More on Health Apps: Opportunities, Risks and the Implications for Population Health Management

It's called "mHealth" but others may call it "health apps." The FDA calls it a target rich regulatory opportunity. Others may call it hype.

The Disease Management Care Blog calls it inevitable.

Writing in JAMA, Drs. Steinhubl, Muse and Topol of Scripps agree and say that the future is bright for mHealth. Its adoption is being driven by the threefold convergence of:

1) the search for solutions that address otherwise unaffordable levels of healthcare spending,

2) the availability of broadband wireless connectivity, and

3) consumer demand for individualized care.

The DMCB suspects any one of the DMCB's 5000 regular readers could have written this article. Like Steinhubl et al, they already know that patients want self-diagnosis and condition monitoring. Health consumers want greater efficiencies and enhanced patient-physician collaboration.

Even tech-skeptics have to admit that it's possible that mHealth could lead to a utilization trifecta of fewer office visits, avoided emergency room visits and decreased hospitalizations. Imagine the handheld that can accurately catalog signs and symptoms that help the user discern between a simple self-limited cold vs. a more serious case of pneumonia, or benign skipped heart beats vs. a more worrisome arrythmia.

Handheld apps for chronic conditions are more available than realized. They are on the cusp of going mainstream with assisting hypertensives, diabetics and asthmatics monitor and act on their blood pressure, insulin dosing and inhalants.

If they work right, providers could review summary data and offer guidance via emails and texts in lieu of adding a patient on to the schedule at 5 PM. If done right, the background algorithms could liberate physicians to pay greater attention to the important stuff that requires their complex cognitive or procedural skills.

The authors point out that that doesn't mean it's going to be easy. Medicine is complex and getting paid for it is more so. There's also worry - warranted or not - about the decline of face-to-face doctor-patient relationship. mHealth can lead to overwhelming data gluts characterized by a lot of numbers with little actionable insight. Finally, there's the danger that an app can offer ineffective, inaccurate or dangerous guidance that leads to patient harm.

Bravo to the editors of JAMA for recognizing the importance of the topic and committing precious space to this manuscript.

That being said, however, this article fails to give a full accounting of all the opportunities as well as risks for "mHealth."

First off, as this Kaiser Health News article demonstrates, there are two additional opportunity dimensions that draw on the population health management business model:

1) Apps are not just for diagnosis and monitoring, but also for wellness, and

2) They're being principally sponsored by commercial health insurers who not only readily embrace innovation, but probably consider apps a "sticky" way to maintain customer loyalty. That is doubly true for engaged enrollees who ultimately represent a better insurance risk.  In fact, the DMCB suspects that value proposition is so compelling that insurers are willing to use apps as a "loss leader."

Oh, and while mHealth can be built, it's far more likely it's being bought. As in population health management vendors.

Risks?  You bet.....

1) The fit of mHealth with the electronic health record (EHR) remains an open question.  The DMCB is no coding geek, but it's safe to say that it's not automatic that two independently contrived technologies can automatically "speak" to each other or that the data from an app can by downloaded, summarized and coherently presented to a user at the point of care.

2)  As noted in this article on telemonitoring, it's also not necessarily true that mHealth can be equated with stand-alone technology. Depending on the condition and the need, mHealth will have to be often tethered to human support services.

3) As even casual observers are aware, allegations of "malpractice" are not unusual in health care.  Rather than comment on its friends who make a living off of contingency fees, the DMCB will only point out that mHealth may offer a target-rich rich environment for personal injury attorneys intent on using the legal theory of joint and several liability to maximum effect.  That threat may slow adoption of mHealth.

Image from Wikipedia

Wishful Ideology About Integrated Delivery Systems

Kaiser Health News has posted a telling interview with former White House health adviser Ezekiel Emanuel MD. In it, Dr. Emanuel repeats a bold prediction about the end of health insurance companies:

Question: You also predict the end of insurance companies as we know them. Rather than continuing to function as the middleman between employers and health care providers, you say insurers may themselves contract with networks of doctors and hospitals, morphing into integrated health care delivery systems. But a one-stop shop isn’t always good for consumers. Networks are restrictive, and at least now, if your insurer turns you down for treatment, your doctor may go to bat for you.

