HEALTHCARE INDUSTRY MOST FOCUSED ON CONSOLIDATION, CONSUMERISM IN 2019

https://www.healthleadersmedia.com/finance/healthcare-industry-most-focused-consolidation-consumerism-2019?spMailingID=15535559&spUserID=MTg2ODM1MDE3NTU1S0&spJobID=1621654766&spReportId=MTYyMTY1NDc2NgS2

A new Definitive Healthcare survey polled healthcare leaders on the most important trends of the year.


KEY TAKEAWAYS

Industry consolidation was listed as the most important trend of the year, leading the way with 25.2% of the votes, followed by consumerism at 14.4%.

Definitive tracked 803 mergers and acquisitions along with 858 affiliation and partnership announcements last year, a trend that is not expected to slow in 2019.

Thirty-five percent of healthcare M&A activity occurred in the long-term care field, according to CEO Jason Krantz.

Widespread industry consolidation as well as the growing influence of consumerism registered as the most important trends healthcare leaders are paying attention to in 2019, according to a Definitive Healthcare survey released Monday morning.

Industry consolidation was listed as the most important trend of the year, leading the way with 25.2% of the votes, followed by consumerism at 14.4%.

Other topics that received double-digit percentages of the vote were telehealth at 13.8%, AI and machine learning at 11.4%, and staffing shortages at 11.1%. Cybersecurity, EHR optimization, and wearables rounded out the list.

The top results are generally in-line with some of the top storylines from the past year in healthcare, including focus on several vertical megamergers and longstanding business models being redefined by consumer behavior.

Jason Krantz, CEO of Definitive Healthcare, told HealthLeaders that healthcare is becoming increasingly more complicated and leaders are looking at a host of business strategies to navigate industry challenges or emerging market conditions.

“Something that’s on the mind of all of the people that [Definitive Healthcare] has been talking to, whether they are pharma leaders, healthcare IT companies, or providers, is that they’re constantly grappling with all of these new regulations, consolidation, and new technologies,” Krantz said. “[They’re asking] ‘What does that mean for my business and how do I address my strategy as a result?'”

In 2018, Definitive tracked 803 mergers and acquisitions along with 858 affiliation and partnership announcements, a trend Krantz does not expect to slow in 2019.

While Krantz cited some of the major health system mergers from last year as examples, he said another area that is experiencing widespread M&A activity is the post-acute care side.

Thirty-five percent of healthcare M&A activity occurred in the long-term care field, according to Krantz, and this is indicative of hospitals seeking to control costs and drive down rising readmission rates.

It also relates to another issue likely to accelerate in the coming years, which are the staffing shortages facing providers.

The sector currently suffering the most are long-term care facilities, which struggle to maintain an adequate nursing workforce due to the advanced age of most doctors and nurses in the face of the rapidly aging baby boomer generation. Krantz warns that all providers are likely to face these issues going forward.

Krantz also expects consumerism to hold steady as a top issue facing healthcare, citing the growing popularity of urgent care centers and the interconnection of telehealth services to provide patients with care outside of the traditional delivery sites.

However, the growth of these are reliable business options are all dependent on figuring out an adequate reimbursement rates for telehealth services rendered, Krantz said, which has not been fully addressed.

“I think until [telehealth reimbursement rates] get completely figured out, it’s hard for the providers to invest heavily in it,” Krantz said. “This is why you see a lot of non-traditional providers getting into telehealth, but I think it is something that people are thinking about and they know they need to adjust to, though nobody’s stepping up and being first in [telehealth] right now.”

For AI, machine learning, wearables, and cybersecurity, though the responses are split into smaller amounts, Krantz emphasized their combined score, which encompasses more than 25% of total votes, as a sign that healthcare leaders are paying attention to the area despite market complexity.

He added that they are all interconnected issues that deal with technological changes health systems are aware they will have to address in the coming years.

One issue related to harnessing technological change is EHR optimization, which Krantz believes leaders on the provider side are finally starting to gain excitement around. He said most leaders who have waited years to set up a comprehensive EHR system and input data are in-line to now utilize the data in their respective system.

“There’s a lot of great data in there and people are starting to figure out how to utilize that and improve patient outcomes based on the sharing of data,” Krantz said. 

 

 

 

Top 12 takeaways from the 2018 JP Morgan Healthcare Conference — while the destination is uncertain, the direction is clear

https://www.beckershospitalreview.com/hospital-management-administration/12-things-you-need-to-know-from-the-2018-jp-morgan-healthcare-conference-while-the-destination-is-uncertain-the-direction-is-clear.html

The recent breathtaking flurry of mega-mergers coupled with increasingly challenging market forces and an ever shifting political landscape has cast a cloud of confusion regarding where the U.S. healthcare delivery system is heading.  

So, where do you go to find the map?

Every year, the JP Morgan Healthcare Conference provides an incredibly efficient snapshot of the strategies for large healthcare delivery systems, the hub for healthcare in the U.S. Most of these organizations are also the largest employers in their respective states. The conference took place this week in San Francisco with over 20 healthcare systems presenting, including Advocate Health Care, Aurora Health Care, Baylor Scott & White Health, Catholic Health Initiatives, Geisinger Health System, Hospital for Special Surgery, Intermountain Healthcare, Mercy Health in Ohio, Northwell Health, Northwestern Medicine, Partners HealthCare System, WakeMed Health & Hospitals and many of the other big name brands in the market. Each provided their strategic roadmap in a series of 25-minute presentations from their “C” suite. If you’re looking for the GPS on strategy and a gauge on the health of healthcare, this is it.  

How do their strategies differ? What direction are they heading in? There is a great line from Alice in Wonderland that goes, “If you don’t know where you’re going, any road will take you there.” You would think that line applies perfectly to the U.S healthcare system, but the good news is it actually doesn’t.

While the exact destination for everyone is TBD, the direction they are heading in is actually pretty clear and consistent. It turns out that they are all using a very similar compass, which is sending them down a similar path.

So, what are the roadside stops health systems consider absolutely necessary to be part of their journey to creating a more viable and sustainable value-based business model?

Based on the travel plans for over 20 of the largest and most prestigious healthcare delivery systems in the country, here’s your GPS and list of 12 things you “must do” on your journey.

