What to expect in 2019

Here’s a brief summary of some leading thinkers thoughts about what to expect in 2019 in health. Have a health and happy New Year!

• Cleveland Clinic top 10 innovations of 2019.
• BBC gives 6 things to look out for in health in the UK in 2019
• HealthExec‘s top 10 challenges for 2019.
• Forbes Top 8 Predictions for 2019.
• Health IT Analytic‘s Top 5 Predictions for 2019.
• CNBC health market 2019 predictions

And looking back…

• CNN‘s top health stories of 2018.
• Committee for a Responsible Federal Budget‘s top fiscal charts of 2018.

What to expect in 2019 posted first on http://dentistfortworth.blogspot.com

FDA sets standards for Real-World Evidence

The 21st Century Cures Act, enacted December 2016, mandated that the FDA consider how to use real-world evidence (RWE) to bring innovative treatments to market faster. To meet this statutory requirement, the FDA has provided guidance outlining its policies for using RWE to support the approval of a new drug indication.

What is real-world evidence?

The document starts out by differentiating between real-world data (RWD) and RWE.

• Real-world data: data relating to patient health status and/or the delivery of health care routinely collected from a variety of sources, such as EHR, claims data, patient registries, patient-generated data,
• Real-world evidence: the clinical evidence about the usage and potential benefits or risks of a medical product derived from analysis of RWD.

Existing applications of RWE at the FDA

The FDA notes that real-world evidence is already helpful for informing clinical trials (e.g., by generating hypotheses to tests, biomarker identification, informing a prior in Bayesian statistical models, informing patient characteristics for enrichment or stratification, or identifying geographic areas to recruit people for clinical trials), but this use for RWD and RWE is already well-established.

The FDA has used RWE to inform drug safety (e.g., through the Sentinel system), but use of RWE to support treatment effectiveness is generally limited to oncology or rare disease single arm trials, which require supportive RWE on response rates from chart reviews.

New applications

However, FDA is looking to expand the use of RWE to measure treatment effectiveness in some cases:

Specifically, FDA’s RWE Program will evaluate the potential use of RWE to support changes to labeling about drug product effectiveness, including adding or modifying an indication, such as a change in dose, dose regimen, or route of administration; adding a new population; or adding comparative effectiveness or safety information….The RWE Program will involve the establishment of demonstration projects, engagement with stakeholders, the use of internal processes that bring senior leadership input into the evaluation of RWE and promote shared learning and consistency in applying the framework, and the development of guidance documents to assist sponsors interested in using RWE to support their work.

The FDA indicated that its experience using EHR data to inform drug safety (Best Practices for Conducting and Reporting Pharmacoepidemiologic Safety Studies Using Electronic Healthcare Data) will inform it’s use of EHR data to inform drug effectiveness. They plan to issue future guidance building on this document to show how to use EHR data to measure drug effectiveness.

While claims data and EHR data are well-known data sources, they typically do poorly in measuring treatment effects on quality of life. Alternatives the FDA will consider in the future include the use of: mobile technologies, electronic patient reported outcome tools, wearables, and biosensors.

Single arm trials are sometimes needed for rare diseases or to avoid ethical issues. One alternative approach to a randomized controlled trial is to pair a single arm trial with a synthetical control based on RWD. FDA is exploring this option, but challenges exist because: (i) populations may not be comparable, diagnostic criteria or outcomes may not be equivalent, differences in how outcomes are assessed, and variability in follow-up procedures. The only statistical method the mention for addressing any of these issues, however, is propensity score matching; other statistical approaches for determining causal inference–such as regression discontinuity or instrumental variables–were not mentioned in the document.

Observational studies could be used to measure drug effectiveness.

FDA intends to evaluate multiple questions of interest that could affect the ability to draw a reliable causal inference, including, for example, the role of existing evidence (e.g., the natural history of the disease) and how the inclusion of a more diverse population can result in a heterogeneity of treatment effects making it difficult to detect smaller effect sizes.

Clearly, the key issue with observational studies is causal inference, and dealing with unmeasured confounders. Also determining the validity of the data, and identifying any necessary sensitivity analyses and statistical diagnostics will be key. Like a clinical trial, the FDA would likely mandate that a study protocol be posted before the study is executed. A website analogous to ClinicalTrials.gov could be considered, or stakeholders could even be required to post their study protocols to ClinicalTrials.gov. The ISPOR-ISPE guidelines on best practices for measuring real-world effectiveness could serve as key foundational guidelines for FDA to follow.

