Sunday, July 6, 2014

The Top 5 Children's Hospitals on the West Coast

US News and World Report recently released its Children's Hospital Rankings for 2014-2015.  The rankings are based on an evaluation of a hospital's performance in ten children's medical specialties:  (i) cancer, (ii) neonatology, (iii) nephrology, (iv) orthopedics, (v) pulmonology, (vi) urology, (vii) neurology and neurosurgery, (viii) gastroenterology and gastrointestinal surgery, (ix) diabetes and endocrinology, and (x) cardiology and heart surgery.  The methodology employed to develop these rankings is discussed in more detail here.  Over the course of the next few commentaries we will provide some regional perspective on these rankings, starting today with a look at the Top 5 Children's Hospitals on the West Coast.

Topping the list is Children's Hospital Los Angeles (map).  As detailed here, Children's Hospital Los Angeles ranks in the top 20 nationally in all pediatric specialties measured in the US News survey, including in the top 10 nationally in 6 of those specialties.  It's two strongest specialties are orthopedics and cancer, where it ranks nationally at the #2 and #5 spots, respectively.  Children's Hospital Los Angeles, which has a teaching hospital relationship with The Keck School of Medicine of the University of Southern California, is also home to The Saban Research Institute, a major pediatric health research facility.  

Taking the 2nd spot of the list of the Top 5 Children's Hospitals on the West Coast is Seattle Children's Hospital (map).  Seattle Children's Hospital is in the top 30 in all pediatric specialties nationally per the US News survey, which includes ranking nationally in the top 10 for 3 specialties and in the top 20 nationally for 4 other specialties.  Its two strongest national specialty rankings are #5 for nephrology and #7 for cancer.  The primary teaching site for the University of Washington School of Medicine Department of Pediatrics, Seattle Children's Hospital also has a research institute that is among the top 5 pediatric research centers nationally in terms of grant funding from the National Institutes of Health.

The Lucile Packard Children's Hospital at Stanford (map) occupies third place on the list of Top 5 Children's Hospitals on the West Coast.  Rated in the top 30 in nine specialties in the US News survey, the Packard Children's Hospital has top 10 national rankings in 3 specialties (#7 nephrology, #8 cardiology and heart surgery and #10 pulmonology) and top 20 national rankings in two other specialties.  A primary teaching hospital of the Stanford University medical school, Packard Children's Hospital is part of the Stanford Children's Health network that provides care for close to 400,000 patient visits each year.

4th place on the list of the Top 5 Children's Hospitals on the West Coast belongs to Rady Children's Hospital San Diego (map).  Ranked in the top 30 in all pediatric specialties, only one Rady's specialty (#3 orthopedics) ranks in the top 10 nationally.  However,  the hospital is rated nationally between 11th and 20th in 4 other specialties and between 21st and 30th nationally in 5 more pediatric specialties.  Rady's Children's Hospital also functions as a teaching hospital for the University of California, San Diego School of Medicine.

Rounding out the list of the Top 5 Children's Hospitals on the West Coast is UCSF Benioff Children's Hospital San Francisco (map).  Ranked in the top 50 in all pediatric specialties covered by US News, Benioff Children's Hospital earned a top 10 national rank in only one specialty (#10 Diabetes & Endocrinology) and only two other top 20 specialty rankings nationally.  But the hospital earns it place on the list by ranking between 21st and 45th in the seven other pediatric specialties that comprise the US News survey.

Honorable mention recognition goes to four West Coast institutions that earned a top 50 rank in at least four pediatric medical specialties:

Sunday, June 29, 2014

Ten States Most Under-Served by Registered Nurses

According to Area Health Resource Files (AHRF) data available from the Health Resources and Services Administration, there are 839 registered nurses employed for every 100,000 people here in the United States .  Among all health professions, that is the largest number of practitioners per 100,000 population in the U.S., which is not really surprising given the essential role registered nurses (RNs) play in quality healthcare delivery.  What may be more surprising is how much disparity exists in registered nurse employment from State to State.  As this map of registered nurse employment per 100,000 population reveals, some areas of the country are much better served by RNs than are others:

Registered Nurses per Capita

There are 31 States in all that have registered nurse employment that exceeds the 839 per 100,000 population national average.  And within this group there are a dozen States, mainly in the Northeast and Great Plains regions, that are particularly well served by registered nurses with employment greater than 1,000 registered nurses per 100,000 population.  But while some States are well served by RNs, there are 19 States, predominantly in the South and West, where registered nurse employment lags behind the national average. Some of these laggards, like California and Texas, actually have RN employment numbers among the highest in the nation in absolute terms.  But even in these two big States, RN employment is proportionately weak given their size.  With 719 RNs employed per 100,000 population, only 9 States are more under-served by registered nurses than Texas.  And the situation in California is poorer still, where just 657 RNs employed per 100,000 population makes the State more under-served by registered nurses than all but three States.  The State most under-served by registered nurses is Nevada, which has just 609 RNs employed per 100,000 people.  Unfortunately, for Nevada and other States that lag behind the national average, the situation could easily get worse in coming years.  The job outlook for RNs indicates a growing need for registered nurses due to a variety of demographic and technological factors.  This trend will will only exert more pressure on States already struggling to attract RNs.  Besides Nevada, California and Texas, here are the Ten States Most Under-Served by Registered Nurses based on current HRSA data:

Tuesday, June 24, 2014

The Top Ten States for Medicare Advantage Enrollment

A few words about Medicare Advantage (MA) Plans before identifying the Top Ten States for Medicare Advantage Enrollment.  MA plans are an increasingly popular type of health plan offered by private companies as an alternative to original Medicare.  These private companies contract with the federal government to provide Medicare Part A and Part B benefits coverage to Medicare beneficiaries in select regions of the country.  With a MA Plan, the government basically pays a stated amount to a private company to provide an enrollee with a health plan that, at a minimum, matches Original Medicare Part A and Part B benefits.  What gives Medicare Advantage plans their appeal is that private companies have been able to bundle Part A and Part B benefits, plus a variety of extra benefits, into their plans at little to no cost to enrollees.

