A Hospital Sector Under Siege

Flare Capital’s Michael Greeley and Dr. Gary Gottlieb published a stellar breakdown of the current challenges barraging US hospitals, unpacking how the convergence of cost pressures and workforce issues is creating a perfect storm of financial distress.

It’s a thorough overview to say the least, but most of the issues fit into a few main buckets that are worth considering when mapping out how to best partner to help tackle them:

  • The median debt-to-EBITDA ratio for US hospitals stands at approximately 3.9x (up from 2.5x in 2021), and 60 health systems have seen their debt ratings downgraded this year. The looming restructuring negotiations are going to be painful.
  • CMS hospital star ratings for 2023, which measure performance along five key areas (mortality, safety of care, readmission, patient experience, timely/effective care), showed slight declines across the board. That directly translates to worse reimbursement.
  • Over 600 of the country’s 1,800 rural hospitals are at risk of closing, and mostly in states with a large number of disenrolled Medicaid members. The upcoming spike in disenrolled patients that no longer have health coverage could be the tipping point for many of these hospitals due to increased bad debt and charity cases.

One “promising shiny penny” for avoiding hospital closures has been the broader adoption of technology to reduce clinical and administrative costs.

  • In today’s environment, hospitals need a clear ROI from their vendors. The writeup makes the case that a more patient-centric care delivery system might sound seductive, but could also actually increase a provider’s overall cost structure. That might give solutions that directly drive better star ratings an edge in the current market.

The Takeaway

Hospitals are a customer base that’s under siege from a ton of angles. It’s tough to solve these problems without first identifying their root causes, and this article is a great tool for honing in on those underlying issues.

HLTH23 Recap and Major Announcements

Another HLTH is in the rearview mirror, and this week’s exhibit hall chatter was a testament to how much things can change in a single year.

It’s hard to believe that this intro for last November’s show didn’t include a single mention of generative AI. In a few short months, nearly every exhibitor has not only thought about incorporating LLMs, but has implemented new features and shipped entire solutions centered around the technology. 

It was also refreshing to see the amount of good ol’ fashioned innovation happening outside of the AI-focused spotlight. To help keep it all straight, here’s our recap of the major announcements, launches, and partnerships from HLTH23: 

  • b.well Connected Health is integrating with Samsung Health to give millions users control of their longitudinal health record plus proactive insights from a growing network of providers, including Walgreens, ThedaCare, Lee Health, and Rise Health.
  • CirrusMD showcased its Physician-first Care & Guidance model that streamlines care journeys by building around the physician, allowing them to overcome traditional limitations of one-to-one encounters through collaborative virtual environments. 
  • Darena Solutions took the lid off its new MeldRx platform-as-a-service that enables the rapid creation of FHIR-compatible healthcare apps, taking much of the guesswork out of app development while ensuring that new tools integrate seamlessly with EHRs.
  • DrFirst unveiled its Fuzion platform that uses “clinical-grade AI” to streamline clinical workflows such as medication reconciliation, eliminating the need for manual data entry while offering analytics on drug fills, patient engagement, and improvement areas. 
  • Google Cloud announced healthcare-focused search capabilities that connect clinical data to the Vertex AI algorithm development platform, functionality that can be combined with Med-PaLM 2 to let providers surface answers to specific medical questions.
  • HATCo – AKA the Health Assurance Transformation Company – is on the M&A hunt after General Catalyst unveiled the company with the intention of acquiring a health system to serve as a proving ground for tech-enabled care. We’ll unpack this one more on Monday.
  • Health Gorilla announced that 17 healthcare organizations have committed to its QHIN once designated (on track to be before the end of the year), a list that included heavy hitters such as Evernorth and Virta Health.
  • MDLIVE, the telehealth arm of Cigna’s Evernorth, acquired the technology behind Bright.md to begin offering asynchronous options for virtual care in 2024, with plans to expand to chronic condition management and wellness visits at a later time.
  • Nuance shared some impressive results from Atrium Health’s roll out of DAX Copilot, which included 92% of clinicians saying the automatic documentation solution was “easy to use” and 84% reporting an overall improved documentation experience.
  • PEP Health put out a stellar report using AI-powered natural language processing on over 25M patient comments across 8.5M unique web pages to create what might be the first national index on experience scores that doesn’t rely on survey data.
  • Solera Health launched its HALO unified benefits platform that allows payors and employers to manage all Solera and non-Solera point solutions within a single interface, including a consolidated dashboard to assess program effectiveness side by side.
  • SteadyMD is rolling out an all-in-one virtual care solution that combines 98point6’s tech backend with SteadyMD’s 50-state clinician network to help short staffed healthcare organizations lower operational costs while handling additional patient volume.
  • Talkiatry debuted its new Mindshare partner program that lets providers easily refer their patients for telepsychiatric care from Talkiatry’s network of 300 psychiatrists across 44 states, with NYU Langone, NOCD, and Transact Campus signed-on at launch.
  • Walgreens is throwing its hat into the virtual care ring as it continues its strategic pivot to healthcare services, with virtual consultations for common medical needs and prescriptions slated to begin later this month.
  • Withings Health Solutions is partnering with Validic to integrate its suite of cellular devices with the IoT platform, providing seamless access devices such as the Withings Body Pro smart scale and the Withings BPM Connect Pro blood pressure monitor.

