Will digital health go where others have failed?
I.e. we’re terrible at at-home dialysis, will digital health be different?
I officially moved to Brooklyn last Thursday (my partner and I drove the U-Haul and lifted everything ourselves and then declared that we’re never moving without professional help again). I fully intended to send a newsletter about dialysis, but I both didn’t have much to offer beyond what this excellent Freakonomics podcast covered and was so exhausted from moving that I couldn’t even consider writing a newsletter. Please accept this photo of my new view as an apology.
Last week, the Wall Street Journal published a reported article about how employers are overwhelmed with all the new digital health options coming on the market. I have no doubt it’s true to some extent—choosing health insurance as an employer gets ever more expensive and complicated. But at the same time, all of those digital health options mean that this is the brightest time in history to be a [white collar employee with good insurance and some measure of health literacy, but hopefully eventually all patients] with a chronic health condition.
And we’re just at the beginning of what is hopefully a years-long rollout and integration of condition-specific health startups (or some iteration thereof). If you have type II diabetes, there’s Virta. If you have Crohn’s disease, there’s Oshi or Trellus. If you’re pregnant, there’s Maven or Oula.
Of course, besides employers being overwhelmed, there are some caveats to what this future might look like. As Chrissy Farr pointed out a month or two ago, only some of the most uncomplicated pregnancy care can happen virtually, and the same goes for diabetes, IBD, and other conditions that the newest startups are tackling virtually.
And like I said above, these startups are small enough right now that many of them are only available to certain employees at certain companies—and those are likely the same employees who have the resources to find decent care within the traditional system.
There’s also a chance that this is the outcome:
At the same time, the pandemic created a backlog of chronic care appointments. The Milbank Memorial Fund, Harvard Medical School’s Center for Primary Care, and CareQuest recently put out a collection of research essays covering just this topic (plus a lot of interesting stuff about primary care).
The first essay, written by Aaron Baum, an assistant professor at Mount Sinai School of Medicine, is specifically about chronic care. He writes (emphasis mine):
In conclusion, during the pandemic thus far, fewer patients with preexisting chronic conditions used primary care, primary care practices had less data on their patients’ biological and behavioral risk factors, fewer new medications were prescribed, and a backlog of undiagnosed new chronic conditions accumulated.
Dr. Baum also reviews evidence suggesting that, while exercise decreased and alcohol use increased across the board, individuals’ pre-pandemic socioeconomic status were generally intensified, meaning that lower income groups suffered disproportionately. People who kept their jobs and were able to work from home were more likely to eat healthier, for example, while people who lost their jobs were more likely to experience food insecurity and have difficulty covering household expenses.
So that got me thinking—what does digital health, and particularly the startups that the WSJ is talking about, have to offer to this situation?
At-home care for chronic conditions
I know this is conventional wisdom for almost everyone in healthcare, but the existing chronic care system is so bad.
I have uncomplicated, well-managed Crohn’s disease, and this week I had to see my new New York provider. I spent more than an hour, round-trip, on the subway, just for a 15 minute appointment at which the doctor told me I need more imaging, because she can’t rely on my previous doctor’s imaging, even though she (after several weeks of effort on my part) has the actual files of the previous scans. The entire interaction, all of it, was a waste of time and healthcare dollars. And, as she didn’t need to physically examine me, the appointment could have been done online.
This is why I have so much hope for condition-specific digital health companies, particularly for complex care, and especially if this care streamlines the existing health system and brings condition-specific expertise under one umbrella. It can be very hard to find that expertise out in the wild, especially if you’re not a health literate person or if you live in a geographic area with only a few providers. And if you can find that expertise, even if you live in NEW YORK CITY, it can take hours of legwork to even access 15 minutes of it.
More than that, aggregating expertise allows that expertise to be shared. Bringing together condition-specific physicians within a digital health startup means that those providers are more likely to cross-pollinate each other, and they may be incentivized by their digital health startup to be particularly up to date on the research in their field.
This is why I’m such an evangelist for digital health for chronic conditions. Imagine, bringing together a group of people who are experts on an illness, giving them the tools they need to provide superior patient care, and most of it can be done within your home. I’m sold.
However, I recognize that I’m also the key audience for such a thing. I’m very comfortable with computers, I have a stable home and internet situation, and I’m not worried about my partner overhearing any sensitive health information and using it in a manipulative or abusive way. There are obviously a great many people for whom one or more of those things aren’t true, let alone the people who don’t have access to an employer-sponsored digital health solution.
