of a year. =           These chronic condition management challenges are worsened, risk-wise, due to the fact that SNAP enrollees tend to be time-challenged, and of course, financially insecure as well as food-insecure. Fifty0six percent of these consumers are less likely to not be actively managing their health. One factor Numerator identified that may constrain peoples’ ability to self-care is that SNAP recipients are time-strapped as they are two times more likely to be a caregiver for over 9 hours a week. One in three SNAP enrollees shops at least twice a week as a caregiver, and one-third have the person they care for living in their home (1.2x more likely than non-SNAP recipients).           Health Populi’s Hot Points: “Supply and demand for basic human needs has severe implications,” a brief co-sponsored by Quest Diagnostics and Pack Health calls out. “Just eat healthier” implores the essay on why diet improvement as a chronic condition management strategy has not been effective for people experiencing food insecurity. The pandemic exacerbated peoples’ food insecurity in the U.S., with demand far outstripped the supply of food provided at food banks. And food insecurity raises peoples’ risks for chronic conditions, the straight-line graph illustrates as a direct correlation. As Pack Health and Quest note, “the lack of resources isn’t just about the food itself. Those who are food insecure are also more likely to be affected by other social determinants that contribute to worsened health outcomes.” To address the food security risk for chronic health conditions, Pack Health couples grocery and meal delivery services with nutrition education and digital coaching. Think: telehealth meats meals-on-wheels meets nutrition education.  

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The Top 10 Patient Safety Concerns for 2023 Are About Social, Mental and Behavioral Health

Ten years ago, ECRI named the top 10 health technology hazards  for 2013: they were alarm hazards, medication administrative errors using infusion pumps, unnecessary exposure and radiation burns from diagnostic radiology procedures, patient/data mismatches in EHRs and other HIT systems, interoperability failures with medical devices and health IT systems, and five other tech-related hazards. In 2014, ECRI pivoted the title of this annual report to “patient safety concerns,” a nuance away from health technology. Fast forward to 2023 and ECRI’s latest take on the Top 10 Patient Safety Concerns 2023. While technology is embedded in this list, the headlines have more to do with social, mental, and behavioral  health than pure-play technology and devices.                 Topping the 2023 list of patient safety concerns is the pediatric mental health crisis. This, in ECRI’s words, “recognizes that children and youth are facing a true crisis. The proportion of youth experiencing mental health challenges is high and growing yet resources and access are limited. The healthcare sector must act now to protect our youngest and most vulnerable population,” ECRI asserts from the start of the report. For each concern, ECRI provides a data snapshot and explanation of the challenge providing context and evidence on the issue. Following the statement, ECRI provides Acton Recommendations that hospitals and providers can consider to address the challenge.               Here is ECRI’s top issue statement for the pediatric mental health crisis. The key safety implications here are lack of access to pediatric behavioral health providers, drug and alcohol use, gun violence, and other stressors. The risk to suicide among young people has been especially acute, with ECRI citing CDC data finding that more young people in the U.S. ages 12 to 17 presented to the emergency department for suspected suicide attempts in the winter of 2021 — 39% greater than in the same period in 2019. In its recommendations for action, ECRI notes that health care providers cannot solve this crisis themselves, but can take specific actions to address the pediatric mental health crisis. These actions include leadership support and resources to shift the organization’s culture toward behavioral health needs, patient and family engagement tactics, and warm handoffs to pediatric mental health services in the community, among many other constructive recommendations.                 I’ll explore one more challenge on this sobering list of safety concerns, which is #3 on the list: uncertainty surrounding maternal-fetal medicine. I support ECRI’s call-out of this challenge as a patient as well as provider safety issue, given the politicization of women’s health care access which has emerged a national as well as State-level crisis for women and the people who love us. Here is ECRI’s discussion of clinician needs in times of uncertainty surrounding maternal-fetal medicine. The issue statement begins with ECRI’s noting, “On June 24, 2022, the Supreme Court held that the Constitution does not provide a right to an abortion, overruling Roe v. Wade. In doing so, the Court returned the full power to regulate abortion to the states,” sourcing the Dobbs decision. The problem statement includes a table on restrictiveness of State abortion laws for some data points and context for the safety challenge. The safety issues include resource and capacity constraints leading to all-time highs of provider burnout, especially in the wake of the pandemic. In addition, patients have seen delays in getting treatment for other conditions unrelated to reproductive services. Of course, cross-border care has complicated women’s health based on the states in which they live, compromising health and potentially life (see this piece in the New York Times providing details on five Texas women suing the state, each dealing with difficult pregnancies and situations).               Specific actions ECRI recommends for stakeholders to address the uncertainties for maternal-fetal medicine including engaging in two-way communications with frontline staff to share concerns and develop guidance for caring for patients (aka “tiered safety huddles”), to create patient education materials for staff to share with patients and families on a state-by-state basis, offer emotional and mental health support for clinicians experiencing high levels of moral distress and burnout, among others. ECRI builds this report of the Top 10 patient safety issues leveraging its long-time expertise in this field: their staff are expert across the health care landscape including people in medicine, nursing, pharmacy, risk management, and of course patient safety and quality. The team reviews the scientific literature, assesses event reports, root cause analyses, research requests they’ve received int he past year, accident investigations and a plethora of other data souuces. The Top 10 risks are based on severity, frequency, breadth, insidiousness (meaning is the problem difficult to recognize or challenging to rectify), and profile — does this safety issue place significant pressure on the organization.               Health Populi’s Hot Points:  Each year, ECRI informs us on their view of the Top 10 patient safety challenges. Year after year, some challenges persist, and these are shown in the last chart here from the 2023 report. Among the dozen+ safety issues are medication safety, health IT, workforce staffing, telehealth and digital health risks, infection prevention and control, and health equity — which ECRI noted as #1 last year in its 2021 review as “racial and ethnic disparities.” Clearly, patient safety challenges in 2023 go well beyond technology in and of itself. Our cultures of care, caring, and social health have as much to do with patient safety as technology glitches and cleaning and disinfection.  