Special thanks to everyone at HLTH who caught us up on the latest and greatest, and welcome to all of our new readers we met at the show! Stay tuned for deeper dives into many of these announcements in next week’s Digital Health Wire.

Health System Partnership Playbook

Andreessen Horowitz partner Julie Yoo and Bassett Healthcare CDO Paul Uhrig recently gave Healthcare Dive their playbook for entrepreneurs looking to partner with health systems, which included plenty of insider tips to stand out in a crowded field.

Getting in the (right) door is the first step to any pitch, but an academic medical center with a healthy mix of payor contracts will have a different lens than a rural hospital serving mostly Medicaid patients.

  • Advice: Research target health systems and make sure they align with your product’s value proposition. Make sure you’re reaching the right person, which usually involves multiple stakeholders across clinical, operational, and financial leadership. The value proposition needs to hold up to each.

Making the pitch will vary by health system (an asterisk that could probably be added to every tip), so it’s important to tailor all information and supporting data to individual priorities. This section stresses that it’s “imperative” to illustrate a positive financial impact. 

  • Advice: Don’t be afraid to ask about budget and clarify your revenue model. Even if stakeholders like the solution, it’s moot if they aren’t able to find the funds for it. 

The evaluation process can run the gamut from informal discussion to formalized diligence, but health systems aren’t usually opposed to giving visibility into the evaluation checklist.

  • Advice: Upfront qualification work is intended to de-risk the implementation process and identify potential blockers early. Be prepared with case studies and references from other customers to support the evaluation process.

Pilot programs are a health system favorite, but clearly defined success criteria and a commitment to move forward if those are met are two key ways to avoid “death by pilots.” 

  • Advice: Try not to get hung up on IT integration, and if possible steer toward an implementation scope that requires minimal integration before phasing into a full-blown integration to ramp up to your product’s full value.

The Takeaway

As Yoo and Uhrig describe it, partnering with providers is a bit like “making an emulsion from oil and water,” especially at a time when many of them are grappling with rising labor costs and slim margins. Health systems see a daily flurry of startups offering to solve these problems, and if this playbook makes one thing crystal clear, it’s that the only way to get a pitch to land is to make it hit squarely in the center of their individual needs.

Atropos Raises Capital to Bridge Evidence Gap

Atropos Health is a tough company to pin down with a short intro. It’s one part physician consult service, one part real-world data network, mixed together to close “evidence gaps” wherever they might be.

Over 70% of care decisions lack sufficient personalized evidence, in large part due to clinical trials excluding the same share of the population. This is the evidence gap that Atropos exists to bridge, and it just raised an undisclosed amount of fresh financing to support that mission. 

The Green Button is the interface that allows physicians to surface answers to their clinical questions by quickly producing retroactive observational studies called Prognostograms.

  • Prognostograms deliver the experience of a second opinion, but backed by real-world evidence tailored to a specific patient.
  • As a result, physicians can incorporate more real-world evidence into their day-to-day practice, while ideally also cutting down on out-of-network referrals.

The Atropos Evidence Platform enables the magic on the front end, serving as a foundation of insights from over 160M de-identified patient records and a partner network that includes big names like Mayo Clinic and Clarify.

  • Data Scoring Solutions guide users toward the most appropriate data source for their question, side stepping the “garbage in, garbage out” problem that challenges some of the LLMs taking the industry by storm.
  • Publication-grade studies and transparency is a versatile value proposition, and seems to be resonating with both providers (Ex. point-of-care support, quality improvement programs) and life science orgs (Ex. clinical trial emulations, unmet need analysis).

Atropos is now setting its sights on the global market, with the recent financing tagged for international expansion and channel partnerships. The round was led by strategic investments from Samsung and Presidio, who will help kick off the expansion in Japan and Brazil.

The Takeaway

Health data is more available than ever and growing every day, yet we’re only scratching the surface of retrieving actionable insights from that complexity. Atropos is helping healthcare organizations realize the benefits made possible by years of infrastructure investments, not with a language model spitting out silver-tongued guesses, but with transparent evidence-based research at the point-of-care.

