We’re witnessing massive demographic and market shifts that will accelerate the race to value-based healthcare. Case in point: The Medicare Payment Advisory Commission (MedPAC) predicts that Medicare Advantage enrollment will soon eclipse traditional Medicare for the first time.
With more people becoming eligible for Medicare than ever before, our healthcare system is experiencing the broad shift from a focus on volume (precipitated by traditional Medicare, which operates on a fee-for-service model) to value (precipitated by Medicare Advantage, which incentivizes health outcomes).
As these value-based payment models gain momentum through the expansion of Medicare Advantage, large health plans are increasingly motivated to find innovative ways to keep people healthy. This rationale led to CVS Health’s $10.6 billion planned acquisition of Oak Street Health and $8 billion acquisition of Signify Health.
The same rationale led to Cigna’s stake, alongside Walgreens, in VillageMD and Optum’s acquisition of Landmark Health. But while simple in theory, the increased emphasis on primary care invites critical questions about capacity. Given ongoing provider shortages, especially in primary care, how can we possibly scale an approach that requires patients to spend more time with their primary care physician?
I believe that the broad-based shift to value-based care and a more proactive care experience is not only beneficial, it’s necessary. Using hard-won lessons from my experiences as chief product officer at Livongo and Teladoc, I am convinced we can combine existing technology with novel care models to scale access to the clinical services that make value-based models successful.
Reframing primary care as a last-mile issue
Scaling access to primary care services is a last-mile issue. Fundamentally, how can we help a limited supply of providers care for a large and widely distributed patient population? I believe the answer can be found by analyzing the most impactful technological development of this century – cellular networks.
Despite the well-publicized lack of access to broadband and high-speed internet in underserved communities, including rural areas, the adoption of cell phones is relatively consistent across nearly all populations. According to Pew Research, broadband adoption among rural Americans saw a nine percentage point increase from 2016 to 2021. However, despite growth, the 2021 survey found rural Americans have consistently lower levels of technology ownership than those who live in urban or suburban areas, and have lower broadband adoption.
So what’s leading to the delta between the number of people with access to high-speed internet access and cell phones? Cellular networks effectively solved the last-mile issue.
In the early 2000s, high-speed internet was delivered through cable modems and DSL, which required internet providers to run a physical line to every home requesting service. As a result, high-speed internet was slow to reach rural America because of the cost required to cover a geographically-distributed population. Even today, many rural communities have extremely limited hard-wired bandwidth due to the cost of installation. In contrast, cellular technology requires no physical infrastructure, surpassing the last-mile problem all together.
The healthcare industry is facing a nearly identical last-mile challenge. Despite significant advances in technology, care delivery networks are still built around a central hospital system and its surrounding “feeder system” of clinics. However, people who do not live near their local health system often must travel many miles just to access care. For these individuals the last-mile issue requires hours of travel to see a provider.
Hard-fought lessons from Livongo and Teladoc
While no healthcare company has overcome the last-mile issue entirely, some of the lessons learned throughout the recent evolution of digital health can inform our approach.
At Livongo, we developed technology that allowed people to transmit blood sugar data to the cloud via cellular networks. Through a seamless data exchange, we could deliver personalized health insights, which allowed our certified diabetes educators to call members who were at an increased risk of an acute health event. Instead of having to see a physician for every health question, Livongo enabled people to receive real-time support from appropriately credentialed health coaches and identify when further clinical support was needed. We went on to extend these principles to the management of hypertension, prediabetes and heart failure — leveraging cellular networks to overcome the last-mile challenges.
At Teladoc, we learned that people are willing to interact with their physician via telehealth, whether by phone or video. This is particularly true for people’s urgent care needs, and a variety of transactional care needs such as prescription refills or routine aspects of care including flu or cold management. During COVID-19, we learned that longitudinal care could also be delivered using telemedicine, and that ongoing care delivery was most effective when there was already a trusted relationship in place. In fact, when telehealth visits spiked significantly in 2020, the majority of those visits were with a person’s own doctor.
There is a cautionary tale here as well: In the years following COVID-19, we also saw that in the absence of that trusting relationship, people went back to using telemedicine almost exclusively for transactional care, with the only notable exception being mental health care. A foundational lesson emerged: we must first establish trust before pushing the technology needed to cover the last mile on an ongoing basis. This was one of the painful lessons learned at Teladoc over the past year, and is increasingly evident.
The four principles needed to scale access to world-class care
With these lessons in mind, I believe there are four key principles to help scale access to the preventative services needed to deliver successful value-based care models.
First, we must effectively align incentives across patients, payers and providers. This is an area where digital health companies have struggled to date, including Livongo and Teladoc. At Livongo, we aligned incentives with patients and payers, and at Teladoc, we aligned incentives for patients and providers, but neither company cracked the code on adequately supporting all three. The broad shift to value-based payment models necessitates that we deliver meaningful value to all three stakeholders.
Second, we must break through care silos and deliver a great experience from consumer-friendly wellness solutions all the way through complex clinical interventions. People have very different care needs at different stages of their lives. Some days, we want trustworthy information on exercise and weight loss. On others, we need to see a cardiologist to manage congestive heart failure.
Third, we must better utilize providers. While there is appropriate attention paid to the overall lack of physicians, we can alleviate that challenge by positioning providers to maximize their work at the top of their licensure. Today, doctors often deliver far too many routine clinical services and are burdened by administrative tasks that can be handily completed by other credentialed providers, including nurses and medical assistants. By leveraging technology to route patients to the right provider at the right time, we can upskill our entire workforce while delivering care at a lower cost.
Finally, we can’t underestimate the value of in-person care. Certain critically important clinical services can only be delivered through in-person care. Whether that’s building trust with patients who have high levels of healthcare needs or administering moderately complex diagnostics or interventions, pure-play telehealth companies risk exacerbating the last-mile issue by bouncing people back into the traditional health system for their in-person care needs without guidance — often resulting in higher cost and inconvenience.
While much has been made about the acceleration of healthcare technology and the shift to value over volume, no single organization has cracked the code on delivering a truly delightful, cost-efficient and clinically effective value-based care experience across populations. By applying lessons learned throughout the evolution of digital health, and by building the strong technology backbone needed to scale access to the primary care services that are critical to a value-based payment model, I believe we can finally deliver the healthcare experience people deserve.
Amar Kendale is the president of Homeward, a company focused on improving access to high-quality affordable, comprehensive care in rural communities. Previously, Amar served as chief product officer at Livongo. He helped take the company through its public offering in 2019 and its acquisition by Teladoc Health for over $18B in 2020. Amar earned both his Bachelor of Science and his master’s degrees in mechanical engineering from MIT and has eight issued patents.