Transforming Care, The Commonwealth Fund’s newest publication, focuses on new models of care, payment approaches, and patient engagement strategies that have the potential to reshape our delivery system to better meet the needs of the nation’s sickest and most vulnerable patients. Published quarterly, the newsletter is a source of innovative ideas for health system leaders, clinicians, and policymakers.
To understand why investors are more interested in digital health technologies for the healthy and wealthy and less for high-need populations including frail elders—even though there may be greater potential to improve their outcomes and lower costs, Transforming Care spoke to a range of experts.
LISA SUENNEN, M.A.
Venture Valkyrie Consulting
For better or worse a lot of investors are a bit afraid of Medicare as a customer even though most of health care is regulated and reimbursed by the government. Some have concerns that reimbursement decisions will be whimsical. There is a lot of anxiety around the viability of self-pay models too. In the venture capital community, there’s also a belief that pure technology—that is technology that’s not tied to service delivery as it is in health care—can be scaled more efficiently, which frankly I don’t believe. This is why they tend to pursue freestanding apps and devices rather than products that may need to be integrated into care delivery models.
The movement toward value-based purchasing may help. As health systems have incentives to manage the cost and quality of care, more may step forward to invest in these technologies. Ideally they will do so in collaboration with entrepreneurs—the great ideas often come from them. To be successful, they need to spend time with the delivery systems and with patients to learn how things work and what the real issues are.
SARA CZAJA, Ph.D.
Center on Aging at the University of Miami Leonard M. Miller School of Medicine
There’s a persistent myth that people over 65 are more or less the same. In fact, they are more heterogeneous than younger adults because they’ve had different life experiences and because not everyone ages in the same way or at the same rate. We see significant variation in cognitive functioning, in health status, and in background demographics—including culture, economic status, and work status. Where patients live and who they live with make a difference. We need to understand these differences to ensure products target the right group and that user testing includes representative samples of patients.
DIANE MAHONEY, R.N., Ph.D.
Director of Gerontechnology Research and Development
Massachusetts General Hospital Institute of Health Professions School of Nursing
One problem I’ve seen is that developers don’t always have the clinical experience needed to understand the limitations and capabilities by disease state. A lot of the products I’ve seen that are designed to help patients with dementia navigate the world, for example, require skill that’s beyond the competencies of someone who would need wayfinding support. It’s important to think in stages of disease and to incorporate clinical insights. It really calls for collaboration across clinical, technological, and social science fields.
I’d also add that income can be a major barrier. I hear again and again from focus groups that they are excited about the new technologies but they are worried about cost. They are looking for ways to rent technology rather than own it. That model may be hard for a company that’s put a lot of money into R&D, but focus groups tell us it could be way to reach lower-income or working-class families that are more price sensitive. Take medication adherence tools as an example—we are going need something between $900 automated pill dispensers and a $2.99 one from the drug store.
That is an issue. The level of testing required to ensure products are safe and effective is quite rigorous. In our research program we have to do accuracy testing before we go into human trials and we need to make sure the products are stable—that they can detect right and wrong actions on the part of the user. For beta testing, we relied on a 69-year-old without dementia who used the technology and kept a log about what worked and didn’t. Technological stability is really important as well. I find this especially true with products for caregivers. If the technology isn’t stable or has glitches, they’ll abandon it. They are under too much stress already.
KATHLEEN KELLY, M.P.A.
Family Caregiver Alliance
It’s a long process. Most companies go through one or two business planning cycles and then realize to secure reimbursement they need to demonstrate outcomes. But few have invested in doing pilot studies. There’s also a fair amount of investment required to educate the marketplace about new products. I liken it to microwaves. No one knew how to cook with them—you have to teach people how to do things differently. For some companies, that’s too much of an investment, especially if they are looking at smaller markets, including those targeting the subset of patients with high needs.
When I present or write something about technologies that involve sensors or monitors, I get responses from people in the ethics field that it is unethical that we are invading people’s privacy and about the intrusiveness of technology. In my work I always ask the participants: how did you perceive this technology? Did you find it intrusive? Did it break your privacy? Did you feel exposed? After 20 years, we’ve never had an issue. I am sure there are cases that can go awry but I don’t think to the degree critics suggest and I feel this impedes the field. My research has shown older adults are willing to give up privacy in order to be able to use technology and stay where they want to stay. People also fear that technology will become a substitute for human contact, but we’re seeing it frees up time to talk about more substantive things. Instead of asking an elderly parent, “Did you take your medicine? Did you eat your lunch?” you can talk about more personally satisfying things such as the grandchildren’s activities. We’re seeing this in our work.