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Growing DTC for Health Beyond the Rx – the New Health/Care at Home

As our homes and health care services continue to converge, we can see signposts of direct-to-consumer strategies from the pillbox (where DTC is a mature thing) to clinical care in peoples’ hands (and on their preferred technology platforms). Some examples this week make this point, which taken together demonstrate the portfolio of ways more people – as health consumers and caregivers – can engage in their health, well-being, and clinical care.             Start with Best Buy’s announcement that they will collaborate with the health system Atrium Health to bolster hospital-to-home effectiveness and activation between hospitals and patients. You know Best Buy for its consumer electronic retail chops, starting up Best Buy Health several years ago as a key pillar for the company’s strategic long term plans. Enter Atrium Health into this mix: the hospital system has had a successful entry into hospital-at-home care, and with Best Buy as partner, will grow the consumer-digital-health front-end capabilities through a trusted retail brand’s Geek Squad expertise. I can’t say it better than Deborah Di Sanzo, President of Best Buy Health, did in the press release: “We knew Atrium Health was the right partner to help tackle the unique challenges within the care at home experience,” said Deborah Di Sanzo, president of Best Buy Health. “We’re excited to leverage our expertise in omnichannel, supply chain, Caring Center support and services, in-home support and our ability to connect patients and providers through Current Health’s care at home platform. Those strengths, combined with Atrium Health’s extensive clinical expertise and deep experience leading in virtual care, will help us improve and enable care in the home for everyone.” Now ad in prescription drugs which is the mature category of DTC in healthcare —  a unique aspect of American medicine as the only country in the world, except for New Zealand, which permits direct-to-consumer pharmaceutical advertising. This week, Teva Pharmaceuticals launched a campaign focused on caregivers — who are among the largest unpaid workforce collectives in the U.S. (For more on this economic and personal challenge, see the good work of ARCHANGELS, led by Alexandra Drane). As actor John Rhys-Davies (whom you have loved in Indiana Jones and Lord of the Rings franchises) attests, “Love doesn’t take a break” when you’re a caregiver. Rhys-Davies knows this so well, speaking out of his experience in caring for his wife until she succumbed to Alzheimer’s disease in 2010. Here, Teva collaborated with the agency VCCP London to raise our awareness of and appreciation for caregivers….baking in the empathy and personal story of Rhys-Davies. Well done, Teva.             On a different self-care front, check out this week’s news that WW (once known as Weight Watchers) acquired Sequence (aka Weekend Health). This acquisition grows WW’s telehealth capabilities, as Sequence built a subscription virtual care platform serving chronic weight management, including the use of GLP-1 prescription drugs. The platform enables patients and clinicians to collaborate in ongoing care and communication to support the long journey of behavior change. As of February 2023, Sequence was serving about 24,000 consumers. There’s more on Sequence here. A concurrent news story in the weight management space is the fast-growing prescribing by clinicians and adopting by consumers of drugs in the weight-loss category, the GLP-1 agonists. If you watch TV or stream radio, there’s no doubt you’ve heard some of the DTC ads for drugs in this group such as Rybelsus, Ozempic and Trulicity (currently three of the top ten DTC Rx spends). Weight-loss has been a top-self-care area for health consumers since the beginning of time, so watch this space closely. (Here’s a salient essay on the “bizarre Americanness” of DTC Rx spending from Vox if you want to know more).                   Add into this mix CHPA’s launch of the Health in Hand app, enabling consumers to access a trustworthy resource for comparing over-the-counter medicines, vitamins and supplements, and digital health devices. Supported by the Consumer Healthcare Products Association CHPA Educational Foundation, is designed for greater personalization, including new sections on My Self-Care and Healthy Living. There is updated support for people to hone in on specific diet/food styles, stage of life, and lifestyle choices.                     Health Populi’s Hot Points:  These are but four examples, in real-time, of the evolving home and self-care phenomenon accelerating in U.S. health care. There are many drivers accelerating this, among them peoples’ growing financial skin-in-the-healthcare game through high-deductibles and more out-of-pocket, more transparent costs borne by families. The current financial stress families feel bolsters peoples’ commitment to more care-in-hand and DIY care flows at home. Furthermore, younger people have shown fast-adoption of digital health techs, and lack of interest in making a permanent commitment to a primary care medical home. As the recent ATA conference chanted, #TelehealthIsHealth for more people, across generations, incomes and ethnic backgrounds. This is a major focus of my work these days in the U.S. and Europe. Keep staying tuned to the Health Populi blog as I continue to grow and learn more in the field on our home as site of care.