Next steps/Additional guidance to be issued

What will the FDA do next? They are developing guidance on the following topics:

• Use of EHR to measure drug effectiveness
• Potential gaps in RWD sources and strategies to address them
• Design of clinical trials that include pragmatic design elements (e.g., recruitment/enrollment, intervention approach, outcome assessment)
• Use of RWD to generate external control arms
• Observational study design using RWD, and whether and how these studies could inform regulatory decisionmaking
• Whether existing guidance documents regarding use of electronic source data (e.g., informed consent for electronic data guidance) can be applied for RWD

FDA is also increasing stakeholder engagement both internally–by creating a RWE Subcommittee of CDER’s Medical Policy and Program– and externally through public meetings convened by the Duke Margolis Center and workshops with the National Academy of Sciences, Engineering and Medicine

FDA sets standards for Real-World Evidence posted first on http://dentistfortworth.blogspot.com

Nurses are the most trusted profession in America, followed by doctors and pharmacists

Nurses rank top in Americans’ minds for the seventeenth year-in-a-row, Gallup found in its annual survey of honesty and ethics in professions.

At the bottom of the list for honesty and ethics in 2018, Gallup points to U.S. Congressional representatives, “Mad Men” and Women of advertising, telemarketers, and folks who sell autos.

Congress-folk and car salespeople have ranked at the low-trust bottom for many years in this Gallup poll.

While the 3 health care professions rose once again to the top of the job-trust roster, nurses rank far greater than doctors and pharmacists by a 17-point margin of consumers rating the nursing profession with very high or high ethics (among 84 percent of all Americans). Doctors and pharmacists were virtually tied with two-thirds of U.S. consumers saying they rank very high or high on the honesty scale.

Note that last year, pharmacists dipped to an historic low in this poll, compared with a high bar set in 2013. Gallup conjectured that in 2017, some consumers were associating pharmacists with contributing to the opioid addiction crisis (that discussion covered here in Health Populi).

Gallup also notes that journalists’ ranking improved by 10 percentage points since 2016, while clergy’s perceived honesty and ethics have continued to decline over the past twenty years.

Health Populi’s Hot Points:  It cannot be overstated that nurses in America are the most beloved profession in and outside of the health care industry.

As the sector learns how to be more consumer and patient focused for customer experience, health care providers would be wise to leverage this highly-valued touch point. Whether in face-to-face health care, virtual/telehealth modes, or call centers, patients love and appreciate nurses.

“Nursing is at the heart of health care,” the 2018 National Council of State Boards of Nursing report on nursing supply in 2018 attested. But as beloved as nurses are, there is a shortage projected as Boomers age and, at the same time, there aren’t enough faculty to teach nursing students. As a result, over 64,000 qualified nursing school applicants were turned away from colleges in 2016 according to the American Association of Colleges of Nursing.

Nurses are indeed priceless – illustrated, literally, by the 2015 sale at Christie’s auction house of Roy Lichtenstein’s 1964 painting of a nurse for $95.4 mm. She looks concerned about the future of her profession, given the projected shortages. Let’s show nurses the love people feel for them by ensuring their human capital is rewarded based on the value they create in U.S. health care.

 

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Nurses are the most trusted profession in America, followed by doctors and pharmacists posted first on http://dentistfortworth.blogspot.com

2018 Demographic Trends

Continuing my series highlighting key trends from 2018, I summarize a post from Aviva Rutkin of The Conversation identifying key demographic trends in 2018. These include:

1. Decreased U.S. life expectancy. For the third year in a row, life expectancy fell in the U.S. The reason for the increase? Increased mortality rates among working age adults due to overdoses from opioids and other substances, as well as increased mortality due to cirrhosis, suicide and homicide.
2. Fertility declines.  The national fertility rate fell by 2 percent, to 1.76 children per women in their lifetime. This fertility rate is the lowest in 30 years. According to the CIA World Factbook, the U.S. is 143 out of 224 countries in fertility; Singapore (0.83), Taiwain (1.13), Hong Kong (1.19), Puerto Rico (1.22), and South Korea (1.26) have the lowest fertility, while Niger (6.49), Angola (6.16), Mali (6.01), Burundi (5.99) and Somalia (5.80) have the highest fertility rates.
3. Americans are getting old. While it’s true at an individual level everyone gets old, as a society America is greying. The average age in the U.S. has increased from from 28 years old in 1970 to 38 in 2016. Again citing the CIA World Factbook, the oldest large countries are Japan (47.3), Germany (47.1), and Italy (45.5); the youngest Niger (15.4), Mali (15.8), and Uganda (15.8). For comparison, Canada is even older than the US (average age 42.2), whereas Mexico is younger (28.3).
4. The end of rural America. Clearly an overstatement, but we do see a dramatic long-run transition of individuals moving from rural ares to urban and suburban areas. Whereas 94% of individuals lived in rural areas in 1900, this was only 60% by 1900 and 19% by 2010.