With typically lower costs and additional benefits, MA Plans can be a great value compared to Original Medicare.  Alas, that added value is frequently created, in part, from the imposition of managed care protocols and restricted provider networks not found with Original Medicare.  While MA Plans can come in a variety of insurance models, the most popular Medicare Advantage plan feature health maintenance organization and preferred provider organization structures.  Yet even with managed care protocols and fewer provider choices, lots of Medicare eligible seniors like the value MA plans offer.  There are currently about 15.3 million Americans enrolled in Medicare Advantage plans, an increase of close to 50% over the past 5 years.  MA plan enrollees now account for 30% of the total Medicare population, up from a 23% share five years ago.

To no surprise, the largest population States contribute the biggest share of Medicare Advantage plan enrollees nationwide.  But only four of those big population States ranked as a Top Ten State for Medicare Advantage enrollment in our estimation.  Those honors belong to the ten States where the MA percentage share of the total Medicare population is greatest.  Of the seventeen States where the Medicare Advantage share of the total Medicare population exceeds the 30% national average, here are the Top Ten States for Medicare Advantage Enrollment:

Source:  Kaiser Family Foundation

Sunday, May 25, 2014

The Provider Shortage Problem: The Definitive Bottom 5 States

So far this month our theme has been provider shortage problems, an issue that plagues every State to one extent or another according to the latest data from the Health Resources and Services Administration (HRSA).  Today we will divulge the Definitive Bottom 5 States, the ones with the overall worst provider shortage problems, based on our analysis of May 2014 data from the HRSA.

To this point we have presented our lists of the 5 States with the worst shortages in three separate areas: primary care, dentists and mental health care.  In our analysis of the HRSA data, the key consideration is the size of the provider shortage in a State relative to its overall population.  The absolute number of providers needed to eliminate a shortage in a particular State does not paint the whole picture.  If two States have the same provider shortage in absolute terms, one might conclude that their provider shortage problem is the same.  Yet if one State has triple the overall population of the second State, it becomes apparent that the smaller State has a more severe problem.  So in our analysis, it is the relative provider shortage that counts the most.

Our assessment of the Definite Bottom 5 States follows the same methodology we used when developing our prior lists.  We looked at the aggregate shortage of primary care physicians, dentists and psychiatrists in each State in relation to the aggregate national shortage of these providers.  We then compared those results against each State's share of the national population.  Our Definitive Bottom 5 States had an overall provider shortage (primary care physicians, dentists and psychiatrists) that was disproportionately out of whack given each State's total population.

So without further adieu, the worst-of-the-worst provider shortage problems, our Definitive Bottom 5 States:

Fifth worst place belongs to Alabama.  Based on May 2014 HRSA data, the State is short 545 providers, which is 3% of the national total of just under 18,000.  Alabama only accounts for 1.5% of the national population, so its shortage is about double what one would expect given its population size.  Alabama is particularly short of dentists, which make up over 55% of its provider shortfall.

Coming in fourth from the bottom is Missouri.  The State, which accounts for about 1.9% of the nation's population, is short 738 providers, or about 4.1% of the national total. Primary care physicians is where Missouri's provider shortage is most severe.

Sitting at third worst in our Definitive Bottom 5 is Arizona, with a shortage of 1,050 providers, or about 5.8% of the national total.  Home to approximately 2.1% of the population, the State's shortage is about 2.7X times more than one would expect given its population.  Arizona is weak across the board, making our "5 Worst" lists for primary care physicians, dentists and psychiatrists.

In the number 2 spot on our Definite Bottom 5 list is New Mexico.  The State is home to 1.9% (347 providers) of the national provider shortage, but its share of the national population is less than 0.7%.  Consequently, its provider shortage is more out of balance with its population than all other States, except one.  Like Arizona, New Mexico has provider shortage problems across the board and also made each of our prior "5 Worst" lists.

And who takes the bottom spot on our list of the Definite Bottom 5 States for Provider Shortage Problems?  That dishonor goes to Mississippi.  The State has an aggregate provider shortage of 495 professionals, or about 2.75% of the national total.  As compared to its population, which is approximately 0.94% of the national total, Mississippi's provider shortage is 2.93X worse than one would expect for its population.  That result barely edged out New Mexico's provider shortage, which was 2.92X worse than expected given the size of its population.

So there you have it.  The Definitive Bottom 5 States for Provider Shortage Problems.  Let's hope the political leaders in each of these States drums up the courage to implement corrective policies that would encourage more primary care physicians, dentists and psychiatrists to set up shop in their respective states.  Sadly, that is probably asking too much.

Monday, May 19, 2014

5 States with the Worst Mental Health Care Shortage

In recent posts we've looked at States with the worst primary care and dentist shortages.  Today we will reveal the 5 States with the Worst Mental Health Care Shortage based on our analysis of data from the Human Resources and Services Administration (HRSA).  As of May 2014, the HRSA estimates that 96 million Americans, spread across close to 4,000 geographic areas, population groups or facilities in the country, lack enough psychiatrists to adequately meet their mental health care needs.  A mental health care shortage area, according the the HRSA, is one where there is less than 1 psychiatrist for every 30,000 people who live the in the designated area.  On a national basis, the HRSA estimates that there is a shortage of just over 2,700 psychiatrists throughout the country, with a psychiatrist shortage being found in every state except Rhode Island and Vermont.

In ascertaining which states have the worst mental health care shortage, the key variable in our analysis is a State's psychiatrist shortage in relation to its total population.  To be a candidate for our "5 States with the Worst Mental Health Care Shortage" list, a State will have a psychiatrist shortage that is disproportionately large given the State's total population.  Each of the 5 States on our list is one where its share of the total national psychiatrist shortage is substantially greater than its share of the total national population.

So which states make our list of the 5 States with the Worst Mental Health Care Shortage?

At fifth worst is Montana.  While having 0.32% of the national population, Montana has 0.78% of the national psychiatrist shortage, giving the state a psychiatrist shortage that is 2.4X more than one would expect given its population.  It's a disproportionately bad number, but not nearly bad enough to seriously compete for the bottom spot on our list.

Barely edging out Montana for the 4th worst place on our list is New Mexico.  New Mexico accounts for 1.66% of the national shortage of psychiatrists and 0.66% of the national population.  With a shortage 2.5X more than one would expect for a state its size, New Mexico did just bad enough to squeak past Montana for the 4th spot from the bottom on our list of 5 States with the Worst Mental Health Care Shortage.