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<div>The Patient Is Still the Payor – And May Skip Paying for Prevention (Eyes on the ACA & Texas)</div>

Many health citizens in the U.S. would likely skip receiving preventive health care services if the Affordable Care Act’s (ACA) coverage for them goes away, a Morning Consult survey found.                   The first chart illustrates the top-line of this research: that most U.S. adults would not pay out of pocket for several preventive services including tobacco cessation, drug use screening, weight loss measures to prevent obesity-related illnesses, as well as screening for depression or HIV. One of the key benefits embedded in the ACA was “free” without co-pay shares for  preventive care. These addressed four broad categories of services for adults and children covering screening and counseling (e.g.,  depression, diabetes, obesity, various cancers, and sexually transmitted infections) as well as prenatal tests, medications that can help prevent HIV, breast cancer, and heart disease, as well as counseling for drug and tobacco use, healthy eating, and other common health concerns. Routine immunizations have also been covered (updated for COVID-19). In addition, preventive services for women are part of ACA prevention list such as well-woman visits, all FDA-approved, -granted, or -cleared contraceptives and related services, and other female-focused care. It’s a lot — and has made a huge difference in public health access for those enrolled in ACA plans. Morning Consult polled 2,199 U.S. adults in late January 2023 to understand how American health consumers felt about paying for health care — in particular, the preventive care services that were embedded in the original Affordable Care Act (ACA), currently on the Texas Supreme Court docket of Judge Reed O’Connor. (If you want to learn more details on the case, it’s formally filed as Braidwood Management Inc. v. Becerra). Judge O’Connor had ruled that the ACA was unconstitutional over four years ago — overturned by the Supreme Court. In September 2022, Judge O’Connor ruled it unconstitutional for the ACA to require health plans to cover preventive services.                 Health Populi’s Hot Points: By late January, one-in-two U.S. adults said they had delayed or skipped medical care due to cost — including preventive services. This included 54% of those earning under $50,000 a year, 50% of people earning between $50K and $100,000, and 38% of those earning over $100,000 a year. People value preventive care, but if they have to cover these services out of their own pockets, the services compete with other household spending that, in the current economic climate, crowds out preventive care for many households.                   Check out the health care services Americans say are the most important for commercial health insurance plans to cover. First comes emergency services, followed by prescription drugs, hospital inpatient care, and then preventive services and chronic disease management followed by mental health and substance use disorder services. Celebrating International Women’s Day today for 2023, we are joining the theme #EmbraceEquity.                   Women’s health care and health rights around the world have been eroded, especially in the wake of the pandemic as well as structural blocks to care (say, in the U.S. Post-Dobbs era of women’s health access challenges). “A woman’s health is her capital and her body hears everything her mind says.” This is one of the mantras for #IWD2023. Health care access and equity cannot be separated from women’s overall well-being – mind, body, spirit, financial. We still have such a long way to go to achieving equity for women across all of these pillars. Let’s continue to collaborate together to advance and #EmbraceEquity this year and ongoing.        

