The Promise of Digital Health and the Privacy Perils – HealthConsuming Explains, Part 4

The supply side of digital health tools and tech is growing at a hockey-stick pace. There are mobile apps and remote health monitors, digital therapeutics and wearable tech from head-to-toe. Today in America, electronic health records (EHRs) are implemented in most physician offices and virtually all hospitals. Chapter 5 of my book, HealthConsuming: From Health Consumer to Health Citizen, details the promise of digital health: wearable, shareable and virtual.

Today, we can also call on Alexa to remind us to take medications, play nostalgic music when we are lonely, check our physical activity status with Fitbit, and query WebMD about a symptom. Just last month, Amazon announced HIPAA-compliant privacy bundled into Alexa skills with Atrium Health, Boston Children’s Hospital, CIGNA, ExpressScripts, Livongo, and Swedish Health Connect.

Broadband connectivity, cloud computing, data analytics and well-conceived artificial intelligence (AI) enable the use of data generated from digital health tools to benefit our health. Increasingly, as connectivity gets to each of us wherever we live, work, play, and learn, and sensors shrink and lower in cost, we can do more self-care at home and in lower-cost venues to help bend that stubborn medical cost curve. This is a health economist’s Holy Grail, and my vision for the home-as-health-hub which is my end-image in HealthConsuming.

As I walk the miles of aisles at the annual CES, I track ten technology categories that can support this paradigm, covering more mature digital health tech like WiFi weight scales and personal emergency response systems to the growing Internet of Things ecosystem for smart and connected homes and cars, an emerging third space for health that Honda, Mercedes, Toyota, et. al., are concepting, which I wrote about back in 2007 focusing on Toyota’s wellness car concept.

Promising, promising.

With every one of these digital health encounters, from Alexa to Zipongo, a bit of data is created. It’s personal stuff, and it’s a tiny little bit about “you.”

All that digital dust can be collected, mashed up and built into a personal profile for your benefit, or for other reasons. The graphic is based on work done by Juhan Sonin of GoInvo, a group that does brilliant work on health data design that’s vigilantly people-focused. GoInvo has been working for a long time on how to communicate health and healthcare data in enchanting ways.

Juhan and another person first shaped my views converging the promise of digital health data through enchanting design, and the perils of Big Data algorithms. Juhan for the former lightbulb moment; and for the latter, Fred Trotter. I interviewed Fred for research I was conducted on behalf of the California HealthCare Foundation (CHCF) in 2014.

For CHCF that year, I wrote Here’s Looking at You: How Personal Health Information is Being Tracked and Used, I took cues from a 60 Minutes‘ profile of third-party data brokers and Latanya Sweeney’s groundbreaking research at the Harvard Privacy Lab. Latanya found that just a few data points — which fell out of HIPAA-privacy protected flows — could re-identify a person with, say, HIV positive status, a mental health DSM-code, or degenerative disease.

Five years later, patients still share their personal health information on Facebook groups, with the promise of crowdsourcing cures, accessing support and advice, and finding community.

As a WEGO Health poll of patient activists found in April 2019, patients continue to share this very intimate data, even in the wake of the Facebook/Cambridge Analytica story, growing cybersecurity breaches of medical data, and a challenging environment for trust and “fake news” for health care.

In researching the thorny privacy issues for HealthConsuming,. I learned the phrase “a concerned embrace of technology” from Deloitte’s 2017 survey of U.S. mobile consumers. Deloitte found that 80% of consumers believed that companies were using their personal data and that their data wsa being shaerd with third parties. But people were williong to share “some” online data (like name or email address), less willing to share health metrics using a phone or wearable device — only 7% of people willing to do that in 2017 based on this poll.

So “concerned embrace” for health means that trust is the enabling bridge between digital health connections and peoples’ willingness to share data — underpinned by stronger privacy protections and true data ownership for each person. Through that ownership and control, people could monetize their own data and treat it as the personal asset it truly is.

This is the plotline between HealthConsuming‘s Chapter 5 on the promise of “Digital Health: Wearable, Shareable, Virtual” and Chapter 6 on “Privacy and Health Data In-Security.”

Tomorrow will be my fifth and final post in this week’s series outlining HeatlhConsuming: From Health Consumer to Health Citizen, focusing on the last two words in the title. Can and will Americans take on the role of health citizens, with health care access as a civil right and full privacy protections, coupled with the responsibilities for self-care and health engagement, and the civic responsibility to vote and engage in civil discourse? We’ll round out this journey in tomorrow’s Health Populi.