One other looming threat to my imagined utopia of digital health solutions: even when there’s evidence of a better patient experience and cost savings, as in the case of at-home dialysis, the U.S. has failed to implement it at scale.
How we fall short on at-home dialysis
I’ve been trying to work this ProPublica article into my writing for months, and finally it’s relevant. It’s heartbreaking, and everyone should be required to read it so it never happens again (although it’s also happening every day). The top line is this: for a variety of reasons, including the corporate power of companies like DaVita and Fresenius, as well as structural racism, insurance issues, policy choices, and a general failure of imagination, the U.S. is simply terrible at offering at-home dialysis services, despite its potential to change patients’ lives. And if we’re going to talk about at-home care provided by a digital health solution, reckoning with the reasons that at-home dialysis has had such a failure to launch is a good place to start.
First note: dialysis at home is a significantly better option for many patients than dialysis in a clinic. Rather than sitting in a DaVita or Fresenius office for hours multiple times a week, at-home dialysis offers more flexibility, including an overnight option, where the patient receives dialysis while sleeping. At-home dialysis relieves many of the discomfort, timing issues, and isolation that receiving dialysis can cause. Other countries do this much more.
But receiving dialysis at home in the U.S. is pretty rare. The American Kidney Foundation notes that it can be “a challenge” to find a clinic that will even offer at-home dialysis. Part of the problem is that DaVita and Fresenius own almost the whole dialysis market—and they’ve got their system of retail dialysis clinics all locked in, no need to try out a new model.
Another problem is the insurance reimbursement. Payment models for at-home dialysis are just now starting to change in a way that will incentivize more at-home care, after former HHS Secretary Alex Azar took a special interest in dialysis care (his father receives at-home dialysis according to the Freakonomics episode linked above).
What dialysis means for digital health
The reason I chose the dialysis example is not that it’s special, it’s that it’s quotidian. The usual stew of U.S. healthcare problems—lopsided corporate power, bad incentives—has combined to deprive patients of a significantly better, at-home treatment option. My hope is that the funding and thought leadership flowing into the digital health space means some of these problems can be overcome. But the failure of the U.S.’s ability to offer easy, cheap, accessible, at-home dialysis portends a bumpy road ahead for all of these companies. Although the digital health industry is mostly too nascent to confront many of these challenges, the WSJ article is perhaps a harbinger that the challenges of maturity are coming.
So all of this to say—
As a patient, my hope is that employers spend more time reviewing digital health companies’ offerings, rather than lumping them all together as an overwhelming morass. As someone who really feels for all patients suffering from chronic conditions, I really hope the majority of dialysis care can be at-home soon, for the good of those patients. And as an industry observer and cheerleader, this is my plea for founders to pay attention to how things have gone before —digital health has so much to offer, for those who can navigate the journey.
This information shouldn’t be taken as investment advice (obviously), and the opinions expressed are entirely my own musings, not representative of my employer or anyone else.
Agree on so many of your points. As a previous nurse who helped advocate for care in older adults homes rather than driving them to offices and dialysis, I learned a lot. A big thing I think digital health can do is help better triage a certain type of patient - the health literate, "healthy" chronically conditioned, over 18, technologically savvy, and those with all mental capacities" to the realm of telehealth and digital specific platforms leaving office visits for those who are not those things or need in-person evaluation due to progression or acute issue with chronic condition. All we hear from nurses and doctors is there is not enough of them yet more people living with chronic conditions and more aging adults. I believe if our health system wants to stay afloat it will need to harness tech to help make up for the people and brain power we won't have to take care of the masses. The story of dialysis is so disheartening and I lived it. I will say home dialysis or any home care solutions for that matter - I fear the work and stress the health system and corporations will place on family caregivers - free labor makes for a great business model.
For what it's worth - I worked as a home hemodialysis nurse for Fresenius for a while through early 2020, and they were really trying hard to move people from traditional clinics into the home. Part of it seems to be because of reimbursement incentives changing to encourage home dialysis (specifically from CMS, but private insurers as well) and part of it is because I think there was a realization that the solution up to that point (continue to build more brick-and-mortar centers as the dialysis patient population grows) wasn't going to work anymore because of staffing issues. Home dialysis is waaay more efficient staffing-wise, at least from my experience.
If you ever do end up writing something about dialysis and would like someone from the field to assist, I'd love to help!