Also, confronted with shrinking budgets and growing costs, the U.S. health care system is under pressure to create value-based health care. Innovative health care technologies play a critical role in the quest for value; they offer the potential to lower costs while enhancing clinical outcomes, all the while expanding the reach of care to at-risk populations. Despite their potential, high-value technologies are under-used, held back by systemic barriers that hinder technology adoption and innovation. This paper seeks to address that missed opportunity and identify technologies with both clinical and financial benefits. Each of the profiled technologies has the potential to improve quality, reduce costs and positively impact the health of chronic disease patients, especially those from safety-net and at-risk populations.
The paper also identities cross-cutting lessons learned about the role of technology in creating value and an overview of some of the barriers that hold back their adoption. The safety-net delivery system is underfunded, understaffed and often lacks the financial resources, human resources and information technology infrastructure needed for proper chronic disease management. Compounding the challenge, the safety-net population is all too often uninsured or underinsured. As a result, many lack access to resources to properly manage their diseases, leading to frequent use of health care services and contributing to unnecessary spending. Adding to the difficulty, the safety-net population faces additional challenges that may limit access to and adoption of mobile and Tele-health technologies.
Additional challenges include literacy, language barriers, housing instability and mobile technology and internet access. Despite these challenges, innovative technologies designed for chronic disease care can support better monitoring and management of chronic conditions for underserved populations, and can reduce unnecessary hospitalizations and lower the cost of chronic disease care. This paper describes how the Chronic Health care has evolved over the generations. The future technology study in this paper seeks to expedite the identification and adoption of technologies, disruptive innovations and new models of technology-enabled care for chronic disease patients, especially those in underserved populations. The Technologies identified has the potential to address the target population of chronic disease patients, identified those technologies with the highest potential for clinical benefit, cost savings and adoption.
This down-selection process utilized criteria including low current adoption, future potential for benefit, alignment with the safety-net population, low cost, broad application, identifiable barriers, positive user experience and multiple products/manufacturers. These identify emerging technologies that have the potential to improve both cost and quality. A global perspective was employed to evaluate the financial benefits of these technologies. Some technologies may require significant upfront investment and appear too costly to implement; however, they have the potential for long term efficiencies and future cost savings.
HISTORICAL ROLES AND RESPONSIBILITIES OF MARKET PARTICIPANTS Identification of Stakeholders, Roles, Responsibilities and Procedures
In the early part of the century medical science was very crude, and often consisted of cures like bloodletting, where the surgeon-barbers cut the veins of the patient to let bad blood escape. In some cases the best outcome you could expect was that the cure wouldnt kill you. It wasnt until the latter part of the 1800s that researcher began to understand how to deal effectively with illness and disease. During 1776-1799 : Poorhouses, almshouses, poor farms, county infirmaries, asylums, or county homes are built to house people who were too expensive to support with outside relief, and required welfare recipients to go to these facilities if they wanted assistance. During 1800-1899: Families disperse, Poorhouse system comes under scrutiny, Old-age homes are established, Hospitals and home health emerge, Early retirement communities appear, Some elderly move to insane asylums, State and employer pension and welfare systems develop.
Unlike the younger, healthier patients, poorhouse patients tended to have chronic conditions that required long term care. People who werent poor cared for the chronically ill at home. Those who were poor and ill, many of whom were also elderly, often ended up in hospitals for very long periods of time (Charity Hospital, 1890). At the end of the century, employers began to take a role in providing assistance for their employees. In 1875, American Express developed the first private employer-sponsored pension program. In studying the evolution of long term care, its important to understand the way that hospitals were evolving, since there was some overlap between old age homes and hospitals.
Hospitals have some roots in the poorhouse system, just as nursing homes do, since from the beginning of the country many of the poor have been old and sick and many of the old and sick have been poor. During 1900-1929: Non-profit old-age homes are built, Elderly have many years ahead of them, Urbanization increases care needs, Home care expands, More cash benefits are available from states and employers, Table of institutionalized elderly from 1900-1930. The spread of tuberculosis was instrumental in spurring the development of public institutions designed to provide chronic care, since patients needed to be maintained for a fairly long period of recuperation. To effectively control the disease, even those who could not pay for their care had to be removed from the general population and cared for at the expense of governments or charities. A large percentage of these patients were indigent. For instance, it was estimated that 85% of those stricken with tuberculosis in Michigan were unable to pay for their own care. (Medical History of Michigan, 1930)
Source: Elderweb.com During 1930-1939: Great Depression adds to poverty and destroys families, State assistance is little help, Social Security Act creates national old-age welfare, New benefits kill poorhouses and stimulate for-profit homes, Federal and state governments share the costs. Old age homes were a perfect cottage industry; they could be easily and often inexpensively launched by mom and pop operators who boarded their elderly customers in unused rooms in private homes. Some were run by unemployed nurses who provided rudimentary care in addition to room and board, giving rise to the term nursing home.