DHW Q&A: The Road to Medication Success With Synapse Medicine

With Clement Goehrs, MD
CEO and Co-founder of Synapse Medicine

In this Digital Health Wire Q&A, we sat down with Synapse Medicine CEO and Co-Founder Clement Goehrs, MD to discuss the challenge of accessing up-to-date drug information and how that data can be used to improve care delivery.

With more medications hitting the market every week, providers face the impossible task of tracking countless new interactions, and software developers don’t have it any easier as they look to equip providers with the right tools for writing safe prescriptions. Dr. Goehrs co-founded Synapse in 2017 to help them do just that, with easy-to-implement UI components making real-time drug data and decision support more accessible than ever.

Can you give the audience a quick introduction to Synapse Medicine and the story arch that brought us to your current solution set?

To put it simply, our mission is to make it as easy as possible to access medication information – wherever it is – and to help providers make the best clinical decisions using that data.

During my time as a physician, I saw first hand how difficult it was to find information for optimizing a prescription, and that we’re also facing a huge public health problem due to people dying from avoidable medication errors. Those are the problems we’re aiming to solve.

And when I say that we’re trying to make drug information easy to find, I mean for our end users (providers, pharmacists, nurse physicians), as well as our clients (usually EHRs, ePrecribers, or telemedicine companies – any type of software company building for clinicians that wants to add a drug information component).

Can you give us a deeper dive into Synapse Medicine’s clinical decision support solution, and walk us through what that user experience looks like?

One of the things that we understood very quickly was that providers don’t want to have multiple tools. That means that if you’re providing some kind of clinical decision support, and you want your end user to have the best experience, you also need to have a seamless integration inside the EHR.

You also have to be able to provide a wide range of tools without making the solution overly complex, and we do that with what we call components. Our components leverage our APIs with a UI layered on top for specific use cases, like drug interactions or side effects. That makes them easy to integrate and customize, but the user doesn’t even notice it’s a third party feature.

To give you an example, if a physician starts a prescription within the EHR, as they begin entering drugs they’ll start to see safety notifications on the side effects, potential interactions, and dosages. All of that is communicated in a way that’s easy to understand. 

No physician wants to see a pile of alerts, but they do want to have info on how to help their patients. So instead of just saying “there’s a severe interaction” like most tools do, we take it a step further by saying “you might want to divide that dose in half to avoid these side effects, and here are the publications supporting that decision.” That explanation is super important.

What are some of the big trends that you’re keeping your eye on, and how do you see them continuing to unfold going forward?

One of the main trends that I’m seeing is that there are a lot of legacy players, very big EHRs and software companies, that aren’t able to innovate at the pace they would like to because they have so much on their plate.

These companies face so many regulatory hurdles and have so many things they need to build, so with all the innovations and AI progress happening every day, more of them have been saying “we can’t keep building every single use case, and we are going to start working with companies that are focused on this specific problem.”

As more EHRs and telehealth companies start to integrate with other players to get the best of both worlds – breadth and depth of features – there’s a big opportunity for the startups working on those use cases.

Has there been anything that surprised you about the recent AI momentum, or as you implemented any new technology into your own platform?

AI is a fundamental part of a lot of what we do, and of course we continue to learn more about it every day. One project that we did with France’s equivalent of the FDA, and probably one of the first healthcare AI projects deployed at that scale, was to help monitor vaccine side effects and other drug interactions on a national level.

As we developed that algorithm, every time we made a major jump in performance, it was never because of the mathematical model. It was always because we ended up back at the data.

We understood the data very well from a medical point of view, and also had physicians on our team that could point out things like why we shouldn’t train the model on certain data. That’s what really enabled most of the fine tuning.

So for the short answer to your question: I’ve been surprised by how much truly understanding your field, and truly understanding your specific use case, is actually what makes AI smarter. It’s not just more data and a bigger model. I think the real progress wiIl come from the AI teams that have physicians and data scientists working together on performance.

What advice would you give to providers or startups that are thinking about improving their own prescribing strategy?

Number one, I would say to think deeply about the end user, about the physicians and the prescribers. That may seem trivial, but that experience is so important, and it’s surprising how often it gets overlooked.

Number two, think about scalability, particularly around adding secure data. What worked for 10 physicians in the beginning might not work as you scale. You’ll probably need better data, and you’ll probably want to do something with that data. If that data isn’t secure from the beginning, you’re going to lose a lot of time if you have to rebuild everything.