South Dakota sits comfortably on our list as the State with the 3rd worst mental health care shortage based on our analysis of HRSA numbers.  The State is home to only 0.81% of the national shortage of psychiatrists.  Unfortunately, that is about 3.1X more than one would expect given that South Dakota has just 0.26% of the overall national population

Moving on, we found that the second worst place on our list belongs to Arizona.  Arizona has a psychiatrist shortage that is over 3.5X more than one would expect for a state its size.  The State has just over 2.1% of the national population, yet it has more than 7.5% of the HRSA's estimated psychiatrist shortage.  Even with this disproportionately bad mental health care shortage, Arizona still lagged our bottom finisher by a solid margin.

Finishing dead last on our list of States with the Worst Mental Health Care Shortage is Wisconsin.  This result was a bit of a surprise as Wisconsin fared well in our analysis of primary care and dentist shortages.  Unfortunately, those favorable conditions in the primary care and dental care arenas did not carry over at all to the State's mental health care environment.  With 7.83% of the HRSA estimated psychiatrist shortage and 1.82% of the national population, Wisconsin's shortage is almost 4.3X worse than one would expect for a state with its population.


Thursday, May 15, 2014

5 States with the Worst Dentist Shortage

Before revealing the 5 States with the Worst Dentist Shortage, a few words about the national problem.  The Health Resources and Services Administration (HRSA) designates nearly 4,900 geographic areas, population groups or facilities across the country has having a dental care shortage.  More than 47 million people, or about 15% of the U.S. population, live in one of these dental care shortage areas.  The trait shared by these areas is that each has fewer than 1 dentist for every 5,000 people who live in the area. 

Based on May, 2014 data, the HRSA estimates that more than 7,200 additional dentists are needed to provide adequate care to residents of these shortage areas.  As with the shortage of primary care physicians, the dentist shortage is expected to worsen in coming years as the growth in demand for dental care services will outpace growth in the number of practicing dentists.

In our last commentary, 5 States with the Worst Primary Care Shortage, we noted that raw shortage numbers alone do not provide a good picture of the problem at the State level.  States with bigger populations typically have bigger dentist shortage numbers than many small States.  Yet relative to their population size, a small State can easily have a more severe dentist shortage problem than their larger brethren.  The variable that keys our analysis is a State's dentist shortage in relation to the size of its population.  To be a candidate for our "5 States with the Worst Dentist Shortage" list, a State has to have a shortage that is disproportionately large for the State's total population.  All 5 of the States on our list are ones where their share of the total national dentist shortage is significantly greater than their share of the total national population.

So who are the 5 States with the Worst Dentist Shortage?

At number 5 in our countdown is Tennessee.  Per the HRSA's May, 2014 data, Tennessee is short 353 dentists, or about 4.9% of the 7,200 dentist shortage nationally.  Since the State accounts for about 2% of the national population, their dentist shortage is 2.4X greater than what one would expect given the State's relative population size. Only 4 States had disproportionately worse dentist shortage conditions than did Tennessee.

In 4th place on our list is Alabama.  Its shortage of 304 dentists is about 4.2% of the national total.  In comparison, its population is 1.5% of the national population, so the State's shortage is over 2.7X more than one would expect to see for a State the size of Alabama.

Coming in 3rd from the bottom of our list is Arizona.  Its dentist shortfall is 6% of the national shortage, while its population is 2.1% of the national total.  Having 6% of the national dentist shortfall, while having only 2.1% of the national population, is abysmal, even if it is better than our bottom two.

Not that it is of much comfort, but Arizonans only need to look their neighbors to the East to find an even worse dentist shortage than their own.  The next to last place on our worst dentist shortage list belongs to New Mexico. The state's dentist shortage is about 1.93% of the national total based on current HRSA data.  That is over 2.9X what one would expect given that the state has just 0.66% of the national population.

And coming in dead last on our list of the 5 States with the Worst Dentist shortage is Mississippi.  The State is 206 dentists short of what it needs.  That raw number comes to 2.86% of the national shortfall total, while its population is just 0.94% of the national population.  At just over 3X more than one would expect considering its small share of the total U.S. population, Mississippi has the most disproportionate dentist shortage in the country.

Congratulations to our 5 bottom-dwellers for their pitiful dental care state of affairs.

Sunday, May 11, 2014

5 States with the Worst Primary Care Shortage

Before taking a look at the 5 States with the Worst Primary Care Shortage, let's examine the national scene.  The Health Resources and Services Administration (HRSA) designates more than 6,000 geographic areas, population groups or facilities across the country has having a primary care shortage.  More than 60 million people, or about 19% of the U.S. population, live in a designated primary care shortage area.

Shortage areas exist in every State of the Union and what these areas share in common is that each has fewer than 1 primary care physician for every 3,500 people who live in the area. Using this metric, the HRSA's May, 2014 data estimates that close to another 8,100 primary care physicians are needed to provide adequate care to residents of these shortage areas.  Some healthcare experts think the actual shortage is more like 16,000, arguing that the formula of 1 primary care physician for every 3,500 people used by the HRSA is understated.

While some experts assess the situation differently, all agree that a sizable portion of the nation lacks adequate access to primary care physicians.  Moreover, everyone agrees that the shortage of primary care physicians will grow worse over the next 5 to 10 years at least.  The fundamental problem is basic supply and demand.  On the one hand, demand is growing due to several factors:  (1) the population as a whole continues to grow; (2) the population over 50, which naturally require more primary care services, is growing at an even faster rate than the overall population; and (3) under Obamacare millions more have, or will have, health insurance coverage than under our "historical" system, thereby making primary care more financially accessible than ever.  On the other hand, U.S Medical Schools are definitely turning out new primary care physicians every year, so the supply of primary physicians is growing.  However, the pace of supply growth has not been, nor is it expected to be, fast enough to keep pace with demand growth.  So with demand growing at a faster clip than supply, the experts agree that today's primary care shortfall, whether it is 8,000 or 16,000, is only going to get worse in coming years.

So which 5 States have the worst primary care shortage?  If we looked at the raw numbers alone, the 5  largest population states would make our list.  But in our analysis, raw numbers alone do not provide an accurate picture.  What matters in our analysis is a State's primary care shortage in relation to the size of its population.  To be a candidate for our "5 States with the Worst Primary Care Shortage" list, a State has to have a shortage that is disproportionately large for the State's total population.

So who are the 5 States with the Worst Primary Care Shortage?