1. You Must Scale

Clearly the headline at #JPM18 was the flurry of major announcements regarding major mergers. With that said, two of the mergers were front and center: teams were there to present from Downers Grove, Ill.-based Advocate and Milwaukee-based Aurora, which will be a $10 billion organization with 70,000 employees, as well as San Francisco-based Dignity Health and Englewood, Colo.-based Catholic Health Initiatives, which will be a $28 billion organization with 160,000 employees. The size and scale of these mergers is pretty stunning. While the announcement of these and the other recent mega-mergers has forced many into their board room to determine what the deals mean to them, the consensus at the conference was this: There are a number of different paths forward to achieve scale. Some, like Baylor Scott & White in Texas, have aggressive regional expansion plans. Others are betting on partnerships to provide the same or even more value. Taking a pulse of the room, two things were clear. The first is there is no definition of scale any more in this market. The second is that, despite this flurry of mergers, “getting really big” is not the only destination.  

2. You Must Pursue “Smart Growth” and Find New Revenue Streams

Running counter to the merger narrative in the market, Salt Lake City-based Intermountain provided a good overview of the movement to what is called an “asset light” strategy of “smart growth.” This is a radically contrarian approach to the industry norm, which is the capital intensive bricks and mortar playbook of buying and building. As part of their strategy, Intermountain will open a “virtual hospital” delivering provider consultations and remote patient monitoring via telehealth. The system will also launch a number of healthcare companies every year, leveraging their considerable resources in a manner they believe will produce a higher yield. Other health systems outlined a similar stream of initiatives they have in motion to diversify their revenue streams and expand their business model into higher margin, higher growth businesses. One example is Cincinnati-based Mercy Health, which achieved strong growth and leverage via their investment in a revenue cycle management company. Advocate in Illinois formed a partnership with Walgreens. Together, they now operating 56 retail clinics and Advocate has seen a significant impact on driving new patients and downstream revenue to their system. The bottom line is all now recognize that they must think and act differently to be able to continue to fund their clinical mission and serve their community.

3. You Must Measure and Manage Cost and Margins

While some are moving aggressively to get scale, everyone is looking to more effectively use the resources they have and get more operating leverage. Margin compression was a consistent theme, with many systems now moving into consistent, stable operating models around managing margins versus launching reactionary initiatives when they find a budget gap. What is emerging is a new discipline and continuous process around managing cost and margins that is starting to look similar to the level of sophistication we have seen in the past for revenue cycle management. To that end, there has been major movement in the market to implement advanced cost accounting systems, often referred to as financial decision support, which provide accurate and actionable information on cost and help organizations understand their true margins as they take on risk-based, capitated contracts. Some during the conference referred to it as the “killer app” for the financial side of driving value. Regardless of what you call it, all are moving aggressively to understand the denominator of their value equation.

4. You Must Become a Brand

Investing in and better leveraging their brand has become a strategic must for health systems. The level of sophistication is growing here as providers shift their mental model to viewing patients as “consumers.” Aurora in Wisconsin cited their dedicated Consumer Insights Group and outlined their “best people, best brand, best value” approach that has been incredibly effective both internally and externally. At the same time, the bigger investments for many health systems relative to brand are more on brand experience than brand image, with a focus on understanding and radically rethinking the consumer experience. As an example, at Danville, Pa.-based Geisinger, close to 50 percent of ambulatory appointments are scheduled and seen on the same day. And every health system is making meaningful investments in their “digital handshake” with consumers, creating and leveraging it via telehealth as well as mobile applications to enhance the customer experience.

5. You Must Operate as a System, Not Just Call Yourself One

One clear theme at #JPM18 is different organizations were at different points along the continuum of truly operating as a system vs. merely sharing a name and a logo. There are a number of reasons for this, but you are increasingly seeing tough decisions actually being made vs. just kicking the can down the road. There has been a great deal of acquisitions over the last few years coupled with a new wave of thinking relative to integration that is more aggressive and more forward-looking. This mental shift is actually a very big deal and perhaps the most important new trend. Many health systems are heavily investing in leadership development deep into their organization to drive changes much faster.   

6. You Must Act Small

The word “agile” is quickly becoming part of everyone’s narrative with health systems looking to adopt the principles and processes leveraged in high tech. Chicago-based Northwestern Medicine is an example of an organization that has grown dramatically in the last five years, now approaching $5 billion in revenue. At the same time, they have still found a way to operate small, leveraging daily huddles across the organization to drive their results. The team at Raleigh, N.C.-based WakeMed has achieved a dramatic financial turnaround over the last few years, applying a similar level of rigor yielding major operational improvements in surgical, pharmacy and emergency services that have translated into better bottom line results.

7. You Must Engage Your Physicians

Employee engagement was a major theme in many of the presentations. With the level of change required both now and in the future, a true focus on culture is now clearly top of mind and a strategic must for high-performing health systems. That said, only a handful articulated a focus on monitoring and measuring physician engagement. This appears to be a major miss, given that physicians make roughly 80 percent of the decisions on care that take place and, therefore, control 80 percent of the spend. One data point that stood out was a 117 percent improvement in physician engagement at Northwestern. Major improvements will require clinical leadership and a true partnership with physicians.

8. You Must Leverage Analytics

Many have reached their initial destination of deploying a single clinical record, only to find that their journey isn’t over. While health systems have made major investments big data, machine learning and artificial intelligence, there was a consistent theme regarding the need to bring clinical and financial data together to truly understand value. Part of this path is the consolidation of systems that is now needed on the financial side of the house with a focus on deploying a single platform for financial planning, analytics and performance. The primary focus is to translate analytics not just into insights, but action.

9. You Must Protect Yourself

As organizations move deeper into data, there is increased recognition that cybersecurity is a major risk. Over 40 percent of all data breaches that occur happen in healthcare. During the keynote, JP Morgan Chase CEO Jamie Dimon shared that his organization will spend $700 million protecting itself and their customers this year. Investments in cybersecurity will continue to ramp up due to both the operational and reputational risk involved. Cybersecurity has become a board room issue and a top-of-mind initiative for executive teams at every health delivery system.

10. You Must Manage Social Determinants of Health in the Communities You Serve

Perhaps the most encouraging theme for healthcare provider organizations was the need to engage the community they serve and focus on social determinants of health. As Intermountain shared: “Zip code is more important than genetic code.” To that end, Geisinger refers to their focus on “ZNA.” They have deployed community health assistants, non-licensed workers who work on social determinants of health and have implemented a “Fresh Food Farmacy,” yielding a 20 percent decrease in hemoglobin A1c levels along with a 78 percent decrease in cost. Organizations like ProMedica Health System in Ohio have seen similar results with their focus on hunger in Toledo. WakeMed has an initiative focused on vulnerable populations in underserved communities that has resulted in a significant decrease in ER visits and admissions and over $6 million in savings.

