CareAlign CEO Subha Airan-Javia on the bloated state of EHR documentation

Value-Based Care

Why Healthcare is a Squid Game

Biotech veteran Wah Yan made a big splash across digital health social media last week after putting out a fantastic article that explores how a playing field of well-intentioned actors has managed to turn healthcare into a Squid Game.

If you missed the wildly popular Netflix show, the article’s subtitle tells you everything you need to know: “why healthcare stakeholders keep trying to punch each other in the face”

Yan lays the foundation for the article by explaining how improving the US healthcare system is difficult due to the mismatch between how revenue is generated vs. how value is measured.

• Revenue is commonly generated per “unit of economic activity” (i.e. per visit or per procedure), so that increasing revenue depends on increasing activity.

• On the other hand, measurements of healthcare value (i.e. a healthier population) are often tied to decreasing healthcare activity (i.e. a healthier population = less visits).

While that might sound like Healthcare 101, Yan goes on to illustrate how this relationship creates an inherently hyper-competitive market because “the value of an innovation is often dependent on declining utilization of other products & services at the population level – even if they’re not in the same vertical.”

• The value of new interventions – whether a drug, a diagnostic, or a service – is increasingly defined by its impact on total cost of care regardless of the reimbursement channel.

• As a result, everything competes with everything else for revenue, regardless if the final payer is a health plan, employer, or patient (e.g. home care reducing hospital utilization, pharmaceuticals replacing procedures).

This hyper-competitive landscape is what Yan contends is accelerating a growing number of Squid Game dynamics, including a land grab for scarce resources and a tendency to favor control over collaboration (e.g. acquiring companies vs. remaining partners).

The Takeaway

Whether or not the shift to value-based care is creating a healthcare Squid Game, Yan’s article provides a great lens for looking at the incentives influencing stakeholder behavior (and vice versa). He goes into a lot more depth than we can cover here, so it’s worth checking out for anyone looking to understand some of the dynamics driving healthcare innovation.

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The Wire

• Half of EHR Notes Are Copy+Paste: It’s no secret that note bloat is a huge issue, but a new study in JAMA found that an eye-popping 50.1% of the total text in clinical notes is copied from previous notes on the same patient. After reviewing over 100M notes, the analysis found that duplication increased from 33% of notes in 2015 to 54.2% of notes in 2020, which the authors say is a rational yet unsustainable response to “a documentation paradigm ill-suited to the task.”

• Instacart Health: Instacart is now the latest tech company to add healthcare bells and whistles to its product offerings ahead of a possible public market debut. Its new Instacart Health initiative includes products and partnerships geared toward “nutrition security, health made easy, and food as medicine,” as well as a Fresh Funds service that enables SDOH-focused organizations to help finance healthy grocery delivery for those in need.

• Johns Hopkins Milestone: Johns Hopkins announced a major milestone after surpassing 1.5M telehealth visits since the start of the pandemic. Over 60% of Johns Hopkins clinicians have now used telehealth, holding virtual visits with over 420k patients. Rebecca Canino, executive director of the Johns Hopkins Office of Telemedicine, summed it up perfectly when she said “the adoption of telemedicine use was a dream come true in a nightmare scenario.”

• Inadequate Health Coverage: A Commonwealth Fund survey found that 43% of US adults had inadequate health coverage in H1 2022, leading to medical debt so significant that nearly 1 in 10 had to take out a mortgage or loan. Out of 6.3k respondents, 42% had problems servicing their medical debt, 46% skipped or delayed care because of the cost, and 49% said they couldn’t cover an unexpected $1k medical expense within 30 days.

• FDA AI Final Guidance: The FDA meant business last week, releasing several dense documents outlining how it will regulate different medical technologies. The most notable was the agency’s final guidance on what kinds of clinical decision support software and AI tools fall under its jurisdiction, and it laid out four nuanced criteria to determine that (section IV on page 3). Although the regulatory jargon is a little tough to wade through, medical imaging systems and sepsis alerts tools are specifically called out as requiring oversight.

• Telehealth’s Evolving Role: New research from athenahealth found that telehealth is now filling more care gaps as it evolves past its early pandemic function of simply replacing in-person visits. The survey, commissioned by athena and fielded by Dynata, polled 2k US adults, revealing that 24% use telehealth when they feel their health concerns don’t warrant an in-person visit and 25% use it to access mental health care without having to meet in-person. Telehealth usage trends among athenahealth network patients complimenting this research also revealed that 23% use telehealth for ongoing chronic condition management.

• Kahun Raises $8M: Israel-based startup Kahun secured $8M in seed funding for its clinical reasoning chatbot as it looks to expand beyond primary care and support new specialties. Kahun’s chatbot takes 3-5 minutes to ask patients personalized questions about their symptoms in order to rule out certain conditions, then cross references medical literature to create a summary for clinicians with notes on areas of concern.

• Hypertension Fuels ED Visits: Researchers analyzed 20.6M cardiovascular ED visits in the US and found that about one-third of these cases were related to high blood pressure. Within this third, hypertension alone (i.e. hypertension not connected to a different health condition) fueled 16% of women’s and 10.8% of men’s cardiovascular ED visits, leading the authors to call for more research to understand the factors driving different cardiovascular disease patterns between genders.

• Walmart + Kindbody: Walmart announced Kindbody as its fertility benefits provider, giving employees covered by the retailer’s health plan access to a wide range of family-building services. Walmart employees can now access over 30 Kindbody facilities across the US for in-person and virtual services including fertility preservation, genetic testing, and IVF.

• Telehealth vs. In-Person Performance: A JAMA study found that telehealth saw higher care quality scores (measured using HEDIS) than in-person care for certain use cases. Among 526k patients (409k in-person, 117k telehealth), telehealth performed better for home-based testing (percentage difference: 5.1%) and consultations on topics like breast cancer screening results (16.9%), although it performed worse than in-person visits for complicated medication management such as with cardiovascular patients receiving antiplatelets (6.7%).

• InfoBionic Remote Cardiac Monitoring: InfoBionic debuted its MoMe ARC (Advanced Remote Cardiology) Platform to streamline the transition from hospital to home care. The cloud-based platform is designed to replicate hospital care by remotely capturing continuous cardiac data without data interruption, alerting clinicians of cardiac events and providing AI-assisted diagnosis of up to 30 arrhythmias.

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