The nursing home industry was becoming primarily a for-profit industry, hospitals continued to develop under government and non-profit sponsorship. By 1935, there were about 6,400 hospitals in the United States, and virtually all were either non-profit or government facilities. Most hospitals had always admitted a significant percentage of charity patients who could not pay their own way, whose care was heavily subsidized by the government or by the religious or charitable institutions that supported the hospitals. They also required more capital and operated on a scale that few private operators would have been able to finance.
During 1940-1949: World War II, Old Age Homes utilization and costs explode, Benefits change family living arrangements, National health insurance proposed but defeated, HillBurton creates healthcare licensing systems, Various buildings converted to nursing homes.
Source: Elderweb.com An unplanned result of the Hill-Burton legislation was that many of the old hospitals that were being replaced were converted to another medical use ” they became nursing homes. In the late 1940s, all kinds of residential and commercial construction resumed, after stopping completely during the war. The pent up demand for construction made it hard to find the resources to build new buildings, but older buildings were coming on the market as they were replaced, and the end of the war ushered in an era of nursing home conversions. Hundreds of hotels, homes, and other existing buildings of all kinds were converted to nursing homes. At the same time, labor unions and the insurance industry were encouraging employers to provide health insurance to their employees as an alternative to a government-sponsored program
During 1950-1959: Government has become the primary payer for nursing home care, Financing is made available for nursing home construction, There is a boom in for-profit nursing home construction, The quality of nursing home care becomes a national concern. During 1960-1969: Government payments escalate, Nursing home quality concerns escalate, Medicare and Medicaid are created and costs explode, Medicare/Medicaid statistics, Medicare slashes nursing home coverage, The Fevered Fifty soar and crash.
In spite of the looming problems with Medicare reimbursement, publicly-traded nursing home chains became one of the hottest things on Wall Street. Everyone viewed Medicare and Medicaid as a risk-free source of revenue that made this a business where no one could lose money. In 1966 there were only a few publicly-traded nursing home chains, by 1969 there were 58, and by 1970 there were 90. The best known were called the Fevered Fifty, and they were promising investors returns of 20-25% a year. In many cases, they went public before they had even completed construction of their nursing homes, with prices at a huge premium to the rest of the market.
Governance and Sanctions
1776 1799: One of the first acts of that government in 1776 was to authorize pensions for disabled Revolutionary War veterans. The initial military pension law offered half-pay for the rest of their lives to soldiers who were so disabled in the war that they were unable to work for a living. 1800 1899: California passed the first state old-age assistance law in 1883. In 1883 a law had been passed giving money to anybody over sixty who was in need. It provided no system of administration. It could be just given out by the counties and was an open end drain on the State Treasury. 1900-1929: Over time, conditions improved in the sanitariums as laws were changed and the government and medical community learned how to provide chronic medical care in institutional settings. The [Michigan] county sanatorium law of 1925 insures high standards and adequate financial support.
The standards require that a sanatorium have a minimum capacity of fifty patients, thus eliminating the old, small tuberculosis hospital that was often nothing more than a boarding-home or retreat for consumptives on county poor farms, where doors and windows were shut, and where medical treatment occasionally consisted of self-administered cough medicine. The institution must employ a full-time physician, provide modern X-ray equipment, have a graduate nurse as supervisor of the nursing staff, and must furnish patients with occupational therapy work. (Medical History of Michigan, 1930) 1940-1949: The Social Security Board drafted a bill Hill-Burton Act, which was introduced in 1943, by Senator Wagner and Senator James Murray of Montana and Representative John Dingell of Michigan. Hill-Burton created a system to provide federal financing for construction of new hospitals in rural and poor areas that did not already have them, and to modernize hospitals in metropolitan areas.
The sponsors did not want to create an uncontrolled explosion of buildings that werent needed, so the bill called for each state to develop an agency to organize and coordinate health planning for the state, and to determine where in the state hospitals ought to be built. 1950 1959: The Advisory Council suggested that these additional payments should be made directly to medical providers, rather than to the recipients. At that time, federal matching for state expenditures was only allowed for payments made directly to the assistance recipient. (Advisory Council, 1948)
Two years later, in 1950, amendments to the Social Security Act said, [The] Federal Government will share in cost of payments made directly to medical practitioners and other suppliers of medical services, which when added to any money paid to the individual, does not exceed the monthly maximums on individual payments. In 1956 the Social Security Act was again amended to eliminate that cap. 1960-1969: Although President Kennedy had not been able to get majority support for a national health insurance program while he was alive, after he was assassinated the programs he had been espousing took on new life. Medicaid was created from the Kerr-Mills program, and it kept many of the aspects of KerrMills, but added new categories of eligible beneficiaries, like the blind, the disabled, and families with children.