2018 Demographic Trends posted first on http://dentistfortworth.blogspot.com

Is the hospital readmissions reduction program bad for patients?

The answer is ‘perhaps’ according to a new paper by Wadhera et al. (2018). They use data from 2005 to 2015, and apply an inverse probability–weighted 30-day and 45-day post-discharge mortality measure stratified by whether there was an associated readmission. They examine admissions for acute myocardial infarction, heart failure, and pneumonia.

Among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for HF and pneumonia, but not for AMI…The overall increase in mortality among patients with HF and pneumonia was mainly related to outcomes among patients who were not readmitted but died within 30 days of discharge.

Hat tip: Marginal Revolution

Is the hospital readmissions reduction program bad for patients? posted first on http://dentistfortworth.blogspot.com

Costs, Consumerism, Cyber and Care, Everywhere – The 2019 Health Populi TrendCast

Today is Boxing Day and St. Stephens Day for people who celebrate Christmas, so I share this post as a holiday gift with well-wishes for you and those you love.

The tea leaves have been brewing here at THINK-Health as we prepared our 2019 forecast at the convergence of consumers, health, and technology. Here’s our trend-weaving of 4 C’s for 2019: costs, consumerism, cyber and care, everywhere…

Health care costs will continue to be a mainstream pocketbook issue for patients and caregivers, with consequences for payors, suppliers and ultimately, policymakers. Legislators inside the DC Beltway will be challenged by the newly-elected Democratic leader of House, Nancy Pelosi, and her party which has healthcare top-of-mind.

We know that a top issue driving American voters to the 2018 mid-term polls was health care, in at least two dimensions: direct costs to the voters (as patients and taxpayers); and, personal and collective concerns about losing coverage due to pre-existing conditions. More people became aware of that wonky term, taking it to heart and to the polls in 2018. Expect health care costs and access to be at least as important to U.S. voters through 2019, and on the Presidential debate stages for both Democrats and Republicans leading up to the parties’ nominees for 2020.

A key health care cost focus of Congress will target prescription drug costs. Expect pharmaceutical companies to raise prices in 2019 — “with a wink to Trump,” Bloomberg News characterized last week — prompting Congressional health care activists (particularly Democrats in the House) to come together on legislation and collaborate with President Trump on this issue which he promised would be a priority when he took office.

An example of legislation newly-crafted to hit the House floor in January 2019 comes from Elizabeth Warren (D-MA) in the form of the Affordable Drug Manufacturing Act. This bill would create a government-run drug company to produce and distribute generic medicines. In 2018, we also saw a response to high drug costs in the form of CivicaRx, a consortium of hospitals coming together to manufacture drugs in short supply at hospitals.

Employers will endeavor to artfully design consumer-directed benefit plans (CDHPs) that nudge insured workers toward healthier habits, while integrating a broader definition of wellness. There’s evidence that companies who cover health insurance are baking more financial wellness into a broader culture of health in the workplace, along with more attention to mental health. Greater awareness of the opioid epidemic, pain and financial stressors drive that trend, along with realization that student loan debt is very serious for both younger workers and, what may surprise you, Boomers who have taken on student debt on behalf of younger family members. Costs are also motivating employers to adopt telehealth coverage, en masse, and also behavioral economic designs to incentivize workers to access care in lower-cost settings like retail clinics, urgent care centers, and those Skype-type visits for care that don’t require a trip to the emergency department or bricks-and-mortar doctor’s office or hospital outpatient clinic.