At number 5 is North Dakota.  According to HRSA's May, 2014 data, the North Dakota shortage was a mere 34 primary care physicians, or just 0.42% of the national primary care shortage.  But with only about 0.22% of the national population, North Dakota's primary care shortage is almost double what one would expect it to be given its population.  We found only 4 States that had disproportionately worse conditions.

Coming in 4th on our list is Missouri.  Its shortage of 363 primary care physicians is about 4.5% of the national total.  In comparison, its population is under 2% of the national population, so the State's shortage is over 2.3X more than one would expect to see for a State the size of Missouri.

In 3rd place is Arizona.  Its primary care shortfall is 5.1% of the national shortage, while its population is 2.1% of the national total.  Not good.

The second worst primary care shortage on our list belongs to Mississippi. The state has a shortage of 230 primary care physicians, or about 2.85% of the national total based on HRSA data.  That is more than triple what one would expect given that the state has just 0.94% of the national population.

And occupying last place on our list of the 5 States with the Worst Primary Care shortage is New Mexico.  The state's 163 primary care physician shortage is 2.02% of the national shortfall total, while its population is 0.66% of the national population.  While Mississippi came in a close second, no other state has a primary care shortage more out of proportion with its state population than does New Mexico.

Tuesday, April 29, 2014

New Insurance CO-OPs Off to a Sluggish Start

New Insurance CO-OPs are off to a sluggish start in the health insurance market based on recently released data.  According to the National Association for State Health CO-OPs, a national trade association, the recently closed Obamacare health insurance open enrollment period saw over 400,000 people sign up for CO-OP coverage.   On an aggregate basis the number sounds good, but with CO-OPs in just 23 states, that comes to less than 18,000 CO-OP members per state on average.  In the health plan world, less than 18,000 members statewide makes you a tiny player and being a tiny player can spell trouble for a health plan.

For the uninitiated, a CO-OP is a non-profit consumer oriented and operated plan organized under provisions of the Affordable Care Act (ACA) to offer health insurance as competition to private health plans.  Under provisions of the ACA, the federal government has provided over $2 billion of loan support to help launch CO-OPs operating in 23 states.  Among various governance and operational requirements set forth in the ACA, qualified CO-OPs are expected to devote any profits towards lowering premiums, improving benefits or enhancing care for their membership.

Without having to pad their premiums to cover profits and income taxes, in theory CO-OPs should be very price competitive with private insurers, all other things being equal.  Unfortunately for CO-OPs, all other things are not equal.  Membership size matters a great deal in the real health insurance world and right now few, if any, of these new CO-OPs have enough membership size to compete effectively. 

The reality in health insurance is that taxes and profits only account for a few percent of the premium dollar, so not having to worry about them provides little edge to CO-OPs.  The key cost driver, by far, for health insurers is the cost of member medical claims, which eats up eighty percent or more of each premium dollar.  After medical claims costs, health insurers will typically see another fifteen percent or more of its premium dollars consumed by their administrative costs.   These administrative costs include all of the expenses associated with the people and systems infrastructure needed to build and manage provider networks, pay medical claims, manage utilization, service customers, distribute products and ensure compliance with a complex set of state and federal regulations.

At the end of the day, health insurance is a capital intensive business where economies-of-scale give a significant advantage to big membership plans.  Big plans can absorb fixed administrative costs more easily and, more importantly, they have serious bargaining power when negotiating medical service rates with healthcare providers.   In healthcare, as in most businesses, suppliers are prone to giving their best rates to the biggest buyers.  And with not much buying power, small insurers rarely get the best medical service rates from providers. Combine higher medical service rates with a proportionally greater administrative cost burden and the financial picture for small insurers is not so good.  Health insurance is a very tough business for the small guy.

Industry participants have known for a long time that bigger is better in health insurance, which is why the industry has seen significant consolidation over the past twenty years.  Small player after small player has exited the business over that past two decades, either through mergers, acquisitions and even plan terminations.  Right now the new insurance CO-OPs are small fry in the health plan business.   It is still too early to write them off as relevant players in the health insurance market.  But if these new CO-OPs want to thrive, they must achieve significant membership growth over the next 3 to 5 years.   Otherwise, many will suffer the same fate that so many other small health plans experienced over the past twenty years.

Monday, April 21, 2014

Is the Internet Giving Old-Fashioned Physician House Calls a Shot in the Arm?

Is the Internet Giving Old-Fashioned Physician House Calls a Shot in the Arm?  At least one innovative healthcare company is hoping to do just that.  As profiled in several commentaries here, internet and smartphone technologies are disrupting healthcare delivery in many ways.  We've got online doctors, online doctors for the webcam challenged, online dermatologists who can treat most skin conditions remotely and a growing number of web and smartphone enabled monitoring and testing devices (like a smartphone ekg) now available to consumers.  Driven by growing demand to make healthcare more convenient and more affordable, innovative companies are busy developing solutions and services that are reshaping consumer expectations about healthcare delivery.

So far a common theme in these new web and smartphone enabled solutions is the absence of any real contact with a healthcare practitioner.  To be sure, many of these new service options involve real-time webcam consultations where patient and provider interact.  And for some common conditions and for some consumers, that degree of interaction will suffice.  However, for many consumers a webcam consultation, even if only used for diagnosing and treatment of minor health conditions, seems inadequate.  We all know that a certain amount of good doctoring requires a tactile examination and more than a two-dimensional visual inspection.

If you happen to be a consumer who likes the idea of more convenient doctor visits, but are wary of the virtual consultation, keep an eye on service solutions like the one offered by Medicast.  The Medicast model allows a consumer to set up an account online or through a mobile app and then request a house call from a participating primary care physician.  After a house call request is made, a Medicast participating physician will call the consumer for a preliminary review of the consumer's symptoms and to arrange a specific time for a visit.  Physician house calls are made within 2 hours and are arranged at the consumer's home or office, or even a hotel room if the consumer happens to be visiting from out of town.  Services provided range from check-ups to urgent care, including the issuance of prescriptions and the administration of intramuscular injections. 

The Medicast service is available 24 hours a day.  Services can be purchased on-demand or on a monthly subscription basis.  Depending on the subscription plan purchased, monthly subscribers are entitled to a set number of free doctor house calls each year, stipulated discounts on additional house calls and services and certain other benefits.

Right now the Medicast service solution is only available in Miami.  However, the Company is indicating that it will be launching its services in Los Angeles/Orange County and the Kansas City markets in the next few months.  And it is actively working on plans to launch its service in the New York City and San Francisco markets in the not too distant future.