11. You Must Help Solve the Opioid Epidemic

The opioid issue is one that healthcare professionals take very personally and feel responsible for solving. It came up in virtually in every presentation, and it’s an emotional issue for the leaders of each organization. This is good news, but the better news is that they are taking action. As an example, Geisinger invested in a CleanState Medicaid member pilot that resulted in a 23 percent decrease in ER visits and 35 percent decrease in medical spending, breaking even on their investment in less than 10 months. While many would rightly argue that the economic rationalization isn’t needed for something this important, the fact that it’s there should eliminate any excuse for anyone not taking action.

12. You Must Deliver Value

The Hospital for Special Surgery in New York is the largest orthopedics shop in the U.S. and a great example of how value-based care delivery is taking shape. Perhaps the most revealing stat they shared is that 36 percent of the time patients receive a non-surgical recommendation when they are referred to one of their providers for a second opinion. This is exactly the type of value-based counseling and decision-making that will help flip the model of healthcare. Some systems are farther along than others. Northwestern currently has 25 percent of its patients in value-based agreements, but other systems have less. As the team from Intermountain re-stated to this audience this year, “You can’t time the market on value, you should always do the right thing, right now.” Well said.  

 

 

 

Dr. Toby Cosgrove: 2019 will be the year of telehealth

https://www.beckershospitalreview.com/telehealth/dr-toby-cosgrove-2019-will-be-the-year-of-telehealth.html?origin=bhre&utm_source=bhre

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Toby Cosgrove, MD, former CEO of Cleveland Clinic, told CNBC he foresees 2019 as the year telehealth becomes ubiquitous.

Although telehealth has already permeated the healthcare space, many patients don’t know it exists, Dr. Cosgrove said. However, as awareness grows, patients are increasingly becoming interested in using video conferencing with their physician as a way to save a trip to a hospital. Telehealth also helps patients with chronic conditions, who may need regular monitoring.

“[Oakland, Calif.-based Kaiser Permanente] is seeing over 50 percent of their patients distantly,” Dr. Cosgrove told CNBC.

Dr. Cosgrove, who now serves as an executive advisor to Google Cloud’s healthcare and life sciences team, also said the cloud will serve as a way to make the tremendous amount of data available in healthcare actionable.

“There’s an enormous amount of data and it’s a problem for us to keep track of and that’s why I think the cloud is going to come in,” he said, noting data can be stored and analyzed in the cloud. “So now you can have huge data sets that you can begin to analyze, and now that’s where [artificial intelligence] and machine learning comes in.”

“As the data goes to the cloud all the major cloud providers have come to an agreement that they will share unidentified information,” he added.

 

Alternative Payment Models: Unintended Consequences

https://www.medpagetoday.com/blogs/ap-cardiology/76490?xid=nl_mpt_DHE_2018-11-24&eun=g885344d0r&pos=&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-11-24&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days

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The way we pay for medical care is changing. In this second episode of a two-part podcast series with Karen Joynt Maddox, MD, MPH, of Washington University in St. Louis, she delves into the unintended consequences of alternative payment models. She has also written in the New England Journal of Medicine on the topic here.

A transcript of the podcast follows:

Perry: … In your editorial, you mentioned that some of these quality metrics can have the unintended side effects of resulting in underutilization for vulnerable populations. Can you elaborate on that?

Maddox: Yeah, so there’s a couple different ways that policies can have negative impacts, and actually, harkening back to a prior question about “Did we roll these out in a systematic fashion and study their effect?” No. When policies are rolled out, we sometimes look for efficacy, we rarely look for unintended consequences, which we’d never do with a drug or a device or something else we were putting out into the ether. If you imagine that every policy is going to have both positive and negative effects just like a drug would or a device would, you would never approve … a medication that reduced heart attacks if it increased bleeding by six times the amount it reduced heart attacks or increased mortality.

We don’t actually hold policies to those same standards. We don’t even measure the positive and negative effects. What are the negative effects of policy? I think there are a few. First, there’s risk aversion. That can be seen in a number of ways. Your example of having a sick patient who was having these complications raises questions of risk aversion. Would that person even have gotten access to a cardiac procedure if someone was very worried about what adverse outcomes were going to be tracked and then paid on?

The concern would be that if we put a lot of money behind PCI [percutaneous coronary intervention] outcomes, mortality after PCI, and we don’t adequately account for how sick or how poor or how vulnerable certain patients are, hospitals are going to look bad, lose money, have negative billboards about them on public reporting for no fault of their own. It’s just not going to be fair, and it will create risk aversion. But then someone is going to say, “We really shouldn’t be doing caths on high-risk patients because we’re just going to get in trouble for it. We really shouldn’t be taking on these people who are going to bleed, because if we have to give them a transfusion, our quality is going to look bad.” That means you’re closing off access to an entire group of people who very well could benefit from a procedure. That’s an obvious unintended consequence, so risk aversion is a big one.

Closely linked to that is the consequences of taking care of very sick patients and then being penalized. If risk adjustment is inadequate, then hospitals that take care of really sick patients are going to look a lot worse than they really are, and hospitals that take care of a lot of really simple patients are going to look better than they are, and you’re going to move money all over the country based on severity of illness as opposed to quality of care.

Perry: Could we actually spend a minute and maybe dig into some of the minutia on that, because I think that’s an important point about different hospitals, different locations, serving different risk populations. How does CMS [the Centers for Medicare and Medicaid] currently adjust for risk currently, because my impression is that the attempt to adjust for your baseline risk is, perhaps, insufficient as how it currently stands?

Maddox: I would agree. Now when you think about the things that we measure hospitals on, some things shouldn’t be risk adjusted. Those are the easy ones. Aspirin for a heart attack. I keep going back to that one because it’s just such a basic quality of care element. It doesn’t matter if you’re poor. It doesn’t matter if you’re black or Hispanic. It doesn’t matter if you’re frail. If you don’t have a contraindication to aspirin and you are having a heart attack, you should receive aspirin. We don’t have to risk adjust that. You can exclude people who have just had a bleeding ulcer. But if you qualify for the measure, you should receive the quality measure. That’s standard care and there we don’t need to adjust. We just need to hold people to high standards.