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How Consumers and Physicians View Digital Health – An Update from the Consumer Technology Association

Most consumers are bullish on the benefits that digital health technologies can play in their health. Most health care practitioners are also positive about the potential of digital health — recognizing room for improvement for better data integration, interoperability, and the opportunity to bridge gaps to achieve health equity and bolster access. So assesses the Consumer Technology Association in the report, Driving Consumer Adoption of Digital Health Solutions,             To paint this profile, CTA engaged Ipsos to poll 1,000 U.S. consumers 18 years and older, 300 health care providers (HCPs), and 12 health tech company stakeholders in August and September 2022. The health tech company leaders were CTA Health Board members including representatives from Abbott, Best Buy, Elevance Health, Google, Humana, Intel, Microsoft, ResMed, Samsung, and Validic, among others. CTA sought to understand the role of digital health applications in U.S. health care from consumers’ perspectives along with the technologies’ influence on HCPs’ workflows.             The first table arrays the growing range of digital health applications that consumers currently use. CTA sizes the market at $29.5 bn in 2022, expecting growth of nearly 7.5% annually to 2027 when the projected market would be over $42 bn. Most U.S. consumers have used telehealth, one in five for at least a year. Satisfaction has been generally high among these virtual care adopters. The most commonly used digital health solutions in 2022 were blood pressure monitors, weight monitoring devices, glucose/diabetes meters, pulse oximeters, sleep apnea monitors, continuous glucose monitors, mobile apps to manage chronic conditions, and personalized medicine applications. The second chart attests that most consumers who have used digital health tech have felt more in control of their health, motivated to take better care of themselves, improved quality of life, and other positive benefits accrued through digital health self-care adoption.             The COVID-19 pandemic accelerated consumers’ greater DIY and self-care adoption: CTA called out three key drivers shown in the third chart which included the need for alternative support due to strained emergency supply; a vested interest in monitoring personal health; and, the need to access medical care from remote locations physically distanced from hospitals and doctors’ offices.                 To that point, then, clinicians/HCPs currently recommend a broad array of digital health solutions, CTA found; these are shown in the fourth chart, with large numbers of providers recommending technologies from blood pressure monitors and diabetes-management tools to medication adherence devices and fall/motion monitors. Note that very few clinicians have “never heard of” any of the digital health tools assessed; the only one of note would be augmented/virtual reality platforms, recommended by 14% of HCPs and “never head of” by 27% of the clinicians.           With these recommendations or digital health “prescriptions” maturing up the S-curve of adoption, clinicians believe digital health solutions can be improved in several ways — through better data integrations and interoperability between the solutions (and the data). Furthermore, clinicians see the potential for digital health tech’s to address and improve health disparities, access and equity in improving personal and public health.             Health Populi’s Hot Points:  Consumers increasingly view health care as a shared work- and life-flow between their HCPs (who are largely trusted — doctors, nurses and pharmacists alike) and themselves — in their hands and in their homes. This last chart here illustrates the devices and consumers currently use or those they are interested in using to help folks manage health. We can see a maturing of adoption for peoples’ use of smartphones (with internet connectivity), computers and laptops, smart TVs, and tablets — all currently used by over 50% of U.S. consumers. There is also emerging consumer demand to use smartspeakers and voice tech (like Alexa), smartwatches, and wearable devices beyond the wrist for health.                         We’ll continue to see the blurring of home (and our bodies and phones) as our health destination. I’ll be brainstorming this with a wonderful panel at South-by-Southwest in Austin on Saturday March 11th at 1 pm at the Line Hotel during Real Chemistry’s Healthcare Innovation Day. Hoping to see those of you attending #SXSW2023 there!  