Because Medicaid was to be a state-run program and no one had thought through what the federal government wanted to accomplish, Medicaid was just turned over to the states to develop and administer as they saw fit, and the states proceeded to create 50+ varieties of Medicaid. By 1968, ECF costs were up to $500 million, and HEW decided drastic action was required to scale the program back. They distributed Intermediary Letter 371, which listed a number of required services which had never before been required and warned the insurance companies that administered the program (the intermediaries) that they should err on the side of denying, rather than approving, Medicare claims. Medicare denial rates shot up more than 600% between early 1968 and early 1970.
PROFILE OF CURRENT MARKET PRACTICE
Government: The Government is exploring all avenues to provide Health care (Medicare and Medicaid), as such it explore all possibilities that will help to bring down the cost of rendering the service to its citizen. The current situation allows such that Government intends to provide affordable health care to all. The use of E-health is promising driver that will help achieve this as well as reduce cost significantly.
Health Insurance Providers: Health insurance companies are like creditors for health care. This enables more capital to be used for research and development within patient care, medication, and bio technology equipment. In essence, they are a business, whose design is to make money. They want providers to follow clear, evidence based, diagnostic plan and reach an accurate diagnosis and treatment plan with the fewest visits and least number of tests.
Health Care Service Providers: Health and service providers tend to benefit immensely from this system of health delivery. With the help of technology, this is a better visibility of patient remotely. Doctors can proactively managed Patients illness via this method whenever signals are received. Likewise, health insurance and technological service companies can make quicker decisions.
Employers: Employers want to maintain or lower their cost contribution. They want the patient/employee to seek only needed care, follow providers instructions, and recover quickly to full utility. Patients should also seek to reduce their health risk behaviors, i.e. diet, exercise and smoking cessation.
Consumers: The growing cost of health care disenfranchises patient from getting the required treatment, since every hospital visit is associated with a cost. Aside from reducing cost, the wait time of seeing a doctor or nurse is reduced or eliminated in most cases and the patient enjoys some convenience as well as members of the family since the patient can be evaluated remotely at home.
Technology Providers: They deliver comprehensive solutions that enable hospitals, health systems and other providers to use IT more strategically for better business, better care and better connectivity. Their capabilities extend beyond EHR and other healthcare IT software solutions to include automation and robotics, enterprise intelligence and analytics, supply chain management and other services that seamlessly connect healthcare providers, physicians, payers and patients across all care settings.
Assessment of Market Pathologies
The United States is a world leader in healthcare services and an innovator in cutting edge diagnostics and treatments. U.S. hospitals, academic medical centers, clinics and laboratories provide sophisticated, technologically advanced care and serve as a platform for biomedical innovation. The United States has the largest healthcare services market in the world, representing a significant portion of the U.S. economy. The industry is supported by a highly skilled and well-trained workforce that includes specialized physicians, nurses and technicians, and is backed by a strong private-sector health insurance industry that provides patients with choices for their medical care.
Connections between the healthcare services industry and the biopharmaceutical and medical device industries also represent additional sources of growth and innovation.
US E-Health Technology Industry: The United States leads the world in the production of medical technologies and is the industrys largest consumer. The market was valued exceeded $100 billion in 2010, representing about 40 percent of the total medical technologies industry. The term can encompass a range of services or systems that are at the edge of medicine/healthcare and information technology, including:
Electronic health records (EHR): enabling the communication of patient data between different healthcare professionals (GPs, specialists etc.); Telemedicine: physical and psychological treatments at a distance; Telemedicine is the stage where a guided self-medication practice is given to the Patient for selfadministration Consumer health informatics: use of electronic resources on medical topics by healthy individuals or patients; Health knowledge management: e.g. in an overview of latest medical journals, best practice guidelines or epidemiological tracking (examples include physician resources such as Medscape and MDLinx);
Virtual healthcare teams: consisting of healthcare professionals who collaborate and share information on patients through digital equipment (for transmutable care); mHealth or m-Health: includes the use of mobile devices in collecting aggregate and patient level health data, providing healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vitals, and direct provision of care (via mobile telemedicine); Medical research using Grids: powerful computing and data management capabilities to handle large amounts of heterogeneous data. Healthcare Information Systems: also often refer to software solutions for appointment scheduling, patient data management, work schedule management and other administrative tasks surrounding health.