Perry: Okay.

Maddox: When you move one notch down the line, now let’s think about something we consider an intermediate outcome, so diabetes control, hypertension control. Clearly that, to some degree, is controlled by the clinician. I decide whether or not I recommend someone get insulin or I titrate up their calcium channel blocker or I add on some other agent. It’s also under control of the patient, and it’s also partly determined by how sick the patient is to begin with. It’s pretty easy for me to control high blood pressure in someone who started out with a systolic pressure of 142. I have many, many choices. Almost no matter what I do, I can get that person under better control.

That’s very different than a dialysis patient who’s had 15 years of persistent resistant hypertension like the gentleman I admitted this afternoon who comes in with a blood pressure of 260 systolic. Me getting that guy down to a controlled blood pressure would take probably some sort of divine intervention.

Perry: Yeah.

Maddox: In addition to a whole lot of hard work on his part and his dialysis facility. It’s a complex undertaking. Now we should all be working together to do it, but if we don’t take into consideration the fact that treating those two people was very, very different, we are going to not really be looking at quality. We’re just looking at how sick the patient is. If you take that one step farther to something like readmissions, which is largely a product of what happens to someone outside the hospital walls and has a ton to do with social determinants of health and access to care and access to exercise and food and the ability to afford medications, you can sort of see how the farther away from a clean process measure you get, the more the ultimate outcome is driven by things out of your control.

If we don’t take into account the things that make those patients different, then we’re not really measuring quality. Right now, CMS does, I think, a reasonable starting point job of trying to control for risk. When they look at a patient, they have claims. They don’t go talk to the patient. They don’t know where they live. They don’t know if they can read. They don’t know if they speak English. They have claims, and so they use the claims to try to adjust to the degree they can for outcome measures. They don’t actually adjust process measures or those intermediate measures, but for outcome measures, they do. If you take something like readmission, they make a logistic regression model and it has patient characteristics on it. Age, gender, whether or not there’s a history of kidney problems, whether or not there’s any history of liver disease, sort of a list of things. There’s somewhere between 70 and 80, depending on which list you’re using, which year. Those elements all go into a risk-adjustment model.

With something like in-hospital mortality, you can actually do a pretty good job of risk adjusting. We think about C-statistics and we think about logistic-regression models. You can get a C-statistic in sort of the 0.8 range. 0.5 would be a coin flip. You’re right half the time. The C-statistic basically compares the probability that your model said something would happen with whether it did or didn’t. 0.5 would be coin flip — model didn’t do anything beyond random. Under 0.5 would be the models worse than random. 0.8 is pretty good. You get some ability to differentiate. For readmissions, the models are closer to 0.6, so just better than a coin flip — probably because so much of what matters to readmission is things that we’re not measuring and whether or not someone has kidney or liver disease, but it’s where they live, do they have access to care, all the things that we just talked about.

You can also imagine that the models work pretty well for people in the middle of the distribution. They do not work well for people who are very sick. A yes/no diabetes, a yes/no kidney function is only going to predict a certain level of risk. We both know from rounding in the hospital that you have people who are at exorbitant risk. They have really poor functional status. They have comorbid substance abuse disorder. They have extreme frailty. They’re institutionalized, whatever the stuff is. Or they’ve had seven admissions this year already for heart failure. The models don’t account for that. What the models typically fail to do is account for that type of risk.

If you had two 75-year-old men, one with diabetes and one not and they otherwise looked the same, the models would be completely adequate. That’s not who we serve, and so right now the models do a reasonable starting point job, but they’re, I don’t think, anywhere near where we need to be if we’re going to actually predicate millions of dollars moving around the country based on them.

We’re really lacking sort of the basic science of risk adjustments in some ways. We’re running logistic regression models because they were the height of technology in the early 2000s. We’ve not moved forward with this data management and data use and modeling in the same speed with which we’re moving forward in devices and cloud-based technologies. We can do crazy things for people, but we can’t systematically measure hospital quality well, yet. I think we really need this sort of big data movement that’s happening. There’s a lot of hype around artificial intelligence and natural language processing and these sort of buzzwords, but somewhere in that hype is real improvement in how we manage data and how we measure quality and how we measure patients, how we compare them to each other and how we use what we know about patients to measure quality and ultimately to incent quality, right? This shouldn’t all be about being punitive. It should be eventually about feedback and improvement and let’s get everyone high-quality care.

I hope we’re going to move into quality measurement 2.0 or 3.0 or whatever we are as we move into these payment models, because the more money we put on the line, the more important it is that we avoid unintended consequences and the bigger those unintended consequences are ultimately going to be if we don’t start doing this a little better.

Perry: Gotcha, okay. Thanks. Now I think I had interrupted you when we were discussing about how these bodies measuring quality outcomes have kind of led to an underutilization. There was one paper that you had cited in your editorial about I think it was specifically about myocardial infarctions in New York and I think they used PCI during that time. Could you give us a summary of what that study showed?

Maddox: Yep, so when someone is coming in for a PCI, it’s a decision whether or not to give them or not give them the procedure. It’s not like when someone gets admitted for heart failure. They kind of show up and they get admitted and that’s that. You have to select into getting a PCI. Someone has to give it to you. In the mid-2000s in Massachusetts, earlier than that in New York and Pennsylvania, there was a big public reporting push. This is actually pre pay-for-performance. This is all just public reporting.

Perry: Okay.

Maddox: Hospital performance, and in some cases, individual interventional cardiologist performance was posted on a website for PCI. We did a research project looking at over time in Massachusetts when this program went into place, and then looking cross-sectionally in New York, Massachusetts, and Pennsylvania versus other states, what did people do in response to that program? What we found is that people got risk averse. The rates of use of PCI for people having heart attacks dropped off significantly in Massachusetts when they started publicly reporting performance. The people who stopped getting the access were the sicker ones.

I think it’s hard to think about how as a physician you would turn away someone who needs something. Certainly, my experience in seeing that and coming to Massachusetts as a fellow from North Carolina as a resident where there were no such pressures was what led us to start thinking about this project, because it really was pretty emotionally striking to see that people weren’t getting access to this procedure because of the concern about their publicly-reported performance.