Medicast is an early entrant into this space, but it is unlikely to be the last.  In various markets around the country consumers can already use telephone-based services to arrange physician house calls.   Expect many of these service-providers to soon be integrating internet and smartphone based technologies into their platforms, giving the old-fashioned physician house call service model a shot in the arm.

Thursday, April 17, 2014

Got the Itch? An Online Dermatogist Can Help

Got the Itch?  An Online Dermatologist Can Help.  As discussed last month in Your Online Doctor Will See You Now, growing demand for more convenient, less costly health care delivery has given rise to a movement toward online medical treatment.  For a variety of minor, common health conditions, consumers can now use web and smartphone enabled services to connect, at their own volition, with board certified physicians and other primary care providers in their State of residence for treatment plans and prescriptions, when medically necessary.

While companies like MeMD, American Well and Zipnosis have focused on facilitating online treatment for colds, allergies, ear infections and a variety of other common ailments, other innovative companies have honed in on specialty care areas that depend heavily on a visual diagnosis.  A prime example is dermatology.  DermatologistOnCall, Direct Dermatology and DermLink are among several companies that connect patients online to board-certified dermatologists for diagnosis and treatment of a wide variety of skin diseases and disorders.  While there is some minor variation between service solutions, in the basic model a patient sets up an online account, answers general health questions, uploads photos of their skin condition and then submits this information for review by a dermatologist.  A consumer can usually initiate a consultation 24/7, but these solutions are not live webcam consultations.  Instead, submitted photos and health information are reviewed by a dermatologist in the consumer's State of residence on a delayed basis, so it can take anywhere from 24 hours to several business days, depending on the service provider, for a treatment plan to be ready for a consumer.  If a prescription is involved in the treatment plan, it can be sent electronically to a pharmacy near the consumer's residence for fulfillment.  If the consulting dermatologist deems that an in-office procedure (like a biopsy) is needed, the consumer can arrange a referral to local dermatologist for further evaluation.

Using a similar online delivery approach, other innovators like YoDerm and PocketDerm have an even narrower focus.  These two services aim specifically at acne diagnosis and treatment, connecting consumers online to dermatologists for acne care and prescription medication.


Using telecommunications to remotely diagnose and treat skin diseases and disorders might seem novel, but it has actually been around since the 90's in one form or another.  The historical teledermatology (yes, there is such a term as Teledermatology) model has been aimed at serving patients who, for whatever reason, have poor physical access to a dermatologist.  Through a provider controlled telemedicine service, the patient is connected to a dermatologist for an online or mobile device consultation.  These provider controlled teledermatology service solutions remain prevalent to this day.  In fact, even the American Academy of Dermatology sponsors its own teledermatology program, called AccessDerm, that connects it member dermatologists to under-served populations in the U.S. via the internet and mobile platforms.  So the concept behind using the internet and mobile platforms to service dermatology patients is not a new one.  What makes these newer services, like DermatologistOnCall and DermLink, noteworthy is that they are providing a platform where consumers, rather than providers, initiate web-enabled  medical treatment for skin conditions and disorders. 

Sunday, April 6, 2014

Colonoscopies No More?

Colonoscopies No More?  That is a question that came to mind as I read about a new at-home colon cancer screening test that is nearing FDA approval.  An FDA advisory panel recently gave its unanimous recommendation to the FDA that the agency approve the Cologuard Colorectal Cancer Screening Test from Exact Sciences Corporation for use in the United States.  As of today, the FDA has not signed off on Cologuard, but given the advisory panels support the odds of approval are pretty strong.  So what is Cologuard and what would its approval mean to the good, old-fashioned colonoscopy that everyone over 50 should have done, yet which so many try to avoid?

Cologuard is a novel approach that looks for certain DNA mutations in a stool sample that are caused by precancerous polyps or cancerous tumors.  Examining stool samples for cancer induced bleeding in the digestive tract are integral to the fecal immunochemical test (FIT), which is one of the more established colon cancer screening tests. The stool DNA approach taken by Cologuard performed exceedingly well in an extensive clinical trial that encompassed almost 10,000 participants.  All trial participants provided samples for Cologuard stool DNA and FIT screenings and then underwent a colonoscopy.  The trial results (which are discussed in this article - Multitarget Stool DNA Testing for Colorectal-Cancer Screening) found the Cologuard stool DNA screening test to materially outperform the FIT at detecting colon cancer and precancerous polyps.  In the study, Cologuard detected colon cancers 92% of the time as compared to 74% for the FIT.  Its sensitivity to detecting precancerous polyps was not as good as its effectiveness at detecting cancer, but it outperformed the FIT by a wide margin at these tasks too.  Based on these trial results, it is easy to see why the FDA expert panel is recommending approval.

So what happens when Cologuard, or another stool DNA test, gets FDA approval?  Probably not much at the outset.  Many physicians will be compelled to prescribe it instead of the FIT because of its better accuracy.  Of course, until health plans agree to cover stool DNA tests, patients will resist paying out of pocket for it.  In due time, health plans will come around and agree to cover these new tests and once that happens, stool DNA tests will likely take market share from the blood based screening tests.

While the Cologuard clinical trial results indicate that it outperforms the FIT as a colon cancer screening test, no one should expect it to diminish the use of the conventional colonoscopy any time soon.  Even as good as stool DNA screening results appear to be, they fall short of what a colonoscopy can do at detecting colon cancer and precancerous polyps.  Stool DNA tests could put a dent in colonosopy volume one day if, with further refinement, they could get closer to 100% accuracy at screening for cancer and precancerous polyps, but that day is not is not imminent.  Until then, the conventional colonoscopy will remain the gold standard for colon cancer screening.

For more information about your colon cancer screening options, visit the Colon Cancer Alliance.

Thursday, April 3, 2014

Online Doctor Service Now Nationwide

One of the companies profiled in our Your Online Doctor Will See You Now commentary was MeMD.  The Company announced earlier this week that its online doctor service is now available in all 50 states.  MeMD users can set up an online medical consultation with a MeMD participating provider and obtain an e-prescription, when medically appropriate, from anywhere in the United States, including the District of Columbia. The Company offers single-use and monthly membership-based options for consumers and businesses seeking telehealth services and health benefits. The MeMD service, like other online doctor services, is aimed at common, minor health conditions that can be safely diagnosed and treated in a virtual environment.  The common cold, the flu, allergies, bronchitis, earaches, sinus infections, urinary tract infections, pink eye, and sore throats are among the many minor health conditions treated by an online doctor service.  With MeMD, users can consult online with a MeMD Provider who is licensed and has prescriptive authority in a patient’s particular state of residence.