Worries about health care costs, now crossing over into higher-earning households, underpins the growth of consumerism. It is difficult to behave like Rational Economic Man and Woman as a patient in the American health care labyrinth; but that doesn’t mean people aren’t exercising new muscles and choosing services delivered in newer, lower-cost sites. The retail pharmacy, for example, is a popular choice for receiving vaccines for flu and filling the childhood immunization schedule; and, the proliferation of web-based telemental health providers is providing an on-ramp for people to access behavioral health in a non-taboo, accessible mode.

We are also witnessing green shoots of understanding across the many layers of health literacy for:

• Personal health financial literacy, a greater appreciation among consumers about the tax benefits of conserving funds in a health savings account, and what “coinsurance” shares mean
• Digital health literacy, greater adoption of wearable tech and tracking apps, FDA-cleared devices that measure medical metrics like heart function, and people going online to sign up for health insurance
• Nutrition literacy, with more clinicians prescribing food and recipes to promote self-care and healthy eating for patients and their families.

Consumerism and payor pressure will grow the landscape for care, everywhere. As employers and commercial payors support the growing use of telehealth and virtual care among insured workers and plan enrollees, so too will patients-as-consumers choose to more frequently receive care in convenient places and, increasingly, at home. The home will begin to emerge, in a pioneering phase, as our health hub. Peoples’ growing adoption of voice assistants like Alexa is already providing a platform for health assistance at home, with skills for a range of self-care like medication adherence, mental health support (say, through music and humor), and healthy recipe suggestions.

Outside of the home, I note the growth of retail health options well beyond (but including) the retail pharmacy. The grocery store is an important destination for health and wellness, along with Big Box retail, schools, church, and other community-based locations where people can create health — where we live, work, play, pray, and learn. The new “front doors of healthcare,” a term smartly coined by Oliver Wyman’s team, will emerge from combinations of stakeholders, such as the CVS + Aetna combination, Walgreens allying with Humana for primary care and Verily (Alphabet, Google) on data-driven chronic care, Cigna + Express Scripts vertical integration, Walmart’s work with a long list of health/care players, Apple branching into health clinics and hiring physicians, and Amazon reaching across the entire ecosystem to cover the landscape. This list, and other names we’ll see creating on-ramps to primary care and self-care to the consumer, will expand in 2019.

We’ll see more edgy digital technologies that speak to sex, drugs, rock ‘n roll: real life, EveryMan and -Woman issues. As I finalize my meeting agenda for CES 2019, I see more invites to developers of techs for adult “toys” (a growing category of sexual health and wellness), mental health and mindfulness, addiction and substance use, and consumer breathalyzers. One new development I find both provocative, sobering and highly useful is the SipChip, a disc roughly the size of a casino chip, which embeds a diagnostic test to check if one’s drink is spiked with common date rape drugs [e.g., Flunitrazepam aka “Roofies,” Xanax, and Diazepam (Valium), among others]. This innovation was developed by a team of college students at NC State University to help stem the college campus epidemic of drug-facilitated sexual assaults.

Investment, too, will come from unexpected places. The announcement this week of Morgan Stanley’s capital influx into Medsphere, an EHR company, is a hint of what more is to come in 2019 as an example of investors’ expanded interest in health IT and new-and-improved healthcare services and business models.

Greater attention paid to the social determinants of health, by payors (both public in Medicaid and Medicare, and in private sector benefit plans) will promote peoples’ access to care, services and social support outside of traditional, legacy healthcare nodes. This will continue to put pressure on the margins and business models of hospitals and doctors’ practices.

To more effectively manage these tight margins, health care providers will continue their use of augmented and artificial intelligence to mine data from both traditional claims and electronic health records, combined with consumer-generated data from wearable tech, surveys, and third party data sources that collect information on social determinants of health, personal finance, and retail transactions.

As consumers take on more self-care through apps, remote monitoring at home, and using social networks for health, people are also becoming more aware of these interactions creating data points. So much of these data flows aren’t covered by HIPAA. At the same time, Americans are more aware of data privacy challenges in the post-Facebook/Cambridge Analytica era, and U.S. Congress’s greater attention to Big Tech’s privacy gaffes and gaps.

Cyber-security and personal data breaches are now front-page (or -screen) news in mass media, as people live lives online and share all kinds of daily experiences with friends and family. More people have come to realize that personal information shared online isn’t seen by “just” friends and family, and can be scraped and re-purposed by third parties. Personal data, too, gets breached — notably, quite frequently, in healthcare provider organizations. It turns outs that medical breaches are quite valuable to hackers, so the frequency and severity of cyber-hacks in healthcare will be  an ongoing phenomenon in 2019.