But then I saw on the front page of the Boston Globe, Massachusetts General cath lab closed because of performance report. Then BI, Beth-Israel, cath lab closed because of performance report. In both of those cases, once they did the deep-dive into why the mortality rates had exceeded their threshold for saying that there was bad things going on, it was because they had accepted very sick patients as salvage from other hospitals who had tried to save them and had been unable to do so. Those deaths counted against them and their cath labs were then shut down for quality-improvement purposes.

They were ultimately found to have no wrongdoing, but it was extremely disruptive, canceled our cases. You’re on the front page of the Boston Globe being outed as this low-quality program when, in fact, that wasn’t true in either case. But that is the effect of making even very, very good people very risk averse. Massachusetts has actually done a lot of good work in trying to make their risk adjustment models better and in trying to carve people out of those programs, so if someone is coding, they’re no longer counted against you. Things like that to really try to be thoughtful about how we can use these programs to measure quality but try to reduce the unintended consequences that goes along with them. They have seen the rates start to go back up. New York has done some similar stuff with shock, having shock as a separate category and not counting folks in shock against you for doing PCIs. And they’re seeing a rebound in the proportion of patients having access to that procedure.

In public reporting, in this case, I think was so dangerous because it was so specific. It was a single procedure. It was attributed to either a hospital or even a person. Many of the other pay-for-performance programs are so broad, I think they are probably both less powerful in incenting change and less dangerous. If you’re looking at a hospital program, value-based purchasing, for example, it’s got multiple domains. It’s looking at multiple different conditions. It’s got 26 measures or something like that. No one of those measures is going to be driving someone’s behavior to try to keep someone out of the hospital or to try to be sort of guarding against performance, whereas a very targeted program like public reporting and public shaming for PCI, I think, really probably had some pretty profound negative consequences. It also really drove people to work on quality. It was a program that terrified lots of people, so that’s the tradeoff.

It’s where do you draw the line between trying to incent quality and doing things that are really going to change access and hurt patients. What ultimately should be the goals underpinning every single one of these programs should be how can we use these financial incentives to drive better outcomes for patients? If we don’t look for the unintended consequences, we’re going to miss that. If you don’t give PCI to sick people, your mortality for PCI looks great.

These are not easy things to think through. For a bunch of policymakers in D.C. or Boston or Jefferson City or wherever, who are not clinicians, it’s not easy. Health care is complicated as we learned. It’s actually not easy to think through what the best way to design these programs is to really try to move the needle on quality and say, “We do not accept substandard care,” while at the same time not hurting providers that care for vulnerable populations or those patients themselves.

Perry: I’m going to ask, probably, an impossible question, but if you could rewrite how hospitals are reimbursed starting from scratch, throw away everything that we have now and just say, “Some magical person is going to reimburse the hospital to ensure the best quality,” how would you write that? How would you design that? Then maybe later we’ll talk about what things are being done now on a local and national level.

Maddox: I’ll give you two scenarios. One scenario under our current health care system, meaning that hospitals have all the money and the power, and most decision-making around healthcare that really impacts healthcare dollar is still directed at hospitals and one scenario in which we would actually rethink the system entirely.

Conditional on the current system, I think we could do a lot with the quality programs to make them more equitable and to make them have stronger positive effect and weaker negative effect by doing things like rewarding improvement, which is done in some programs, but not all, by judging hospitals against their peer groups as opposed to assuming that we can judge large economic centers against small rural centers against small safety net hospitals in the south versus big urban centers. Those are not all the same. The patients are not all the same. We don’t have the data, as we discussed, to adequately risk adjust, so we need to make some decisions about what fair comparison would look like. Within the current system, I think we could make things better just by being more thoughtful about how we make comparisons and how we drive quality, and then putting money behind that to incent people to actually do something about it.

But ultimately, why do we care about readmissions and not admissions? Why do we care about bleeding after a PCI and not whether or not someone had a heart attack in the first place? The reset to how we really ought to be trying to do this is incenting more care out of the hospital. We should be trying to keep people out of the hospital, for one thing. There’s no reimbursement for the kinds of sort of multidisciplinary team-based care that we know can help people who are chronically ill. Until recently, there was almost no reimbursement for telehealth. We sort of grossly underutilized community health workers and other low-cost ways that we could really start to improve health in the community to keep people out of the hospital.

A payment program that focuses on a hospital is never going to succeed in keeping people out of the hospital. You wouldn’t pay Apple to not sell people iPhones, right? That’s both odd and actually highly economically inefficient. You’re paying to not do something. Many of these programs that start to shift towards alternative payment models are functionally saying we’re going to pay you not to do things. That doesn’t make a ton of sense to me.

Perry: No.

Maddox: But reimagining the system as one that rewards health is not so simple because it probably involves taking a lot of things out of the hospitals. Why does someone have to come to the hospital and stay in the hospital when they have heart failure? In Australia and in a few other countries, there’s a lot of use of what they call it hospital at home. When you think about our heart failure patients that we see for 5 minutes every morning, and then they diurese all day long, and we check a lab in the afternoon, and then we see them for 5 minutes the next morning. There is no reason they couldn’t be doing that in the comfort of their own home with some sort of a patch taped to their chest that gives us their telemetry monitoring with labs being drawn a couple times a day, with the nurse visiting to help out.

That would be fundamentally disruptive to the system in the kind of way that would promote all sorts of cost reductions and probably much happier patients and better outcomes, certainly a lot less of in-hospital infectious disease transmission. But there’s absolutely no reason that a hospital would ever sign up for that program unless we change how they’re paid.

Perry: It’s because it’s eliminating the cost for the bed in the hospital itself is the most expensive thing. The nebulous bed, whatever it is so magical about that really uncomfortable, poorly-functioning bed.

Maddox: What if you have a heart failure, I keep using heart failure as an example. I should think of something else. Let’s say you’re a dialysis facility. Why do you not have a monitor at every patient’s home on their scale or something that tells you when people are missing dialysis or when their weight starts to go up or if their potassium is 6 and lets you do something about it, that lets you get people in early if you need to or postpone? Maybe not everyone needs exactly the same amount of dialysis three times a week.