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<div>We Are All Health Consumers Now – Toluna’s Latest Look at Consumers’ Health & Well-Being</div>

The challenging financial climate at the start of 2023 is impacting how people, globally, are perceiving, managing, and spending money on health and well-being, based on the latest (Wave 21) Global Consumer Barometer survey conducted by Toluna, a sister company of Harris Interactive.               Globally, one-third of health citizens the world over are confronting greater stress levels due to the higher cost of living in their daily lives. One in two people say that rising cost of living is negatively impacting their health and well-being. On the positive side, one in three people believe they will be more satisfied with their personal health and well-being by the end of the year — and as health consumers, expect to spend more money on healthcare, vitamins and supplements, and personal care and hygiene. I asked Lucia Juliano, who discussed the global findings in a webinar in February, if she could share U.S.-specific data with me for the Health Populi blog and my upcoming talks about health consumers at SXSW and the Virgin Pulse Summit happening in the next month. Lucia with her team including Esther Ward, and Ian Smith generously put together a special data cut for us to consider, key points of which I share with you here in this Health Populi post.             The green-bar chart shows us the U.S. data responding to the question of how the financial climate is re-shaping Americans’ health across physical and behavioral aspects. Stress is the most common impact shared by U.S. health consumers, followed by eating less healthfully and buying less health-supportive products such as vitamins and supplements. Looking forward to the next few months, 27% of U.S. consumers expect to spend more on health care as well as personal care and hygiene, 24% of folks more on vitamins and minerals to support health as well as 24% on medications and health insurance coverage.             Roughly one-half of U.S. consumers will spend about the same on personal care and hygiene, VMS, meds, and health plans. Several other granular points to note about U.S. consumers in light of the current fiscal challenges households face: 1 in 2 Americans say the rising cost of living is impacting their health and wellbeing 21% expect to spend more on fitness, sports and exercise 25% expect to spend more on vitamins, minerals and other items to support personal health 25% expect to spend more on health care services 23% expect to spend more on medications 24% expect to spend more on personal care, toiletries and hygiene products 22% expect to spend more on health insurance, and, 30% of U.S. health citizens are looking for more cost-effective solutions for health, wellness and fitness. The Barometer’s findings bolster our ongoing appreciation for consumers linking their financial fiscal lives and livelihoods to their physical lives and well-being, continuing to morph people into health consumers.                         Health Populi’s Hot Points:  “In 2023, inflation will influence most consumers’ purchasing decisions — and purchases of food, fuel utilities, healthcare services, and more will undergo greater scrutiny,” the 2022 Consumer Survey from Access One observed. Note that at least one-half of consumers across generations, from Gen Z to Boomers, were likely to delay healthcare expenses in 2023. Furthermore, across incomes, it’s 1 in 2 people expecting to delay healthcare expenses in 2023, ranging from 48% of people earning $100,000 or more a year to 58% of folks earning between $50K and $100K annually. In the U.S., and the larger world, health citizens are all health care consumers now.

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Enabling better health care, everywhere – my conversation with Microsoft

I am grateful to have been given the opportunity to brainstorm omnichannel health care for people to enable better health care for all, anywhere and everywhere, with Team Microsoft. Key opinion leader Molly McCarthy and I covered a lot of ground in this webcast conversation as part of Microsoft’s series of three “Expert  perspectives on trends driving change in healthcare.”             Molly and I covered a lot of ground here, starting with the key forces shaping and accelerating virtual care across the continuum. While these were in place before the COVID-19 pandemic, the public health crisis turbocharged telehealth and its many flavors from real-time clinical encounters to HIPAA-compliant secure messaging “asynchronously” as well as plain-old text messaging which can be a preferred communications channel for many patients — especially those who may lake access to predictable, quality broadband connectivity.               That led us to a discussion on the determinants of health and basic human needs — now with Wi-Fi akin to clean air, clean water, food, and shelter for survival. We learned this lesson during the pandemic quite clearly — connectivity as a social determinant of health. Molly and I then segued into how the health system incumbent players — hospitals, plans, clinicians, and life science companies — can (and should be) part of the telehealth ecosystem and solutions to deliver care, everywhere. In addition to my discussion with Molly, you should also listen to two insightful colleagues’ conversations in the series, with: Dr. Bonnie Clipper, Founder and CEO of Innovation Advantage, sharing learnings on high-tech and high-touch in nursing; and, Gil Bashe, Chair of Global Health and Purpose at FINN Partners, discussing the growing importance of connected data in health care – think AI, machine learning, and the criticality of breaking down siloes of information. Thanks to Microsoft for its leadership in enabling better healthcare, everywhere.