Don’t be surprised for a major hack in or closely adjacent to healthcare to occur in 2019 that could reach the scale of the Experian breach. This would prompt Congress, driven by Democrats and moderate Republicans, to propose more stringent privacy legislation which industry will try to rebuff. It will be a wild card whether sufficient voter pressure could motivate the Congress and President to usher in a U.S.-style GDPR (the General Data Protection Regulation promulgated in the European Union).

Health Populi’s Hot Points:  There is one hot point that’s most important on Boxing Day and, truly, Everyday. That’s that love is the killer app — and our positive social connections bolster our health. May you delight and thrive in those loving touch-points in your life, and be mindful of minimizing the negative ones.

Here’s to your health, to love, loving kindness, and peace in 2019. I wish you very well…

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2018 Feel Good Health Stories

• 25 million doses of a new cholera vaccine were administered globally, and preparations began for the largest vaccination drive in history. UNICEF
• France revealed a sharp fall in daily smokers, with one million fewer lighting up in the past year, and cigarette use among Americans dropped to its lowest level since the Centers for Disease Control and Prevention started collecting data in 1965.
• Rwanda became the first low income country to provide universal eye care to all of its citizens, by training 3,000 nurses in over 500 health clinics. Global Citizen
• India registered a 22% decline in maternal deaths since 2013. That means on average, 30 more new mothers are now being saved every day compared to five years ago. The Wire
• In 2018, New York and Virginia became the first two US states to enact laws requiring mental health education in schools. CNN
• South Africa, home to the world’s largest population of people living with HIV, shocked health officials by revealing a 44% decline in new infections since 2012. Telegraph
  

A selection taken from a story by Future Crunch.

2018 Feel Good Health Stories posted first on http://dentistfortworth.blogspot.com

What were the top health questions of 2018?

This list is according to Google searches, as reported by CNN:

1. What is the keto diet?
2. What is ALS disease?
3. What is endometriosis?
4. How long does weed stay in your urine?
5. How long does the flu last?
6. How long is the flu contagious?
7. When does implantation bleeding occur?
8. Why am I always tired?
9. What does heartburn feel like?
10. What causes high blood pressure?

What were your top questions for 2018? What topics do you want to see this site cover in 2019?

Wishing all my readers a very happy holiday season.

What were the top health questions of 2018? posted first on http://dentistfortworth.blogspot.com

Smile-Worthy Fort Worth Events!

School is out, and guests are in town for the holidays! What a ride. No matter the size of your house or how much you love you guests, the walls might start to feel like they’re closing in on you after a couple days.  

 

You’ll probably be ready soon to get out of the house! And while we know Fort Worth is brimming with activities for young and old, it can be hard to think of things to do or places to go when you’re put on the spot. It can also be difficult to bridge age gaps and preferences when choosing an activity. 

 

To help break the stalemate on decision making and to get folks off the couch, we have provided some of our holiday favorites in North Texas. Let us know if we forgot anything, because we’re sure others would love to crowdsource ideas! 

 

Gift of Lights in Fort Worth  

 

Ever dream of hitting the Texas Motor Speedway? Here’s your opportunity! Cruise around the raceway through the Gift of Lights and experience over 150 new light displays this year. At the end of the tour, explore Santa’s Village for family-friendly activities, including photos with Santa. Admission is $25 per car; however, if you bring an unwrapped gift for Toys for Tots, you’ll receive a $5 discount. The event benefits local charities and is open daily from 6pm-10pm. 

 

Historic Grapevine Light Displays 

 

There is a reason Grapevine is considered the “Christmas Capital of Texas.” With three different nights dedicated to decking the halls, there’s no reason to miss out on the excitement! While the Christmas tree lighting happened just after Thanksgiving, there is still time to catch the Parade of Lights and the Twinkle Light Boat Parade. The Parade of Lights in is the largest lighted Christmas parade in North Texas and will feature more than 100 lighted floats and marching bands! And if that isn’t enough, head to Lake Grapevine to watch boats decked out in holiday decor and lights parade from the Twin Coves Marina to Silver Lake Marina. Each event is free and open to the public.  