Why when we’re monitoring our diabetics do we say, “Come back in a year or come back in 6 months?” There’s no basis for come back in a year or come back in 6 months. This is an incredibly diverse group of people that need different management strategies. Some need intensive weight loss. Some need counseling on nutrition. Some need a ton of insulin. Figuring out how to sort of manage people to keep something bad from happening requires a total rethinking of how we actually deploy health resources. It’s probably not a lot of doctor time, for one thing, which is obviously the most highly reimbursed thing. It’s probably not as much hospital time as we have right now.

I think the industry is moving in that direction, so if you follow the JP Morgan health conferences and the Amazons of the world and the business side of the world is coming out and saying, “This is crazy. This system is insane.” We’re paying just absurd amounts of money to support this infrastructure that for a lot of what we do isn’t necessary. Every time someone comes to the emergency department and gets treated for something that doesn’t need to be in an emergency department just gets paid.

Part of that payment is going to the fact that there’s an ECMO team on call, right? That’s part of the fixed cost of maintaining a big academic medical center. There’s a helicopter. All these costs are built in to so much that we do that the hospital, then, is sort of required to pay for all of that fixed cost to provide a set of services that are essential. But somewhere in there is a real loss of efficiency, because we’re no longer connecting services to cost to prices to people. It’s all just sort of the system we have built right now, and it doesn’t make a ton of sense.

Dismantling that is not straightforward and I think the kind of disruptions that are going to really change things are not going to come from the hospitals. They’re probably going to come from insurers and I include in insurers the self-insured large companies. Most large companies self-insure, meaning that rather than pay for a plan, rather than pay for everyone to get Blue Cross and then Blue Cross assume all the risk…

Perry: They just pay the cost of the hospitalization themselves.

Maddox: They just pay for what happens, so they’re essentially acting as the insurer and they have a middleman processing claims, but they essentially take on all the financial risk. It makes more sense for most big companies to do that. Their incentives are therefore in line to keep people out of the hospital and to say, “You can have your MRI at a community-based MRI building that will charge you $500 instead of $3,500 to go have it in the hospital where all these extra sort of fixed costs are built in to the payment for that.” That kind of disruption is not going to come from payment models from Medicare, ultimately. It’s going to come from disruptions in industry and in innovation from some of the payers and potentially from patients who are increasingly recognizing this is not a very patient-centered system, and I think appropriately demanding a more holistic patient-centered approach to how this is all going to work.

But that’s the many years down the road of how a health system could be better, and in the short term, we’re living with the system that we’re living with, so we need to work on this one while we look toward the future for someone to really dismantle it.

Perry: What are things that are being done now?

Maddox: Some of it I mentioned. Some of the real innovative, some of the real disruptive stuff, who knows what Amazon and Berkshire Hathaway or whoever else will do. I think Medicare is in a bit of a holding pattern right now. They had been pushing towards more alternative payment models. They have now more and more financial incentives for people that get into these alternative payment models. That would be something like a bundle or an accountable care organization where you’re on the hook for spending for a year, which then gives you incentive, obviously, to reduce spending. They had planned to push out a lot of experimental models from the innovation center, from the Center for Medicare and Medicaid Innovation, or CMMI. A lot of that got put on hold when we had a secretary of HHS [Health and Human Services] who then was no longer the secretary of HHS, and the initial secretary under this administration, Tom Price, as the surgeon, had been a very outspoken opponent of essentially meddling with the doctor-patient relationship. He had done all these payment models, all these changes, anything that gets in the way of doctors making decisions independently about what they’re going to do is not okay. His big thing was to rollback a lot of this type of stuff.

The good thing that comes out of that is that people are thinking a little more consciously about burden and about the burden that we’re putting onto clinicians by all these measures and payment models and all this sort of stuff, when most people just want to take care of patients. But the bad thing that came out of it was a real slowdown in what was coming out of CMMI around testing some of these things.

In contrast to what a lot of the policies have been in the early 2000s and through the early teens, the last administration put a big push over the last term, basically, around trying to use this innovation center as a test ground, so to do what you had suggested. Let’s roll this out in a limited sense. Let’s learn. Let’s figure out what works and what doesn’t, and if things work, then let’s push them out more broadly. A lot of that stuff has slowed down. The ones that had already started in the prior administration are still running, so there’s some neat models for cancer care, for dialysis, but we haven’t seen much new coming out of them. There’s now a new head of HHS who has actually been quite outspoken about the need to keep moving toward value in health care. Also pushing burden reduction, which I think is good, and a new CMMI director was just named. We’ll see in the next year whether or not we start to see more of these experimental kind of models coming online.

I think one thing that has been really lacking in the development of these models is the engagement of the physician community, I should say not just the clinician community, not just physicians, but also nurses, therapists, all the sort of people that make up the clinician community have really not been involved in developing most of these models. We can sit here and say, “That model sounds crazy,” but if clinicians haven’t sort of stepped up to be part of it, it’s not clear why a policymaker would know that sounds crazy.

I hope that as things start ramping back up there’s more attention paid to finding models that people can agree on, that a group of cardiologists could come together and say:”Yeah, actually, as a profession, we think that anticoagulation for atrial fibrillation, that appropriate secondary preventative medications for coronary disease, that this bundle of medications for heart failure, reducing admissions for heart failure, and I don’t know, reducing admissions for stroke are our core goals. We, as a clinical community, are going to put financial incentives in place or we’re going to accept risk or do whatever, but we agree that these things we all ought to be working on together. Let’s grow in the same direction and let’s improve cardiovascular care. Here’s a way we can design reimbursement to help reward that.”

That, to me, sounds much, much more reasonable than some of the stuff that has come out policy-wise that basically says here’s a Frankenstein payment model that’s going to pay you 1% more for sending in data on one of 270 quality measures, which is what the current outpatient payment program is. I think getting clinicians involved in actually designing things that incent innovation, that free up money to invest in monitoring or nurses or whatever we think as a group will make our patients better would be good. I just don’t know if this next year will show us moving in that direction or not. We’ll have to see what this group decides to do.

Perry: A lot of interesting ideas and things to chew on. I appreciate it. I want to be respectful of your time. Thank you so much for meeting with me.

Maddox: Sure, I always glad to talk about this stuff. Sometimes I wish it were less of what we had to deal with when we’re rounding or when we’re in the hospital or when we’re seeing patients in clinic, but ultimately, this stuff really does impact clinical care, so I feel lucky that I get the chance to work on it and think about it and hopefully help be part of the solution.

Perry: Thank you so much.

Maddox: Thank you.