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People Using Health Apps and Wearable Tech Most Likely Track Exercise and Heart Rate, Sleep and Weight – But Cost Is Still A Barrier

Over one in three U.S. consumers use a health app or wearable technology device to track some aspect of their health. “The public’s use of health apps and wearables has increased in recent years but digital health still has room to grow,” a new poll from Morning Consult asserts, published today.                   Among digital health tech users, most check into them at least once every day in the past month. One in four use these tech’s multiple times a day, the first pie chart illustrates. Eighteen percent of people use their digital health tech’s a few times a week. Among those people who do not yet use health apps or wearable tech for health, cost is the top reason they haven’t adopted digital health tools, Morning Consult found. Why do people own and use health wearables? Primarily, to be encouraged to achieve their fitness goals (31%), followed by being interested in tracking their personal health data (24%). In a distant third place is encouragement in losing or controlling weight (13%).                 Those fitness goals are reflected in this next chart which quantifies the share of people using health applications by clinical reason: first, being exercise, fitness, activity tracking, or heart rate monitoring (not blood pressure, but heart rate). Then it’s sleep and weight health consumers are most keen to track (for about one-half of those using health apps and tech’s), and then diet/food/counting calories (41%), and in fifth place, tracking blood pressure (for 36% of digital health tech users). Nearly 1 in 4 consumers use digital health to track medications , mental health and mood.                     Health Populi’s Hot Points:  We’ve traditionally expected health apps to come out of “digital health” companies, the likes of which we’ve seen exhibit annually at CES, the big consumer electronics show. Once upon a time in digital health, it was Fitbit, Nike, Garmin, and Apple who were populating the app stores with health tracking apps. Today, we’re downloading health-oriented apps from new touchpoints playing growing roles in consumers’ self-care and health tracking: like grocery stores and retail pharmacies on the pure consumer side, and from Abbott (which launched the Lingo app for metabolic health at CES 2022) and other FDA-regulated companies on the more clinical side of patients’ work-flows.         Here in today’s Hot Points, I’m featuring Albertson’s recently-released Sincerely app, which marries healthy behaviors with good food and financial incentives. The second graphic titled “ready to start your health journey” kicks off the downloading of the app and creating an account, and ends with a $10 off grocery coupon. As many consumers told Morning Consult, “price” and cost of apps are top-of-mind when it comes to opting-in to their adoption and continued use. Our groceries stores have become key touchpoints for our health and well-being in a larger retail health/self-care ecosystem that underpins our homes as our health hubs.                       This has been a consistent health consumer sentiment for a long time: here’s how I covered PwC’s study on The Wearable Future back in 2014. Note the chart at the left from PwC’s study, showing that consumers would be much more likely to use wearable tech if their employer paid for it whether a smart watch, fitness band, or smart glasses. The Morning Consult poll gives us some insights into this, nearly ten years later, through the observation of Scott Whitaker, chief executive of the medical device industry group AdvaMed, who is quoted in the study press release. For context, Morning Consult notes that, “One way to help increase adoption is for public and private payers to open up coverage for devices that can cost hundreds, if not thousands, of dollars. Another factor for device coverage is paying for data processing systems and artificial intelligence services that some products use, in addition to paying for the device itself.” Scott Whitaker of AdvaMed then notes that while Medicare has “opened up a bit over the past several years to cover more apps and wearables,” the payor is still “stuck in the ‘60s” in fee-for-service — not able to be reimbursed for digital health devices and apps. Whitaker told Morning Consult, “I’m not sure that as a payer, Medicare fully understands the value of wearables and other forms of technology to lower cost and improve health care outcomes for those in the Medicare program.” As employers increasingly pay attention to worker wellness and population health, the enterprise-coverage vision that PwC began to quantify in 2014 is (finally) gaining traction. I’m looking forward to discussing this at the upcoming Virgin Pulse Thrive Summit in April 2023. 