 

Panther Island Ice 

 

If you’re looking to work off some of the holiday treats that litter every surface, then ditch the tennis shoes for ice skates! Hitting the ice makes everyone feel like a kid again. Located at Coyote Drive-In, the Panther Island Ice rink is the only outdoor ice rink in Fort Worth. Bring your gloves for a great, family-friendly time! 

 

Enchantment Fort Worth 

 

Get lost in the world’s largest holiday maze that is based on the children’s book Eddie, The Mischievous Elf. While winding through the maze, hunt for lost presents and help Santa save Christmas! For the shoppers among you, peruse more than 100 local artists and businesses. Bring your appetite for festive foods and warm drinks to keep you cozy as you explore this winter wonderland.  

 

For the sports lovers… 

 

If you’re missing your traditional Saturday college football, take in the post-season college football games hosted in Fort Forth. The Armed Services Bowl takes place in the TCU stadium on Saturday December 22. This year the Houston Cougars will take on the Army Black Knights. This is the 16th annual Armed Forces Bowl, so many North Texans make this a part of their annual holiday traditions! 

 

 

We hope that this holiday season you’re able to take time and reflect on the real gifts of 2018—the memories and experiences past. Here at Dr. Ku’s office we have been so fortunate to serve our patients and the community over the past year, and to have been named the #1 dentist in Fort Worth by the Star Telegram for the second year running! We look forward to spending time with each of you in 2019, too! 

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Can legalizing marijuana save lives?

In recent years, a number of states have legalized medical marijuana. While marijuana may not be good for you, can it be used as a substitute for more dangerous substances such as prescription opioids and heroin? To use an analogy, perhaps marijuana is to vaping ans opioids/heroin are to smoking.

In fact, a recent paper by Powell et al. (2018) finds that this is the case:

Recent work finds that medical marijuana laws reduce the daily doses filled for opioid analgesics among Medicare Part-D and Medicaid enrollees, as well as population-wide opioidoverdose deaths. We replicate the result for opioid overdose deaths and explore the potential mechanism. The key feature of a medical marijuana law that facilitates a reduction in overdose death rates is a relatively liberal allowance for dispensaries. As states have become more stringent in their regulation of dispensaries, the protective value generally has fallen. These findings suggest that broader access to medical marijuana facilitates substitution of marijuana for powerful and addictive opioids.

Can legalizing marijuana save lives? posted first on http://dentistfortworth.blogspot.com

Links

• “The influence of referring physicians is dramatically greater than the effect of patient cost-sharing”
• Why is Obamacare enrollment down?
• One simple reason why value-based care may fail: poor patient attribution methods.
• MDMA for PTSD.
• Do veterans prefer VA or Medicare?
• Amazon Prime Health?

Links posted first on http://dentistfortworth.blogspot.com

Blood Pressure From the Wrist for the First Time – Welcome, Omron HeartGuide

For the first time, we can take a clinically accurate blood pressure measurement from our wrist — welcome to the first of its kind wrist-worn blood pressure monitor, HeartGuide, brought to market by Omron.

I know this journey has been a long, patient one, as I came to know Ranndy Kellogg, Omron’s President and CEO, several years ago at CES. Back in 2017, I spoke with Ranndy about the vision for BP measurement for Everyday People that would be a streamlined, simple consumer experience that the traditional armband and pump didn’t offer. I wrote about that conversation in The Huffington Post nearly 2 years ago.

Here’s the press release for the announcement, which lets you know these are available for pre-order beginning today, at a price of  $499, directly from the Omron store. The HeartGuide will be available at retail beginning January 9, 2019 — during the week of CES in Las Vegas.

This is roughly the price of an Apple Watch. It may sound high, but an Apple Watch hasn’t yet been cleared by the FDA to take clinically validate blood pressure.

Furthermore, let’s get real about health care costs, which of course, is a Health Populi/THINK-Health modus vivendi. The average cost of an ambulatory care visit is now nearly $500, and an inpatient stay, about $22,000. Self-care for a heart patient or someone at-risk for heart disease can prevent an emergency room visit or inpatient admission, $499 could be a great preventive care investment.

One reason this device, which might look like a typical smart/activity watch, is higher-priced than that generic watch is that Omron worked a long, long time with the FDA on satisfying all of the clinical end-points and requirements to meet the Agency’s stringent hurdles. For example, to be cleared as a medical device — which this indeed is — Omron had to use oscillometric technology. This was one of the FDA’s requirement to clear the watch as a non-invasive blood pressure monitor. [This monograph from the NIH National Library of Medicine further details how oscillometric technology works].

