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The healthcare revolution at home

Before becoming a doctor, David Levine was a high school teacher in a tough neighborhood in Chicago, where he would often make house calls to tutor students and check in on them. “That’s where I learned this amazing power of taking care or teaching in people’s homes,” says Levine. “You immediately understand a lot of the drivers and things going on in their lives and from that you can then look for solutions for them.”

Nowadays he is applying the same principle in medicine. He helps reimagine ways for hospitals to take care of sick patients in the comfort of their own homes, as the medical director of strategy and innovation for Brigham Health Home Hospital in Boston. For a century, Americans have been trained “to call 911 and go to the hospital when they’re sick,” says Levine. But a growing body of evidence shows that for some conditions, high-level care provided in the home can result in better patient outcomes at a lower cost. Levine was the first author of a randomized controlled trial that found home-hospital care was on average 38% less expensive than care delivered in the four walls of a hospital. Plus, patients were less likely to have to be readmitted within 30 days.

In November, the federal government announced it would start reimbursing home- hospital services for 60 different conditions at the same rates as in-hospital services. Like many trends in healthcare, big change comes on the heels of Medicare reimbursement, as commercial insurers often follow suit.

Two Boston-based startups—Medically Home and Biofourmis—are among a growing number of companies providing the technology that makes this transformation possible more widely. And the revolution isn’t limited to patients requiring hospitalization. There’s also been a raft of new technologies from companies like Teladoc Health and Dexcom that help patients with chronic diseases, like diabetes and hypertension, better monitor day-to-day fluctuations and stay healthy.

The right combination of sensors, artificial intelligence and trained staff can monitor issues ranging from infections to heart failure in the home. But the challenge for doctors and companies in this space is getting the word out. “We have a big public health messaging campaign to do—to basically retrain people and say, ‘The hospital is definitely the place to go for some things,’” says Levine. “But a home hospital may get you even better care, even better outcomes for certain conditions.”

Retrofitting The Home
Hospital expenditures in the U.S. totaled nearly $1.2 trillion in 2019. That was before the Covid-19 pandemic swept the globe, inundating intensive care units with ventilated patients and postponing many elective procedures. It ushered in a new era of telehealth, as providers scrambled for ways to interact with patients outside of brick and mortar facilities. “People don’t want to go to the hospital because they can’t have visitors. They’re separated from loved ones, and they’re worried they’re going to get Covid if they don’t already have it,” says Eliza “Pippa” Shulman, a primary care physician and chief medical officer of Medically Home.

How Do You Make A Home Hospital?
“I really want to approach technology in a way that it’s so easy to use, it disappears for the patient,” says Shulman. “For our patients, what they comment on over and over again is the relationship that they have with their care team.”

Biofourmis started with an outpatient monitoring system and is moving into the home-hospital space. More than 110,000 patients have used the company’s wearable sensors and artificial intelligence platform in the past year, ranging from Covid-19 to heart failure. The Biovitals platform analyzes biomarker signals from patients and communicates any worrisome changes to their physicians, which CEO Kuldeep Singh Rajput, likes to call an “early warning score.”

An old reliable standby for doctors to check on their patients’ heart health is the electrocardiogram, which records signals from the heart and requires a patient to come to the office. When reviewing those signals, doctors are ensuring they don’t reach a certain threshold. The drawback is that this method is binary: The signals either hit the threshold or they don’t. The Biofourmis system, by contrast, is more nuanced: It takes a composite of a bunch of different signals and considers them together. The startup has co-developed a patient and clinician portal specific to home-hospital care with Brigham and Women’s Hospital.

Rajput, an alum of the 2019 Forbes Asia 30 Under 30 list, is expecting a huge boost to the company’s hospital business as more health systems are looking for vendors on account of the federal rule changes. The company raised $100 million led by Softbank last year and is beginning to offer clinical services in conjunction with its technology. “We are really transitioning ourselves from being a technology vendor to a tech-enabled healthcare provider,” says Rajput.

Managing Chronic Conditions At Home
Ninety percent of $3.8 trillion in annual healthcare spending in the U.S. can be traced back to patients with chronic or mental health conditions, according to the CDC. Those costs could be significantly reduced if it were possible to catch problems early, so patients didn’t have to go to the hospital. Technology has the potential to play a role here, too.

Last year, Teladoc Health merged with chronic disease management platform Livongo in an $18.5 billion deal. The combined company says that it is taking a “whole person” approach to maintaining health, looking beyond one disease, like diabetes, and considering other issues the patient is facing. “So often these things are tackled in silos, and it means that a person doesn’t know what to focus on next,” says Amar Kendale, chief product officer at Teladoc Health. “If you try to focus on everything, of course, you’re not focusing on anything.”

But here’s the thing: People don’t want to have to spend big chunks of their day monitoring multiple chronic conditions. “You want to have the best possible outcome with the least possible effort,” he says. That was the idea behind Livongo’s connected blood glucose meter. Blood glucose levels need to stay within a certain range in order to avoid complications, which at the most extreme end could result in diabetic coma. With traditional methods, patients may take regular blood sugar measurements by pricking their finger with a needle-like device known as a lancet, but not record them. Livongo says it’s simplified the process. Patients are automatically sent test strips and lancets free of charge. The blood sugar measurements are automatically uploaded to the cloud. That data fuels a smartphone app that uses both artificial intelligence software and human coaches to give personalized recommendations to diabetes patients.

Now Teladoc is partnering with Dexcom, which manufacturers continuous glucose monitors, on a new pilot program. The program intends to explore whether continuous glucose monitors might improve the health of those with Type 2 diabetes. More than 30 million Americans have diabetes—which means their body has trouble producing insulin, which helps the body regulate blood sugar levels. Type 1 diabetics don’t produce any insulin, which means they need to continually monitor their levels through a sensor attached to the skin and inject insulin. The pilot program will explore whether Type 2 diabetics, who do produce some insulin naturally, would benefit from this type of monitoring.

“There’s going to be a lot of opportunity for us to think about using it maybe once a quarter, or once a month,” says Kendale. One example would be when someone is changing medication or looking to change their diet. The next step will be incorporating the virtual physician support, which is Teladoc’s core business.

This combination of remote monitoring and telemedicine support is what Kendale believes could really accelerate the potential for keeping people out of the hospital. “This is really a part of what we see as a systematic shift in consumer adoption expectation,” he says. “The pandemic has been a big accelerant, but now that people have a taste of what it’s like to receive clinical-grade support at home, we see this as the future.”

Forbes

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