That brings me to number three: I wouldn’t recommend doing that by yourself. There are new drugs every week. There’s drug information all over the place, a lot of terminology, and few standards tying it all together. It’s a complex mess, and it would be a mistake to only consider the resources you would need to build it, because it’s maintaining it over time that gets really painful. You can probably avoid a lot of pain by having someone else do it.

For more on Synapse Medicine’s clinical decision support for medication success, head over to their website or reach out to [email protected].

What’s Behind the Medicare Slowdown?

Since Medicare coverage first took effect almost six decades ago, the program’s runaway spending has played a leading role in the story of the federal budget. Now, the end of that growth is stealing the spotlight.

An excellent piece in The New York Times highlighted how Medicare’s unsustainable climb reached a turning point in 2011, and for reasons that aren’t exactly clear.

In 2011, Medicare spending per beneficiary (MSPB) reached $13,159, nearly double the level it was at near the turn of the century.

  • If historical growth had sustained beyond that point, we’d currently be sitting at roughly $22,006 MSPB. Luckily, that’s not what happened.
  • Spending leveled out, and we now find ourselves at $12,459 MSPB, a nearly $4 trillion gap compared to previous projections… yet the underlying cause remains a mystery.

The trillion dollar question: what changed? The authors call out obvious shifts in Medicare policy, namely the Affordable Care Act in 2010, and its reduced Medicare payments to hospitals and payors with private Medicare Advantage plans.

  • While ACA was certainly a contributor, most of the reductions are attributed to a category that the budget office calls “technical adjustment,” which describe changes to a wide base of topics such as the expansion of cholesterol and blood pressure medicines.

The NY Times concludes that the true reason for the change is a hard problem that remains unsolved, but the smart folks on social media were quick to pick up where they left off, floating possibilities such as:

  • As MA lives increased, the types of MA plans also improved due to the phasing out of inefficient plan designs
  • Age of death increases stopped around this time, so US citizens aren’t living to older ages with increasingly complicated health issues 
  • The rise of ACOs started in 2012, although we just covered why that factor probably doesn’t account for a huge share of cost reductions

The Takeaway

Savings attribution has always been a fundamental challenge for the healthcare industry, underpinning many of the issues with value-based care and other alternative models. Now that we’ve found ourselves at an inflection point where Medicare spending is slowing but still outpacing the federal budget, the solution to that savings attribution problem will also be what lets us identify the levers that will keep the trend heading in the right direction.

Everything That Washed Ashore at Epic UGM

Epic went with a Castaway theme for this year’s User Group Meeting, and it’s easy to see why considering Tom Hanks would need years on a deserted island to sort through all the new features and partnerships announced at the show.

Luckily for Hanks, we already rounded up all the biggest news from the event, starting with the headline grabber: 

Microsoft and Epic are going all-in on AI. Microsoft CEO Satya Nadella even attended in-person to lay out how the partnership will reshape clinical workflows with generative AI.

  • Ambient clinical note generation powered by Nuance DAX Express 
  • Added in-basket messaging features that auto-generate first-draft responses
  • Rev cycle enhancements that provide coding staff with suggestions based on EHR data
  • New Look-Alikes program that matches patients with unidentified conditions to others with similar symptoms to help inform novel treatments

Epic CEO Judy Faulkner also took the stage in a sweet island explorer / Burning Man costume to share Epic’s overhauled partnership program, which now includes four distinct categories.

  • Cornerstone Partners – tech that serves as the backbone of Epic’s own software (InterSystems, Microsoft)
  • Partners – market leaders in specific areas (Nuance for ambient voice, PressGaney for consumer surveys)
  • Member Services – established integrations providing complementary value 
  • Pals – new category that allows innovative vendors to work closely with its EHR, including Abridge for ambient voice and the just-announced addition of Talkdesk for contact center workforce management

A new app “Showroom” will be the home base for the above partners, replacing the App Orchard that Epic shut down last year. 

  • When Showroom officially launches in a few weeks, it’ll be exclusive to a much more curated cohort of Partners and Pals than the Orchard’s 800+ third-party vendors, a decision that Epic said will help users find the “signal in the noise” and facilitate deeper collaborations. 

The Takeaway

Under the bright lights of an island-themed stage, Epic’s new features look nothing short of transformative, and its newfound willingness to play nice with partners could make a huge impact on nearly all aspects of care delivery. The real question will be whether these enhancements can be deployed as envisioned so that they can live up to their potential. It’s a massive undertaking, but there are countless clinicians that would love if Epic could pull it off.  

Elevance: Hospital Acquisitions Harming Patients

Elevance just published a great report leveraging data from its affiliated health plans to color in the picture that’s been loosely outlined by a few other studies: patients face higher prices and lower care quality after independent hospitals are acquired by health systems.