That’s the argument for health citizenship, our topic for tomorrow’s #5 of five posts plotlining HealthConsuming: From Health Consumer to Health Citizen, all this week in the Health Populi blog.

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What We Know We Know About ZIP Codes, Food, and Deaths of Despair – HealthConsuming Explains, Part 3

“There’s a 15-year difference in the life expectancy between the richest and poorest Americans.” That’s the first sentence of Chapter 7 in my book, HealthConsuming: From Health Consumer to Health Citizen.

This data point comes from research published in JAMA in April 2016 on the association between income and life expectancy in the U.S. (That’s endnote #399 in the back of the book, one of 519 notes I use to support the plotline).

Today, the Brookings Institution convened a meeting on the funding for social determinants of health to address disparities, costs, and quality of healthcare in America. The overall theme is about building healthy neighborhoods through cultures of health with touchpoints of housing, nursing and local health workers, public libraries, grocery stores, schools, “third places” (beyond home and work, like a retail store for mental health meet-ups or online social networks) and, indeed, hospitals that bolster community health.

Chapter 7 of my book, HealthConsuming: From Health Consumer to Health Citizen, is titled, “ZIP Codes, Genetic Codes, Food and Health.” The plot begins with the importance of “place,” our personal physical geographies and what they portend for our individual health — beyond our genetic code and inherited health risks. As the JAMA article notes, “The differences in life expectancy were correlated with health behaviors and local area characteristics.”

This graphic on SDoH comes out of the book, illustrating the many external factors that influence personal and community health: among them, food, job security, education, environment (think: clean air if you live in Los Angeles, clean water if you live in Flint, Michigan), job and income security, and safe and green spaces among them. While not traditionally called out as a social determinant, I’ve added in broadband connectivity (with net neutrality baked in) as an influence on health and wellness, as well.

To introduce the ideas in each chapter of the book, I ask big hairy “What If?” questions that I endeavor to answer. Here, I wonder, “What if… America reduced health disparities, increased health equity, and our ZIP codes didn’t determine our health outcomes and life expectancy?”

The shocking reversal of life expectancy in the U.S. has been termed the “deaths of despair” by the brilliant researchers Anne Case and Sir Angus Deaton who are based at Princeton University. Their latest work on the phenomenon has revealed the role that (less) education plays as a risk factor for shorter lifespans, which I discuss in HealthConsuming as a tragic feature in U.S. public health — uniquely American versus the rest of the developed world. Opioids and social isolation (read the book Bowling Alone for more insights) contribute to this reversal-of-longevity.

“There is mounting evidence that some of these [SDoH] initiatives are associated with improved health outcomes and reduced health care utilization,” a report from Deloitte asserted in a new report on social determinants of health published this week. The growth of public sector incentives in Medicare for social supports, and growth of value-based payment in commercial plans, are forces nudging health care providers toward bundling SDoH services into targeted programs. The graphic from the Deloitte study illustrates a few of those strategies, including multi-tasking social needs, referring people to services with high-touch, partnering in the community with service providers, and monitoring and tweaking the SDoH interventions in a continuous-improvement mode.

This seventh of eight chapters of HealthConsuming concludes: “Our communities are our local health ecosystems. Centuries’ worth of evidence, from Hippocrates in Athens, Greece to
Geisinger Medical Center in Danville, PA, shows us that how we live, the daily choices we make or are constrained from making, and the built and natural environments we live in shape our health well beyond the local doctor and hospital do.”

As U.S. policymakers are in the throes of designing an infrastructure bill allocating $trillions of taxpayer dollars, they should be mindful of “baking” social determinants of health into the plans. This concept is recommended in the last chapter of HealthConsuming as the plot moves to the question of whether health consumers will emerge as health citizens in America.

Tomorrow, we’ll focus on the promise of digital health and the perils of privacy. Digital platforms and tools can help scale social determinants to people who need services. But without privacy protections that address our current reality of how we live and share online, the best-designed technology won’t be effective, or worse…could exacerbate already-challenged health outcomes and disparities.

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How much would Medicare for all cost?

Health Consumers Are Now Amazon-Primed for Healthcare – HealthConsuming Explains, Part 2

As patients now assume the role of health consumer, they rationally expect retail-level experiences with greater first-dollar payment for health insurance, health care services and medical products like prescription drugs.

Consumers know what good retail looks and feels like, and are focusing that experiential lens on health care, Aflac found when their Workforces Survey polled Americans on what they’d like their health insurance shopping process to feel like. One in two people said, “like Amazon,” and another 20% of folks said, “like retail.”