For more details, visit the MeMD Blog.

Monday, March 31, 2014

Follow Your Heart on a Smartphone

Yes, it is possible for you to follow your heart on a smartphone.  And we are not talking about the heart of metaphors and symbolism.  We are talking about the real deal, that vital human organ whose maladies require treatment in the U.S. that runs in excess of $440 billion per year (CDC Heart Disease and Stroke Prevention at a Glance). Monitoring your heart, or at least its electrical activity, is now possible with over-the-counter, FDA approved, EKG devices that work in conjunction with a smartphone.

The humble electrocardiogram (EKG or ECG for short) has long been valued for its ability to measure the electrical activity in the human heart.  From EKG readings a physician can learn a lot about the health of your heart and detect a broad range of coronary health problems.  While best known as a test administered at a medical office or facility by a healthcare professional, portable and hand-held EKG testing devices for at-home use have actually been around a long time.  Some of these at-home devices even provide internet and smartphone connectivity that allow recorded EKG results to be stored electronically and transmitted to a user's physician. 

While EKG devices with internet and smartphone connectivity have actually been available for some time, up until recently consumers could not access these devices without a doctor's prescription.  That barrier has come down.  In recent years two innovative, smartphone compatible EKG products have earned FDA approval for over-the-counter distribution.  One is made by San Francisco based AliveCor.  The AliveCor Health Monitor fits like a phone case and works in conjunction with a mobile app for select iOS and Android smarthphones.  Holding your enabled phone as instructed will yield EKG results that are stored for the user for future reference or can be accessed by a user's physician through the user's AliveCor account dashboard.  The AliveCor Heart Monitor currently costs $199 and the mobile apps are free.  For an additional charge, a user can have his or her EKG results analyzed by experts who are U.S. board certified cardiologists or U.S. based cardiac technicians.

Another FDA approved, mobile-enabled EKG device is ECG Check, a product manufactured by Utah-based Cardiac Designs.   ECG Check works in conjunction with a mobile app on select iPhones.  It too fits like a case on an iPhone and, when held as instructed, will yield EKG results that can be stored and, if desired, shared with your physician.  Currently priced at $99, for an additional charge your EKG results can be submitted for independent review by qualified technicians.  The OTC version of ECG Check takes a full EKG reading, but only displays select parts of it to the user.  It will, however, tell you if you're readings are normal or abnormal.  To have full EKG readings displayed and additional reporting made available, a doctor's prescription is required.  The OTC version of ECG Check can be readily upgraded to a prescription version.  In either OTC or prescription mode, ECG Check stores the results and supports distribution of those results to your physician or submission of EKG results for independent review.

Although available over-the-counter, consumers should understand that these particular products, while clinically accurate at what they do, are not replacements for the EKG one gets at a physicians office or in a hospital.  Some physicians have embraced these over-the-counter EKG devices that integrate with smartphones as they facilitate more efficient monitoring and managing of their patients, even if these devices are not quite on par with conventional EKG equipment.  Many physicians are taking a "wait and see" approach toward these devices.  Over-the-counter, smartphone enabled, EKG devices are a fairly new entrant in the remote heart monitoring arena.  As innovative telemedicine companies continue to refine and enhance the capabilities of these products, patient-administered EKG tests via a smartphone device will likely become an increasingly valuable tool in cardiac care.

Monday, March 24, 2014

Say Wello to My Little Friend

Say Wello to My Little Friend.  Forgive me for the lame title.  I could not resist spinning Tony Montana's famous line as I drafted this commentary about Wello, another new product that aims to be a little friend to American healthcare consumers by melding medical diagnostic and smartphone technologies.

Developed by Azoi, Inc,. Wello is conceptually very similar to the Scanadu Scout in that it is designed to measure and track your key vital signs - temperature, blood pressure, heart rate, blood oxygen levels, heart rate variability and an electrocardiogram reading - in conjunction with a smartphone platform.  Whereas the Scout's sensors are incorporated into a stand-alone, pocket-sized device, Wello's sensors come in a phone case for your iPhone.  By holding your Wello enabled iPhone for a few seconds as instructed, Wello will capture your vital sign data and then record, display and store the data through a mobile app. Wello is compatible with Anroid smartphones, but initially only as a stand-alone unit and not as a phone case. 

Like the Scandu Scout, Wello is seeking Federal Drug Administration (FDA) approval and cannot be shipped in the U.S. until such approval is granted.  It can, however, be pre-ordered, then shipped once FDA approval is received.  Getting FDA approval will be an important step in affirming the quality of Wello's vital sign measurement accuracy and its potential usefulness as a source of clinically reliable information.  From what we can tell, assuming no bumps for Wello in the FDA approval process, it will probably be sometime next year before the product is ready for use by the general U.S. healthcare consumer. 

While there can be no assurances about Wello's specific impact on healthcare delivery, much less its success at getting FDA approval, Wello nevertheless is another example of an innovative health delivery solution from companies that are integrating diagnostic and increasingly powerful smartphone technologies.  These innovative companies, some of whom are also integrating web technologies into their solutions, have been and will continue to bring forth products and services that are changing healthcare delivery. It is a fact that for many years now we have already seen significant advances in telemedicine, where the successful integration of testing and monitoring technologies with telecommunication platforms have made possible remote healthcare delivery that was difficult to imagine just twenty years ago.  While "traditional" telemedicine platforms have been provider oriented, some of today's telemedicine innovators are looking to expand the scope of remote healthcare delivery.  These new breed innovators, like those behind Scout and Wello, want to provide solutions that empower consumers more in the remote healthcare delivery process.

The internet and mobile technologies have significantly advanced the ability of consumers to access information about almost every kind of medical condition or treatment over the past fifteen years.  More recently, these same technologies have made it possible for consumers to seek out and receive treatment, even prescriptions, for minor health conditions from board certified Online Doctors.  And sooner than some might imagine, we expect consumers to have access to a wide range of mobile and web enabled solutions that will provide clinically relevant data to physicians and other members of the consumer's healthcare delivery team.