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The American Hospital Association Looks at Retail and Tech Health Care Disruptors

Ever since Clayton Christensen explained the concept of disruptive innovation in 1995, health care became one of the poster children emblematic of an industry ripe for disruption. Nearly 30 years later, disrupting health care continues to be a theme which, in 2023, seems open for those slow-moving tectonic driving forces to finally re-form and re-imagine health care delivery. So in today’s Health Populi we turn to a new report, Health Care Disruption 2023 Outlook, part of AHA’s “The Buzz” market scan initiative. The American Hospital Association is taking disruption seriously right here, right now, as the U.S. hospital sector is facing major challenges on all fronts: staffing (especially nursing and more broadly, clinician burnout), supply chain, financial stressors, demographics, and cross-industry politics vis-à-vis pharma and health insurance.             The report explores the healthcare market moves for seven major players in retail and tech including Amazon, Apple, CVS Health, Google, UnitedHealth Group (exploring both Optum and UnitedHealthcare), Walgreens Boots Alliance, and Walmart. The top-line theme of the report is that, “The $260 billion primary care market is dominated by traditional providers in a fee-for-service arrangement, but that is changing rapidly,” the report begins. “By 2030, nontraditional players could own as much as 30% of the primary care market.” The report then provides one-page analyses addressing each of the seven companies profiled, describing their respective approaches to the health care ecosystem. In brief, in alphabetical order…. Amazon has been investing to expand primary care (virtual and in-person), diagnostics and therapeutics, pharmacy, disease management, and leveraging AWS for data-driven tools and analytics. Apple won’t be one of the contestants in the retail health/primary care battle royale (as I discussed here in Health Populi over the week of 25th July 2022), but instead will focus on using platforms of Apple Watch and the iPhone to partner across the health care ecosystem and support people through healthy living and chronic disease management. CVS Health continues its vertical integration with Aetna, primary care (again, virtual and in-person), home care, and retail health via the pharmacy storefront and omnichannel platforms. Google (Alphabet) will be all about tech-driven health care, leveraging AI for more personalized health care which will also support research and development. In addition, like Amazon’s AWS, Google will be partnering via the Google Cloud with health care providers, pharma, and other innovators to accelerate health care transformation and innovation. UnitedHealth Group has many moving parts between Optum and UnitedHealthcare, expanding services from primary care and mental/behavioral health to care coordination and virtual care. Optum’s merger with Change Healthcare expands the organization’s data and analytics capabilities, too. And the company has acquired thousands of physician practices, with now more than 70,000 employed or aligned doctors in over 2,200 sites as of 2023 — more physicians than Kaiser or even the VA have on their staff. Walgreens has grown its primary care footprint through the VillageMD connection, now owning 2/3 of the company and expanding PCP practices to over 25 U.S. markets by 2025 and planning for 1,000 by 2027. Like CVS Health, Walgreens is also expanding home care services and post-acute care, and specialty pharma to complement pharmacy operations. Walmart has long committed to health care, leveraging pharmacy as a “front door to primary care,” AHA describes. The largest retailer in the U.S. is expanding virtual care and telehealth, and building long-term partnerships across the health care ecosystem — including one with UnitedHealth Group over a ten-year agreement. Together, the AHA sees these seven companies potentially capable of developing and offering innovative care models that could “significantly alter” the health care landscape, enable the shift to value-based care models, and grow alternative care sites and channels of care.               Health Populi’s Hot Points:  In concluding the report, AHA poses four questions providers should consider in light of the seven health care disruptors’ moves: Is there an omnichannel presence that supports consumers’ demands for access, convenience, pricing and transparency? Is there an opportunity to partner with one of the primary care transformers? Can the provider leverage the earned trust and relationships with existing patients to grow consumer-facing services? Can the provider partner with tech firms on data and research projects to improve care?             What underpins and inspires the seven “new” entrants to disrupt health care is consumer expectations. In 2016, I called out that most patients-as-health-consumers looked at Amazon as a model for health care experience to emulate well before Amazon acquired PillPack or invested in the industry as a major corporate vertical market strategy. Now that patients feel increasingly like health care payors — facing high-deductibles and out-of-pocket costs — all health care looks/feels like retail. And as such, the seven companies featured in AHA’s disruptors report illustrate the kinds of benefits these kinds of companies can bring to bear to health consumers’ experiences. Beyond the seven in this report, don’t count out Microsoft, Salesforce and Samsung on the technology sector side, and retailers Dollar General, Target, and grocery stores like Kroger out of the mix of disruptors-for-better-patient-experience.

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