Chapter 3 of HealthConsuming is titled, “How Amazon Has Primed Health Consumers,” and explains this re-shaping of patient expectations. Here’s one of my paragraphs from the chapter, noting that, “Health consumers are hungry for Amazon’s brand of transparency, convenience, and streamlined interactions for medical care. The Amazon Prime-ing of the U.S. consumer has raised peoples’ expectations of what health care services could be: personalized, customized, anticipatory, immediate or on-schedule, and convenient – where we live, work, play, pray, learn and even drive.”

People trust Amazon for daily retail experiences. The bar chart from research by Market Strategies shows that a plurality of consumers also trusts Amazon to try on for healthcare products and services. The company has been multi-tasking a broad range of tactics throughout the health care ecosystem. Every publicly traded market segment Amazon has touched has had moments of shattering stock prices.

In the past couple of months, Amazon announced many health-related plans and developments, including:

• Accepting medical and health savings accounts (HSAs) to pay for consumer health products like over-the-counter drugs.
• Developing Alexa-skills that are HIPAA-compliant to bolster users’ personal health information privacy collaborating with Atrium Health, Boston Children’s Hospital, CIGNA, Express Scripts, Livongo Health, and Providence St. Joseph Health. In each instance, the developer organizations see voice as the next frontier for conveniently accessing health care services.
• Marketing PillPack, the subscription prescription drug service, to consumers, with the subtext that this may be Amazon Prime-eligible.
• Naming the Amazon-JPM-Berkshire Hathaway venture in health care organization “Haven,” and announcing plans to hire staff in New York City.
• Expanding Alexa skills to join the growing tele-mental health supply side.
• Launching a private label skin care line, Belei, covered in Allure magazine here. (The name is a combo of “believe” and “beauty,” and the disruptive ingredient with this beauty brand is that no product exceeds $40.

Jim Cramer of CNBC’s Mad Money has been studying up on digital health, recently recommending that Apple buy Epic, the health IT behemoth. (See more on that recommendation, and subsequent social media frenzy, here on Health Populi). This month, he recommended that companies and investors need to study Amazon as a sort of “Death Star” in how the company re-defines industries — whether movies or music, retail or….health care.

For health consumers, Amazon’s multi-tasking efforts are re-shaping health care service delivery and channeling.

Most importantly, in this immediate moment, Amazon has re-shaped patients as health consumers — our expectations for what is possible in health care delivery, price transparency, peer-to-peer advice, and convenience.

In tomorrow’s Health Populi, we’ll dive into a third key theme in HealthConsuming: that’s what we know-we-know about ZIP codes, food, deaths of despair, and the social determinants of health. Where we live portends how healthy we are…and why spending on social care is key to addressing health and longer life spans…the personal health version of surviving a death star.

On Thursday, my post will raise Amazon’s role in health/care again, looking more deeply into the promise of digital health and the perils of privacy for health, retail, and other personal data. Amazon isn’t just about convenient delivery of health care “things.” It’s about the data generated by those transactions, which help to construct profiles on you and me. Using such profiles can be very helpful for health, if that’s the intent of the data-miner. But as the Financial Times pointed out today in an op-ed written by its editorial board, “Platform companies from Amazon to Google to Apple are getting deep into the healthcare field, allowing us to do everything from communicate with doctors to check on prescriptions. The privacy implications are troubling….they are [also] surveilling consumers at the same time — gathering, analysing and, in many cases, selling sensitive data. In many countries, personal healthcare data are subject to strict regulation. In the US, the Health Insurance Portability and Accountability Act (HIPAA) imposes criminal and civil penalties for breaching confidentiality of healthcare data. But the rules apply only to entities covered by HIPAA such as healthcare plans and providers, or clearing houses that process healthcare claims.”

Stay tuned to tomorrow’s post, on social determinants of health and social spending. By Friday, the dots will converge on the topic of morphing from health consumers to health citizens.

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Sedation Dentistry – Your Ultimate Guide

There are a number of reasons that adults—grown adults—avoid trips to the dentist. 

 

According to the American Dental Association, over 17% of people admit they avoid going to the dentist due to anxiety. And this “demotivator” is right behind the very real inability to pay for dental services that leaves millions of patients avoiding appointments each year. There are still others who have special needs or who are facing complex dental procedures, which result in fear or apprehension when faced with a visit to the dentist. 

 

If you or a family member—even children—can identify with any of these issues, then it might be worthwhile to consider if sedation dentistry is right for you. Don’t let the word “sedation” cause more anxiety, though! This option is a safe and gentle for almost all ages. Keep reading as we break down the types of sedation available as well as the groups of patients who may be best served by sedation dentistry.  

 

What is sedation dentistry? 