Tuesday, March 18, 2014

Is Scanadu the Future of Consumer Driven Healthcare?

Is Scanadu the Future of Consumer Driven Healthcare?  Unless you are a healthcare techie who stays on top of such things, we imagine your most likely response to this question is: Who or what is a Scanadu?  Let's start with some basics. Scanadu is a young technology company, based in Silicon Valley, with a vision for consumer driven healthcare that integrates medical diagnostic and smartphone technologies.  It is developing a suite of medical devices based on this vision that could profoundly alter the consumer healthcare landscape in the not too distant future.  We say "could" because the company technically does not have a product on the market just yet.  It's initial product, called the Scanadu Scout, is about to roll out on a clinical trial basis as the company seeks Federal Drug Administration (FDA) approval before making the Scout available to the general public.  If all goes well, Scout could be on the market next year

The Scanadu Scout is a pocket-sized device that, by just holding it against your forehead for a few seconds, facilitates measuring, tracking and analyzing your key vital signs - temperature, blood pressure, heart rate, blood oxygen levels, heart rate variability and an electrocardiogram reading.  The device can then transmit your vital sign information via Bluetooth to your smartphone for tracking over time and, if some vital sign readings are out of the ordinary, Scout will let you know about it.  Moreover, the vital sign history you compile via Scout can be readily shared with your doctor, making those office visits more productive.

What is noteworthy about the company's approach is that it is investing extra time and money to subject the Scout to clinical trials required by the FDA approval process.  Getting FDA approval would attest to the Scout's clinical-grade accuracy and position it with the physician community as a viable source of clinically reliable information. 

Scanadu's vision goes beyond the Scout.  Also in development is a disposable urine testing kit that will link to a smartphone app that will walk the user through the testing procedure, then process, store and explain the test results. And as with Scout, a user will be able to electronically transmit their test information to their doctor. In addition, the company is purportedly working on a flu test that presumably will integrate with a user's smartphone.

So is Scanadu the future of consumer driven healthcare?  The company has an impressive vision for consumer driven healthcare, some strong financial backers and a stellar group of medical advisors, so they have the potential to be a profound force one day.  Yet getting from development stage company to a major player in the healthcare market is a herculean task and there is no telling if Scanadu, the company, can travel that path.  That said, Scandu's vision of enabling consumers to measure and monitor their own health through the integration of medical diagnostic and smartphone technologies, and then to electronically share that information with healthcare providers, is a powerful one that is shared by other healthcare innovators.  It is just a matter of time, and we think that time will be sooner than one might think, before innovative healthcare companies like Scanadu will be empowering consumers in ways that would have been hard to imagine just a few years ago. 

Wednesday, March 12, 2014

Online Doctor Visits for the Webcam Challenged

As discussed in our last post, someone with a minor health condition can now arrange, at their own volition, webcam consultations with licensed medical practitioners.  More importantly, that online doctor visit will typically yield a personalized treatment plan and, if medically necessary, e-prescriptions to be fulfilled at a local pharmacy.  So what if you could benefit from an online doctor visit but don't have a webcam or you are otherwise webcam challenged?  Fear not, because at least one innovative healthcare company lets you arrange an online doctor visit without a webcam.  

Zipnosis, a healthcare start-up that was recently named an innovation award winner by The Minnesota Heath Action Group, a healthcare purchasers association, can fill the void for you webcam challenged types in need of online doctoring.  Like other online doctor services, Zipnosis hones in on about about two dozen minor health conditions that can be safely diagnosed and treated online.  Among these conditions are colds, influenza, sinusitis, strep throat, allergies, urinary tract infections, yeast infections, cold sores and mild acne.  And as you would expect, the diagnostic question and answer session is at the heart of the process.  While other online doctor service providers push the patient into a webcam consultation for the diagnostic Q&A, Zipnosis handles it through an interactive, online questionnaire using its adaptive software technology.

The diagnostic Q&A is naturally an adaptive data gathering exercise.  You tell your doctor what hurts, she asks a few questions about your ailment, you give some answers, depending on the answers you give she asks more questions.  And so it goes until your doctor has enough information to diagnose your condition and recommend a treatment plan.  The Zipnosis technology semi-automates this diagnostic Q&A data collection process.  

Using an adaptive approach, the Zipnosis software leads the user through a series of diagnostic questions to capture the patient's medical history and pertinent symptom information, just as a clinician would do. According to the company, their typical diagnostic interview lasts less than 5 minutes.

Once the Q&A process is complete, the user ends the interview session and awaits a response.  Behind the scenes the user's diagnostic Q&A results are  reviewed by a board-certified clinician who sets a treatment plan for the user, then submits it to the user's account .  During business hours, a clinician will respond back to a user within an hour according to Zipnosis literature.  When medically necessary, a clinician will include in the treatment plan prescription drugs (excluding pain medications and narcotics).  When prescriptions are part of the treatment plan, users can have their prescriptions sent electronically to one of 80,000 pharmacies nationwide for fulfillment.   

If a user has a condition that cannot be treated virtually, Zipnosis will direct the user to an appropriate healthcare provider.  The Zipnosis service is available 24/7 and can be accessed through any device with an internet connection, including mobile phones and tablets.

Zipnosis does not provide pharmacy services, so any prescription costs are the user's responsibility.  However, at its current cost of just $25 per diagnostic session it is even less expensive than other  online doctor services we have found.  Faster, less expensive and more convenient than an office visit sounds like a potential winning recipe to us.

Zipnosis is still in its early stages and is not yet available in all States.  However, this innovative, cost-effective online platform has drawn interest from the broader healthcare community.  Most notably, Fairview Health Services, a major Minneapolis based health system and one of just 32 Pioneer Accountable Care Organizations nationwide, has incorporated the Zipnosis platform into their web presence.  In addition, reports indicate that the company is working with the University of Alabama and UCLA Medical Center on initiatives set to be rolled out later in 2014.

While it is still too early to predict the future of the Zipnosis service itself, you can rest assured that there other many other companies working on innovative ways to use the internet to deliver healthcare more efficiently and cost effectively. 

Monday, March 10, 2014

Your Online Doctor Will See You Now

Various healthcare entrepreneurs hope to make the online doctor visit an integral part of the healthcare delivery system, particularly when it comes to treating common, minor health conditions.