Perry: To recap from today, we learned about how quality payment models have had an unintended consequence of limiting access to care for some vulnerable populations. Specifically, we discussed about the example of cardiac cath in Boston in the 1990s, when after quality measures had been reported publicly, it then resulted in hesitancy from providers to offer cardiac caths to their sickest patients. I think this is an important issue and I’m glad I was able to have the time to discuss with Dr. Maddox about some of the details of this. I hope you found it as useful and as interesting as I did. Thank you for listening to today’s episode and we’ll see you next time.

 

 

The Last Company You Would Expect Is Reinventing Health Benefits

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Frustrated with insurers, some large companies — including a certain cable behemoth — are shedding long-held practices and adopting a do-it-yourself approach.

It’s hard to think of a company that seems less likely to transform health care.

It isn’t headquartered in Silicon Valley, with all the venture-backed start-ups. It’s not among the corporate giants — Amazon, Berkshire Hathaway and JPMorgan Chase — that recently announced, with much fanfare, a plan to overhaul the medical-industrial complex for their employees.

And it is among the most hated companies in the United States, according to many surveys on customer satisfaction.

It’s Comcast. The nation’s largest cable company — the $169 billion Philadelphia-based behemoth that also controls Universal Parks & Resorts, “Sunday Night Football” and MSNBC — is among a handful of employers declaring progress in reaching a much-desired goal. In the last five years, the company says, its health care costs have stayed nearly flat. They are increasing by about 1 percent a year, well under the 3 percent average of other large employers and below general inflation.

“They’re the most interesting and creative employer when it comes to health care benefits,” said Dr. Bob Kocher, a partner at Venrock, a venture capital firm whose portfolio companies have done business with Comcast. (The cable company declined over several months to provide executives for an interview on this topic.)

Comcast, which spends roughly $1.3 billion a year on health care for its 225,000 employees and families, has steered away from some of the traditional methods other companies impose to contain medical expenses. It rejected the popular corporate tack of getting employees to shoulder more of the rising costs — high-deductible plans, a mechanism that is notorious for discouraging people from seeking medical help.

Most employers now require their workers to pay a deductible before their insurance kicks in, with individuals on the hook for $1,500, on average, in upfront payouts, according to the Kaiser Family Foundation. Instead, Comcast lowered its deductible to $250 for most of its workers.

“We believe that no one should be required to be an expert in health care,” Shawn Leavitt, the executive overseeing benefits at Comcast, said in a 2015 interview with a consultant. “Our model is based on providing employees support and assistance in making the right decisions for themselves and their families. Employees should not feel alone, confused and overwhelmed when it comes to understanding and selecting their benefits.”

Cable TV subscribers who have felt confused and overwhelmed when dealing with Comcast customer service may be surprised to learn how nimbly the company has upgraded services for its employees. While Comcast continues to work with insurers, it has largely shunned them as a source of innovation. Instead, it has assembled its own portfolio of companies that it contracts with, and invests in some of them through a venture capital arm, Comcast Ventures.

Turning to health start-ups for new benefits

One such company is Accolade, in which Comcast is an investor, and which provides independent guides called navigators to help employees use their health benefits. Another, called Grand Rounds, offers second opinions and help in finding a doctor. Comcast was also among the first major employers to offer workers access to a doctor via cellphone through Doctor on Demand, a telehealth company.

“We see the start-up community as where the real disruption is taking place,” said Brian Marcotte, the chief executive of the National Business Group on Health, which represents large employers. “We weren’t seeing enough innovation.” The group now vets some of these companies for employers, including Comcast.

Comcast “is the tip of the spear,” Mr. Marcotte said.

The corporation, of course, is controlling costs and offering these unusual benefits out of self-interest. And these services are sometimes handed out at the expense of improving wages. In a tight labor market, Comcast also needs to remain competitive for not only highly skilled employees, but also lower-wage workers whose direct contact with customers has generated so much dissatisfaction over the years. “We do these things because it’s great for business,” Mr. Leavitt said.

But much of what sets Comcast apart is its willingness to directly tackle its medical costs rather than relying on others — insurers, consultants or associations. It’s a luxury only the largest companies can afford, and roughly a fifth of big companies continue to see annual cost increases of more than 10 percent, according to Mercer, a benefits consultant.

While fate may play a role — a single expensive medical claim can drive up a company’s costs in any given year — employers, like Comcast, that use a variety of strategies tend to have the lowest annual increases. “You attack this thing from different angles,” said Beth Umland, Mercer’s director of research for health and benefits. “The intensity of effort pays off.”

Some companies are shaking up hospitals and doctors

Other employers are focusing more attention on unsatisfying hospitals and doctors. Walmart has been at the forefront of efforts to direct employees to specific providers to get medical care, even if it means paying their travel to places like the Mayo Clinic.

The retailer said it had found, for example, that employees were being told they needed back surgery even when they would not benefit from the procedure. “Walmart isn’t going to stand for this,” said Marcus Osborne, a benefits executive, at a health business conference. “We aren’t going to sit around to try to build another coalition or bureaucracy.”

The majority of working-age Americans — some 155 million — get their health insurance through an employer, and most companies cover their own medical costs. The companies rely on insurers to handle the paperwork and to contract with hospitals and doctors. Insurers may also suggest programs like disease management or wellness to help companies control costs.

But employers, including that Amazon-Berkshire-JPMorgan alliance, are increasingly unhappy with the nation’s health care systems. Companies are paying more than they ever have. And their employees, saddled with escalating out-of-pocket costs and a confusing maze, aren’t well served, either. “The results haven’t been there,” said Jim Winkler, a senior executive at Aon, a benefits consultant. “There’s frustration.”

At Comcast, some workers probably miss out on the new ventures altogether and others don’t have much choice but to go along. The company’s relationship with labor is often strained, and it has largely managed to fend off efforts by groups like the Communications Workers of America to organize its employees. Robert Speer, an official with a local of the International Brotherhood of Electrical Workers in New Jersey that represents about 180 workers, noted the company’s use of independent contractors to do much of its work, none of whom are eligible for benefits and can be paid by the job rather than hourly. “You are making no money,” he said.

And, like many other workers, many employees are being pinched by the rising cost of premiums, Mr. Speer said.

Comcast workers with company coverage are told to go to Accolade first. Its phone number appears on the back of their insurance cards and on the benefits website. “The key to Accolade’s success is being the one place to go,” said Tom Spann, a co-founder of the company.