 

Sedation dentistry offers patients relief from anxiety and pain and ensures a pain–free procedure—many times without any memory of the appointment. While many complex procedures are performed with some form of anesthesia, it is possible for general cleaning to also take place under sedation for those patients who suffer from severe anxiety. 

 

There are several levels of sedation we use, all depending on the complexity of the procedure. The American Dental Association, in conjunction with state guidelines, offers a set of best practices for the administration of local anesthesia, sedation, and general anesthesia. Your dentist will decide which level of sedation is best for you. Below is a breakdown of the varying types of anesthesia typically used: 

 

• Nitrous oxide: This is the most common form of sedation, and while it doesn’t put you all the way to sleep, it can reduce anxiety during a dental procedure. More commonly known as laughing gas, nitrous oxide is combined with oxygen and administered through a mask that is placed over the nose. This sedative can wear off quickly, so your dentist will actively monitor your anxiety and pain levels throughout the procedure.

  Another benefit of nitrous oxide is that you can drive yourself home after the procedure. This is a good option for your bi-annual appointment or for less invasive procedures.  

 

• Oral sedation: Also known as enteral sedation, this option encompasses all types of sedation that come in pill or liquid form. This option is helpful for easing nerves prior to getting to your appointment. Many times, this option is used in conjunction with nitrous oxide. Typically, the prescribed pill is Halcion, which is a member of the same drug family as Valium and is taken about an hour before the procedure.

  This pill will make you drowsy, though you’ll still be awake. A larger dose may be given to produce moderate sedation. Depending on the dose, you might fall asleep during the procedure. 

 

• IV sedation: This type of sedation will put you in a deeper level of sedation, rendering you totally unaware of what is happening around you. While technically still awake, most patients report no memory of what happened during a procedure.

  And, just like with nitrous oxide, your dentist will continuously monitor your level of sedation through the procedure and adjust it as necessary. 

 

• General anesthesia: This is the deepest level of sedation and should only be performed by highly–qualified practitioners in appropriate settings. This type of sedation is used most frequently for patients with special needs or who require the most complex dental treatments.  

 

Who’s eligible for sedation dentistry? 

 

Anxious patients 

 

As mentioned, dental anxiety is a highly present issue among adults. If you suffer from dental anxiety, but have trouble articulating your fears with your dentist, your provider might choose to utilize the Corah’s Dental Anxiety Scale. Developed in 1969, this four question survey allows patients to choose from five answers. Each answer corresponds with numerical score. The total score allows the dentist to determine how anxious you are about the appointment.  

 

Another assessment tool is the Modified Dental Anxiety Scale. This survey consists of five questions, each with a five-category rating scale, ranging from “not anxious” to “extremely anxious.” One difference in this survey is that it has an extra item about the respondent’s anxiety to a local anesthetic injection as well as the dental procedure itself. 

 

Based on the results of the survey, your dentist may recommend sedation as part of your treatment.  

 

Special needs patients 

 

The special needs population is diverse and has a wide range of dental needs. Due to this, the reasons for the use of sedation dentistry are equally varied. Not only does this influence the type of anesthesia used, it also makes an impact on how the anesthesia is introduced.  

 

For instance, special needs patients may have physical limitations as well as intellectual disabilities, each of which are vital components that are taken into consideration. One common example of special needs dentistry is serving those with autism. Since the dentist’s office can present an array of sensory challenges such as new tastes, smells and textures, sedation can offer a calmer experience. If you or your child have special needs, have a conversation with your dentist ahead of time to discuss options to make the patient most comfortable.  

 

Complex procedures 

 

Finally, some dental procedures can take several hours to complete. Since many patients would prefer to be in the chair for the least amount of time possible, they choose to break these procedures into multiple visits. However, sedation density allows patients to calmly complete complex procedures in a single visit. For example, patients who need extensive rebuilding procedures or multiple cavities filled at one time may be good candidates for sedation dentistry.  

 

Are there risks to sedation dentistry? 

 

As with any procedure, it’s important to discuss with your dentist if you are a good candidate for sedation dentistry. For those with sleep apnea or adverse reactions to anesthesia, it’s important to discuss your medical history with your dentist prior to any procedure.  

 

Finally, everyone reacts differently to the different medications used for sedation. This includes how much is needed for complete sedation as well as any adverse feelings upon “coming to.” If you are concerned about how you may react, make sure to ask your dentist prior to your appointment. 

 

Sedation dentistry has the ability to transform the practice of dentistry for those that avoid it due to anxiety or fear of pain. If you are interested in what Dr. Ku’s office has to offer, give us a call today!  