The basis for online doctoring comes from telemedicine, which has been practiced for over 20 years.  According to the American Telemedicine Association, over 50% of U.S. hospitals use some form of telemedicine and that within the U.S. one can find about 3,500 telemedicine service sites and close to 200 telemedicine networks.  Through these telemedicine networks, physicians and other healthcare providers have been providing medical consultations and remote monitoring services for many years now.

While virtual doctoring has actually been around for more than a decade, patient access to any such service was basically dependent on (a) the patient's doctor or healthcare provider participating in a telemedicine service and (b) that provider agreeing to work with the patient on a telemedicine basis.  A consumer driven process, where a patient can get a medical consultation and a real treatment plan over the internet, rather than a private network, is a more recent development.   Today one can find a number of entrepreneurial companies pushing the envelope on the online doctoring front.  MeMD and American Well, for example, are among a number of young companies offering medical consultations and treatment plans through the internet.

The basic model for these companies is to facilitate an online webcam consultation between a user and a licensed, certified healthcare practitioner in the user's state of residence.  Practitioners are typically a physician, but some companies may also use physician assistants or nurse practitioners who are licensed in the user's state of residence to provide primary care medical services.

By design, these online doctor models restrict their service to common, minor health conditions that can be safely diagnosed and treated in a virtual environment.  The common cold, the flu, allergies, bronchitis, earaches, sinus infections, urinary tract infections, pink eye, and sore throats are among the many minor health conditions treated by these online doctor organizations.  These online doctor visits normally run 5 to 15 minutes, after which the patient is issued a treatment plan.  If the treatment plan requires prescription medications, e-prescriptions are transmitted to the user's local pharmacy where they can be picked up and paid for by the user.  While prescriptions are issued when needed, most online doctor services typically will not issue a prescription for any drug on the DEA Controlled Substances list and may not issue scripts for certain elective medications, like those used to treat erectile dysfunction, hair loss and obesity.

These new online doctor services are usually available on a 24/7 basis.  And the cost for an online doctor visit and a personalized treatment plan?  In the case of both MeMD and American Well, less than $50 per consultation, excluding prescription costs billed by that users local pharmacy .  No taking time off from work to have your minor health condition treated.  No insufferable waits at a doctor's office.  Prescriptions, if needed, are sent electronically to your local pharmacy for fulfillment.  Compared to a regular office visit, an online doctor visit is way faster, way more convenient and, in many cases, less expensive too.

Right now we are in the early stages of the online doctor visit.  From experience with telemedicine, it is known that many minor health conditions can be effectively treated in a virtual environment.  Considering ongoing advances in internet, mobile and diagnostic technologies, the types of conditions that can be effectively treated in a virtual environment will undoubtedly grow in the future.

In our next post we will take a look at another company that is pushing the online doctor visit envelope a bit further.

Thursday, March 6, 2014

Are Accountable Care Organizations a Silver Lining to Obamacare?

For critics, Obamacare has no silver linings. Yet silver linings may indeed exist with the Affordable Care Act (aka Obamacare) and one development that merits watching is the Accountable Care Organization. Within the context of Obamacare, ACO’s are collaborations of healthcare providers who provide high quality care to Medicare populations. The goal of the ACO is ensuring that patients, especially the chronically ill, get the right care at the right time, while preventing medical errors and avoiding unnecessary duplication of service. For decades now, health experts have recognized that the traditional healthcare system can foster uncoordinated care that, at a minimum, leads to costly unnecessary medical care and, at its worst, can lead to medical errors that adversely affect outcomes for patients.

The idea of coordinating care that underlies ACO’s is hardly new. Kaiser Permanente, Group Health Cooperative (Seattle), and Kelsey-Seybold Clinic (Houston) and dozens of other organizations around the country have been successfully operating coordinated health delivery models for decades, some as far back as the 1940s. By design, Obamacare is attempting to expand the presence of coordinated delivery care models in the marketplace through financial incentives. For ACOs who succeed in both delivering high-quality care and spending health care dollars more wisely, the Federal government will allow them to share in the savings they achieve for the Medicare program. There are 3 incentive programs available to interested ACO’s: (1) the Medicare Shared Savings Program - a program that helps a Medicare fee-for-service program providers become an ACO; (2) the Advance Payment ACO Model - a supplementary incentive program for selected participants in the Shared Savings Program; and (3) the Pioneer ACO Model - a program (which is no longer accepting applications) designed for early adopters of coordinated care.

Provider interest in these incentive programs is self-evident. Since becoming operational in 2012, enrollment in these programs has grown to more than 360 Accountable Care Organizations serving almost 5.3 million Medicare beneficiaries. Moreover, in January the Centers for Medicare & Medicaid Services (CMS) released findings on a number of its initiatives and the interim results for its ACO initiatives were encouraging. Savings from both the Medicare ACOs and Pioneer ACOs topped $380 million. To be sure, it is still too early to judge if these programs will continue to yield positive results much less improve upon them. Savings of $380 million is better than nothing, but it amounts to a tiny drop in the $600 billion per year spending bucket that is Medicare. And that spending bucket is on a trajectory to grow to $1.1 trillion in 2023 with continued growth in the Medicare population and sustained health cost inflation.

The advancement of ACO’s is a good thing for patients in our estimation. Research on integrated healthcare delivery systems does indicate that coordinating care has a positive effect on the quality of care provided to patients. That same research does not, however, show solid evidence that costs are materially reduced through better coordination of care. Nevertheless, we expect that as time goes by cost advantages from coordinating care will become more apparent and broader trends in the healthcare marketplace will increasingly benefit the coordinated care principles of ACO’s. Even before the passage of Obamacare, there has been a discernible trend toward shifting more of the healthcare cost burden to individuals. Obamacare has only accelerated this trend. As this cost shifting trend continues to evolve, we expect healthcare consumers to become increasingly price sensitive. In this very possible future healthcare marketplace, market forces will likely favor more efficient providers who are better positioned for price competition. Accountable Care Organizations, most of whom are investing heavily in the information systems infrastructure needed to support coordinating care, could win big in the future healthcare marketplace. That same information systems infrastructure will give ACOs a leg up on the efficiency front and put them in a strong position from which to compete on price in the future healthcare marketplace.

So are ACO’s a silver lining to Obamacare? We are not inclined to jump to that conclusion just yet. However, we do think that certain market trends being accelerated by Obamacare could mean that Obamacare has a silver lining in it for ACO’s.