Geoff Girardin, 27, used Accolade when he worked at Comcast a few years ago and he and his wife were expecting. “Our introduction to Accolade was our introduction to our first kid,” Mr. Girardin said. He credits Accolade for telling him his wife was eligible for a free breast pump and helping find a pediatrician when the family moved. “It was a huge, huge help to have somebody who knew the ins and outs” of the system, he said.

For employees like Jerry Kosturko, 63, who survived colon cancer, Accolade was helpful in steering him through complicated medical decisions. When he needed an M.R.I., his navigator recommended a free-standing imaging center to save money. “They will tell me what things will cost ahead of time,” Mr. Kosturko said.

A nurse at Accolade helped him manage symptoms after he had surgery for bladder cancer in 2014. He developed terrible spasms because, he said, he wasn’t warned to avoid caffeine. The Accolade nurse thought to ask him and quickly urged him to call his doctor for medicine to ease his symptoms.

Mr. Kosturko also turned to Grand Rounds when his doctor thought he might need to stay overnight in the hospital to be tested for sleep apnea. The second opinion convinced him he did not.

In complicated cases, Grand Rounds can serve as a check on the network assembled by the insurer. It pointed to the case of Ana Reyes, 39, who does not work for Comcast and had contacted Grand Rounds after treatment for cervical cancer. When she continued to have symptoms, she says, she was told to wait to see if they persisted.

“This is my life at stake,” she recalled in an interview. “I need to know what I’m doing is the best plan.” Grand Rounds asked a specialist at Duke University School of Medicine, Dr. Andrew Berchuck, to review her case.

“Grand Rounds was able to get all my medical records, which is over 1,000 pages,” Ms. Reyes said. Dr. Berchuck reviewed and wrote his opinion in one week, recommending a hysterectomy because she was likely to have some residual cancer. “The same day, my treating physician, she called me to schedule a hysterectomy,” Ms. Reyes said.

Insurers are usually none too pleased with the employers’ use of alternatives: They’re reluctant to share information with an outside company and poised to undercut a potential competitor by offering a cheaper price. They may even refuse to work with some of the companies.

The largest employers push back. Fidelity Investments insists on cooperation between insurers and outsiders, said Jennifer Hanson, an executive at Fidelity Investments. “Those who don’t will be fired,” she said at a health business conference.

For Comcast, the next frontier is the financial well-being of its employees, many of whom live paycheck to paycheck and may not be able to afford even a small co-payment toward a doctor’s visit. Employees who run into financial trouble have no independent source of information, Mr. Spann said.

After talking to hundreds of companies, Comcast Ventures could not find a financial services start-up that would help employees without trying to sell them a product or earning their money on commissions. So Comcast recruited Mr. Spann to serve as chief executive of a new company, Brightside, that it created and invested in.

Employees who are less worried about their finances may be less likely to miss work or suffer from health problems, Mr. Leavitt said. Ultimately, he said, “there is a productivity play for Comcast.”

 

 

Trump signs spending bill into law: Here are health IT’s biggest wins

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HIMSS Senior Director of Congressional Affairs broke down how the massive spending bill will boost telehealth, Medicaid and other crucial health IT.

Congressional leaders passed the spending bill last night, after a 5-hour government shutdown. Senate passed the spending bill around 1:45 a.m. with a 71-28 vote, while the House pushed through the legislation at about 5:30 this morning with a 240-186 vote.

The shutdown was caused by a one-man protest by Sen. Rand Paul, R-Kentucky, who opposed adding another $320 billion to the federal budget deficit. Indeed the massive spending bill adds hundreds of billions of dollars for the military, disaster relief and domestic programs.

While budget appropriators will have until Mar. 23 to determine how to specifically dole out the funding, there are a lot of wins for healthcare, according to Samantha Burch, senior director of congressional affairs for HIMSS.

The bipartisan agreement will raise the budget cap to allow the total budget allocation for defense, non-defense and non-discretionary items, which is “a big win for HIMSS priorities,” Burch said. Those caps will not only help federal agencies with military needs, but it will support health needs and threats for the country.

One of the biggest gains from the budget was the inclusion of the CHRONIC Care Act, which unanimously passed the Senate in September. HIMSS provided technical feedback on for developing the bill, which Burch said is aimed at modernizing Medicare to streamline care coordination and improve outcomes.

Not only will the bill expand telehealth to Medicare beneficiaries, it will also generate patient data on those beneficiaries.

“We’ve been huge supporters of the CHRONIC care act,” said Burch. “Getting that bill over the finish line is an important first step. There’s all of this momentum around health IT on Capitol Hill, but it’s been incredibly hard to get bills across the finish line and signed into law.”

“This is really the first time that we’re seeing a complete package that would expand telehealth access to Medicare beneficiaries,” she continued. “It’s an incredible step forward.”

The spending bill also included provisions for Community Health Centers, National Health Service Corps and Medicare programs that help rural area providers, said Burch. CHIP was also extended for a longer period than anticipated, which provides some stability and certainty to the industry as a whole.

The budget also provides at least $2 billion for the National Institutes of Health for two years and $6 billion for the opioid epidemic.

What’s incredibly valuable is that the two-year budget gives appropriators a “longer runway for the FY19 budget.”

“But there’s much more work to be done,” said Burch. “It’s never a silver bullet… like with the CHRONIC Care bill, we’re trying to bridge this major gap where technology and innovation is, and where regulation and policy is.”

“The bill takes us a little way there, but there’s certainly more to do,” she added.

HIMSS will be continuing to work on progressing these needs moving forward, while concentrating on cybersecurity, interoperability and infrastructure.

Although the industry has come a long way, cybersecurity continues to be a major issue for healthcare, said Burch. HIMSS played a major part of Sec. 405 of the Cybersecurity Act of 2015, which it developed with the Senate HELP committee.

“[That work] got the attention of the Department of Health and Human Servicesand got the ball rolling, which created a more active relationship between HHS and the private sector,” said Burch.

But one of the biggest needs — and perhaps the biggest push — will continue to be around infrastructure needs. Burch explained that while Congress continues to have these conversations around infrastructure and public and rural health, there’s a lot of work to be done.

“We’re still trying to impress upon lawmakers that yes, our roads and bridges may be crumbling, but we still have those with no access to broadband,” said Burch. And that has some of the best use cases for health IT and telehealth.