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Patients Become Healthcare Payors, Now Consumers – HealthConsuming Explains, Part 1

We Are All Health Consumers Now. That’s the title of the first chapter of my new book, HealthConsuming: From Health Consumer to Health Citizen. I start this chapter quoting President Ronald Reagan in 1983, who recognized that health care costs were growing at three times the rate of inflation during the first term of his Presidency.

It’s déjà vu in health care all over again, but 35 years later, it’s the patient now facing sticker-shock with first dollar payments in high-deductible health plans, six-figure prices on specialty drugs to treat cancers, and a poor return-on-investment for personal health spending.

Thus begins my journey, with you the reader, explaining how patients-as-payors, now nudged into the role of consumer, could morph into health citizens: with rights to health care, bolstered privacy protections; more care in the community and at home to boost quality and safety and reduce costs, and, more opportunity and responsibility for self-care.

In the Health Populi blog this week, I’ll take each weekday to explain one part of this story: the patient-as-payor, now consumer; how Amazon has primed health consumers, with informed retail service expectations; what we know about ZIP codes, food, deaths of despair and the social determinants for health; the promise of digital health and perils of privacy; and finally, whether health consumers in the U.S. can/will emerge as health citizens. All of these themes are backed up by 519 endnotes in the back of the book, as I connect the dots of the rich evidence base for telling this story.

First, let’s explore the scenario-reality of the patient-as-payor, now consumer. This is a contentious issue, debated from my admired economist-guru Paul Krugman in the New York Times in 2011 when he contended that patients weren’t consumers; to last week in Medscape, when bioethicist, and another admired thinker, Dr. Art Caplan, echoed the same.

Health Affairs covered this topic, too, last month, which I discussed here in Health Populi.

The data, though, demonstrate the growing adoption of high-deductible health plans, co-payments and coinsurance for health plan members. When people face first-dollar out-of-pocket spending, they are assigned the role of consumer in choosing to spend that money out of household budgets. The latest research from the Bureau of Labor statistics is that on a median household basis, 20% of spending goes to healthcare.

That’s the immediate situation for real people facing real diagnoses, today and tomorrow, in 2019.

“Today’s high deductibles are tomorrow’s bad debt,” a Moody’s analyst recently wrote. This starts the theme of the second chapter — The Patient is the Payor.

Health care costs stress out people at all income levels in the U.S., according to the American Psychological Association‘s annual study on Stress in America. And this goes, too, for people both uninsured and insured. This isn’t a new-new finding: even families earning over $90,000 a year cited health care costs as their #1 pocketbook issue, a Kaiser Family Foundation study learned in 2015.

This sets the stage for understanding how patients, now consumers, paying more directly for health care in deductibles and OOP expenses are, justifiably, expecting greater service, experiences, value and return-on-investment from th ehealth care industry. Welcome to the next section of HealthConsuming, the Amazon-Prime-ing of health consumers, in tomorrow’s Health Populi blog,

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Will you be able to afford senior housing when you get old?

As the U.S. ages, more and more individuals have chronic conditions or functional limitations which may at some point require senior housing, such as independent or assisted living facilities and nursing homes. The question is, will individuals be able to afford this type of housing? According to a paper by Pearson et al. (2019), the answer for most people the answer will be ‘no’.

…by 2029 there will be 14.4 million middle-income seniors, 60 percent of whom will have mobility limitations and 20 percent of whom will have high health care and functional needs. While many of these seniors will likely need the level of care provided in seniors housing, we project that 54 percent of seniors will not have sufficient financial resources to pay for it.

The authors come to this conclusion by projecting future chronic conditions, functional limitations and income levels trends derived from the Health and Retirement Survey (HRS). Note that assisted living costs about $44,400 on average per year and costs have risen over time. Perhaps surprisingly, it may not be the poor who will not be able to afford senior housing, but instead middle income individuals may the ones get squeezed.

Seniors housing operators and investors have largely focused on the upper end of the income distribution. For lower-income people, state and local programs provide housing and care services via means-tested programs such as Medicaid… Although some middle-income people are living in seniors housing, the industry has not primarily focused on this cohort. This income group is generally too wealthy to qualify for public means-tested programs, yet not wealthy enough to pay the costs at many seniors housing communities for a sustained period of time.

The decrease in employer use of pensions and under-saving by employees through 401(k) options, make this issue even more acute.

Source:

• Caroline F. Pearson, Charlene C. Quinn, Sai Loganathan, A. Rupa Datta, Beth Burnham Mace, and David C. Grabowski. The Forgotten Middle: Many Middle-Income Seniors Will Have Insufficient Resources For Housing And Health Care Health Affairs.

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