It’s no secret why a growing number of independent hospitals are getting scooped up each year. Elevance found that operating expenses fell by an average of 6% after an acquisition, about 60% of which can be attributed to personnel reductions.

  • The share of U.S. hospital beds that belong to health systems spiked from 58% in 2000 to 81% in 2020, and a quarter of markets no longer have any independent hospitals.
  • Hospitals inked 20 M&A moves in Q2 alone, opting for consolidation in order to secure additional resources and negotiate more favorable contracts with payors.

That isn’t exactly great news for patients. Independent hospital acquisitions resulted in 5% higher costs for patients with commercial health coverage, and increases ranged from 5% to 8% across top diagnostic categories by volume (Ex. digestive, respiratory, and circulatory). 

  • Elevance also noted that its members receiving cardiac care saw readmissions increase over 10%, and that acquired hospitals with greater staff reductions unsurprisingly experienced a greater increase. Readmissions for Medicare patients with acute non-deferrable conditions saw a more conservative increase of 2-3%.
  • The numbers were a little more vague surrounding access to care, although the study “observed the closure of maternity wards, which were concentrated in rural hospitals.”

What’s the solution? In Elevance’s view, regulators should seek assurances that patients won’t face higher costs following an acquisition, especially considering the efficiency gains for the health system. Regulators might also consider implementing quality standards during the approval process to ensure that readmissions and access aren’t harmed as a result.

The Takeaway

Elevance might have its own reasons for wanting to keep costs down at health systems, but it’s also putting out some credible evidence that suggests hospital acquisitions aren’t doing patients any favors. That said, there are plenty of very real pressures driving hospitals toward consolidation, and reports like this are important for helping policymakers chart the best path forward.

Which Components of CBT Actually Drive Outcomes?

“Cognitive behavioral therapy for X” is the backbone of many mental health startups and digital therapeutics, yet it’s unclear which individual components of CBT actually drive outcomes.

A recent study in JAMA Psychiatry attempted to tackle that question, randomizing 767 adults with depression into cohorts that received some, but not all, of the seven individual components of internet-delivered CBT.

  • Those include: activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption training, and self-compassion training

While internet-delivered CBT resulted in reduced depression at six months (mean follow-up difference in PHQ-9 score: -8.63), the researchers were surprised to find that none of the factors appeared to drive an impact independent of the others.

  • The one exception? Absorption training.

The absorption training module taught individuals to become immersed in what they are doing in the present moment to “improve their direct connection with experience and enhance contact with positive reinforcers.”

  • Patients completed a behavioral experiment where they compared memories of being absorbed versus not absorbed in a task, learned about flow states, and identified activities that make them feel absorbed. 
  • Although statistically significant, the effect of adding this module was still only one-fifth of a PHQ-9 point.

The Takeaway

At least within this study, none of the components of CBT – with the exception of absorption training – significantly reduced depression symptoms relative to their absence, despite an overall average reduction in symptoms. The findings suggest that treatment benefit from CBT probably accrues from factors common to all CBT components (e.g. structure, making active plans), and non-specific therapy factors (e.g. positive expectancy).

Laudio Lands $13M to Tackle Burnout

Workforce management startup Laudio landed a $13M Series B round to tackle labor productivity and burnout, two challenges proven large enough to attract funding in any environment. 

Unlike staffing solutions aimed at adding more people, Laudio helps retain the talent healthcare organizations have already invested in by automating repetitive work and nudging managers toward next best actions.

  • Laudio’s AI-driven software automates tasks such as employee rounding, new hire check-ins, quality audits, and overtime assessments. It also helps with reminders for events like employee birthdays and work anniversaries. 
  • Example: If a nurse has worked several consecutive shifts with new employees, Laudio will alert the manager to reach out and thank them, deliver scheduling recommendations, and suggest follow-ups.

Laudio plans on using the funding to build out its AI capabilities and recommendation engine, while adding more partnerships with health systems throughout the country.

  • Over 20 health systems already use Laudio, and it attributes its early success to its focus on becoming an all-in-one platform for frontline managers, who frequently turn to a variety of point solutions for quality audits and employee engagement.
  • Laudio counts major systems like Novant and UNC Health among its early adopters, and reports that the platform has reduced RN turnover by 26% by driving a single meaningful interaction every month between frontline managers and nursing team members.

The Takeaway

Health systems have been stuck in a vicious cycle of high turnover leading to burned out workers leading to even more turnover. If Laudio can use its Series B funds to prove it can break that chain, it’ll have no shortage of hospitals lined up to streamline the workflows of their frontline managers.

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