Answer: I don't agree with you. In general, integrated systems do a pretty good job compared to lots of other ways care could be delivered. We like the adversarial system. We believe that’s the best. On the other hand, with integrated networks you can have better coordination of care. And people are mildly sticky. Once you pick an insurance network, you tend to stick with it. That's also good for the insurer. If someone selected you, year in and year out you'll be with them. That changes the dynamic. And to the extent people are long-term keepers, that’s going to be a better arrangement.

"Better arrangement?" The Population Health Blog isn't so sure:

1. As pointed out at the start of the interview, health insurance has been around for more than 200 years. Its staying power is testimony to the enduring value proposition of pooling and monetizing risk. We discard that our peril.

2. Assuming "integrated systems" will competently manage that risk is a stretch.

3. Part of competently managing that risk - even for provider groups - is utilization review.  While the interviewer unflatteringly portrays that as "your insurer turns you down for treatment," the truth is far more complicated mix of advantages and disadvantages that have been heavily regulated (an example here) for decades.

4. Can enlightened "coordination of care" make utilization review unnecessary?  The luxury of Dr. Emanuel's anti-health insurer ideology makes it easy for him to say yes.  So far, inconvenient facts about the ACO pilot program suggest a different story.

5. Plus, can restrictive networks also make utilization review unnecessary?  It remains to be seen whether consumers will appreciate the irony that this invention of managed care is now being embraced by Dr. Emanuel and other progressives, or agree that significant limits on provider choice will be a "better arrangement."

6. Last but not least, doctors like the PHB have been trained and acculturated to put the individual patient's interests before any other consideration, including the success of an integrated delivery system. Unable to say no, our loyalty will translate to the usual specialist referrals, sophisticated testing, the latest technology and the priciest drugs.  Culture trumps everything.

Like it says, the PHB isn't too sure.  Maybe with the right combination of patient incentives, decision support, shared decision making, risk stratification and tailored population health, integrated systems will ultimately prevail.  Time will tell.

Give credit, however, to Dr. Emanuel for being consistent over the last two years.

The same is true for the PHB.  Based on the emerging facts on the ground, the PHB still thinks the odds remain against Dr. Emanuel.

And the offer of a $1000 bet still stands.

A Health Policy Test

The Disease Management Care Blog remembers those frustrating medical school exams that asked for the best combination of answers from two columns. Unfortunately, the DMCB never quite mastered the professors' trickery.

In response, the DMCB has fashioned it's own test. The good news is that for this quiz, there is no right answer!

Match the numbered statements to the best lettered conclusion below:

1) Asking the White House to fix healthcare.gov's "back-end" enrollment problems will be like.....

2)  Labor leaders are discovering that the Washington DC's commitment to AMA-style special carve-outs is like....

3) The White House's surprise that health insurers act like, well... health insurers when it comes to reconciling price, quality and network access is like......

4) Having the "non-partisan" Kaiser Health News saying "it will be challenging for the Affordable Care Act to fully live up to it's name" is like....

5) Assuming market-dominant hospitals will do the "right thing" for the Affordable Care Act is like.....

+++++

A) ..... trying to sell Putin bobble-head dolls at a LGBT Pride parade

B) .... hiring the mayor of Atlanta as the tour guide on a trip to the Peoples' Republic of Northeast Vortexistan

C) .... giving Justin Bieber a dozen eggs and a bottle of Xanax.

D) .... the NFL kicking off a "we're knocking concussions out of the game" ad campaign.

E) .... being surprised that a smart former chief federal law enforcement officer in New Jersey has no evidence of personal involvement in a revengeful plot to close some bridge lanes