#20 - Improving high-touch healthcare, and not with mobile apps

Right-sizing the level of care can go a long way to improving health

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Aaron E. Carroll wrote about the prospect of delivering low-level healthcare services in barbershops this week in the NY Times

Carroll discusses a trial where researchers trained barbers to screen their patrons for high-blood pressure. For those found to be suffering from hypertension, a control group was provided with pamphlets or referred to physicians, while the intervention group met with pharmacists in the barbershop and received medication or direction on lifestyle changes. The results, described by Carroll:

In the intervention group, though, blood pressure had dropped 27 mm Hg to 125.8, which is close to “normal.” If we define the goal of blood pressure management to be less than 130/80, more than 63 percent of the intervention group achieved it, compared with less than 12 percent of the control group.

It gets better. The rate of cohort retention — measuring how many of the patients remained plugged into the study and care throughout the entire process — was 95 percent.”

Not only did the intervention work for the majority of the subjects in the group, but the group had 95% retention. Viewed through a healthcare lens, this retention metric might be termed as “compliance.” Nobody achieves a 95% compliance rate on a treatment plan. 

I’d argue the biggest success driver in this approach was the convenience of the intervention, and of follow up meetings. Having the intervention - in this case a pharmacist - in the barbershop and available to talk, made it that much more likely respondents would participate and derive value. There’s an element of self-selection bias as participants would already be primed to be willing to seek help for their blood pressure by agreeing to be in the study. Even still, the study shows that having an intervention in situ, rather than one that requires a physician appointment at another place and time, is a key difference maker. 

While it’s just a single study, it helps confirm that a demand-driven (or patient centric) view of healthcare is much better for delivering value. Conversations about lifestyle change, and even the prescription of low-risk medications to control blood pressure, don’t require the direct involvement of a physician. However most of these conversations currently happen with a physician because our system is supply-driven: patients are forced to conform to the needs of the system. Primary care physicians are the providers that the system has determined should be responsible for this type of non-intensive and lifestyle-focused care, when in reality even the PCP is ill-equipped for this high-touch service. 

Barbershops, for this specific community, are a much better venue for lifestyle-focused healthcare interactions, mostly because of the convenience of frequent visits. A patient in generally good health should see their primary care physician once a year. This is likely sufficient for screening purposes for pre-diabetes or hypertension, but detection is only half the battle. Once instructions for lifestyle change have been delivered, patients must return to their primary care doctor for intervening follow-up appointments. These visits come with inconveniences like missing work, sitting in the waiting room, and high costs. In contrast, someone might already go to their barbershop once a month, if not more often. It’s easier for a provider to check-in on progress and how well the patient is complying with a lifestyle plan when they interact more frequently, and patients are more likely to comply with a treatment plan if it’s more convenient. 

Technology can be used to enhance a physician’s ability to interact with patients on a more regular basis. Another recent study, this one done retrospectively on a cohort of hypertension patients at Massachusetts General Hospital, showed that there was no difference in blood pressure levels when patients had follow-up appointments using a video-visit when compared with traditional in-office visits. While this shows that technology in this regard isn’t detrimental to care benefits - lower blood pressure - shifting in-office visits to video ones does little to increase overall value. Patients are still seeing physicians for care that could be delivered just as well by a nurse, pharmacist, or even a health coach. 

Pitting these studies against each other makes it clear there is a value benefit in aligning the frequency of the intervention with the frequency of the behavior it is intended to change.  For controlling hypertension, patients must alter their diet and exercise habits. These are daily activities. Moving the frequency of intervention as close to daily as possible will increase the likelihood of success.  

It’s important to remember that when discussing value, cost is crucial. Value is created when patients derive a benefit at a lower cost. If prehypertensive patients met with their PCP once per week it would most likely have a lowering effect on blood pressure, but it would drive costs through the roof. By moving this intervention to a venue with a cost structure that can tolerate more frequent visits, we can increase overall value by delivering a bigger benefit at a lower cost. 

This argument is nothing new. In fact, a bevy of digital health solutions are predicated on the notion of leveraging the addictive use patterns of mobile devices for good, and creating game-ified applications that encourage healthy behavior change. Even though mobile device use can be categorized as an “hourly” activity, digital health applications haven’t been able to come close to being as effective as PCPs, let alone pharmacists in barbershops.

Digital health draws attention, both from venture capital and the press, because the solutions are delivered using technology, and because that technology makes them scalable. When you’re a VC hunting for your next potential unicorn, scalability is at the top of the priority list. What’s far less sexy is utilizing existing interaction points with patients that are external to the healthcare system and driving at overall cost reductions, rather that monetization of daily active users, for example.  

When there were rumblings of Walmart acquiring Humana, I took a flight of fancy to imagine Walmart managing the risk of a patient population. I argued that Walmart would be a better population health manager than our healthcare system, and it’s largely for the reasons I describe above. In addition to being a weekly - if not more frequent - stopping place for many Americans, they’re well suited to high touch operations. 

Many of our widespread chronic healthcare problems - obesity, diabetes, heart disease, etc - can be detected early, and controlled and mitigated through lifestyle changes. Our health system is designed to treat the sick through interventional care - it does a poor job when it comes to encouraging and helping people to live healthy lives. Walmart, and barbershops, as places we already go on a regular basis, are much better positioned to provide the regular positive nudges people need to make lasting behavior change. 

If we’re hunting for the products and services that will improve value at the low end of healthcare, we can learn a lot from this barbershop study. Making both detection and intervention convenient to the patient is key. Aligning the frequency of intervention with the frequency of the targeted behavior is also important. Arguably most crucial for creating an actionable new mode of care is ensuring that the value delivered is greater than in the previous model - if we can solve hypertension by assigning every prehypertensive patient a physician to call at every mealtime to consult on dietary choices, overall value would diminish once cost was factored in. 

As it always does, it comes down to delivering the right amount of care, at the right level, and at the right time. Now if we could just get the healthcare system to do it.  


Other things worth reading:

  • Days of information blocking look numbered from Meg Bryant - Health data interoperability is a regular topic of discussion when triaging the biggest problems facing the healthcare system. When patient data is held tightly within provider groups, it inhibits provider competition by increasing the difficulty for patients in switching providers. Byrant talks about how CMS has taken a renewed interest in forcing companies to stop blocking information transfer, and how business incentives might drive companies to actually want to be more open with their data. 

  • How to Make a Fortune on Obamacare from Bryan Gruley, Zachary Tracer, and Hannah Recht - This story, from November of last year, is a deep dive into the business practices of Centene. The Missouri-based insurer has employed narrow network strategies for catering to populations underserved by other insurers in the individual markets. And Centene is quietly doing very well.