Adding to cost, and clinical quality, are some 89 patents filed that this wrist device incorporates. Consider this: the miniature blood pressure pumps and valves in the watch are the size of a grain of rice. Furthermore, due to the clinical importance of this device, Omron had to build in redundancy as back-up, so there are two pumps and two valves in each watch.

The watch has a complementary mobile app, called HeartAdvisor, which communicates what a user’s blood pressure readings mean along with recommending steps to take to improve heart health.

Lest we forget, this medical device also performs consumer health tracking like activity (steps and distance), calories burned, and sleep monitoring. The watch also channels messages and calls.

Health Populi’s Hot Points: As patients continue to morph into payors, we’re becoming more aware of our health care costs. Prevention has a more visceral, transparent ROI for a health consumer today than it might have had just a few years ago.

Self-care is the new black, as I have written and proselytized. Prevention is especially powerful for heart health – the social determinants of healthy eating/nutritious food, physical activity, and access to primary care all bolster a healthy heart and resilient living.

We have entered an era where our home and body are becoming our personal health hub. Wearable tech is getting better designed, more accessible for people who don’t have to be trained clinicians to use — and the HeartGuide is an example of this opportunity made real.

Today is December 20th: if you’re late in purchasing a gift for someone in your life dealing with heart issues, what a great IOU gift this could be.

As a scrapbooker, in both digital and paper modes, I created this Christmas or New Year’s gift card just for the occasion. [I didn’t do this because Omron compensated me to; I do this to share the good news and gift of health, which is part of my mission-driven work].

Wishing everyone a loving, healthy holiday — and my gift to you on Boxing Day, 26th December 2018, will be the annual Health Populi TrendCast for 2019. Stay tuned to my 2019 tea-leaf readings for health, technology and consumers next week…and in the meantime, remember that love is the greatest social determinant of health of all.

 

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Value of Unpaid Work and Leisure time

Oftentimes, cost effectiveness analyses of new treatments measure health benefits less medical costs.  However, getting treatment often involves a significant amount of time cost.  Some cost-effectiveness analyses take into account take into account lost productivity amount individuals who work. However, these analyses rarely take into account lost time that could be used for unpaid work or leisure time.  

Consider the case of renewing your driver’s license at the DMV.  If you were measuring the cost and benefits of enforcing driver’s license, you may measure the benefits in terms of fewer accidents from making sure individuals have good eyesight, and are decent drivers and the costs would be the costs of administering the system.  As anyone who has visited the DMV knows, however, this cost-benefit analysis would greatly underestimate the cost of the system.  If people are working and the DMV is only open during work hours, individuals need to take time off of work to go to the DMV to renew their license.  However, if someone is retired, should we count the lost time waiting at the DMV as part of the cost-benefit analysis?  I would argue certainly so.  This DMV wait time certainly imposes disutility, even among retired individuals.

If we want to include the value of this time among retired or nonworking individuals, what value should we place on it?  A paper by Verbooy et al. (2018) conduct a contingent valuation survey to measure both willingness to accept a reduction in leisure time or unpaid work and willingness to pay for additional time for leisure or unpaid work.  Using this approach, the authors find: 

The average WTA value for unpaid work was €15.83, and the average WTA value for leisure time was €15.86. The mean WTP value for leisure time was €9.37 when traded against unpaid work, and €9.56 when traded against paid work. Differences in monetary values of unpaid work and leisure time were partly explained by respondents’ income, educational level, age, and household composition.

With this information from  Verbooy et al. (2018) we can now apply this cost into standard cost benefit analysis in the medical sector.  For instance, if there is an intervention that is more expensive, but imposes significant wait times on patients, we can now estimate the value of this interventions among both working and non-working individuals.

Source:

• Verbooy K, Hoefman R, van Exel J, Brouwer W. Time Is Money: Investigating the Value of Leisure Time and Unpaid Work. Value in Health. 2018 Jul 14.
• 
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Rationing Care in America: Cost Implications Getting to Universal Health Coverage

It would not be surprising to know that when the Great Recession hit the U.S. in 2008, one in three Americans delayed medical treatment due to costs.

Ten years later, as media headlines and the President boast an improved American economy, the same proportion of people are self-rationing healthcare due to cost. That percentage of people who delay medical cost based on the expense has remained stable since 2006: between 29 and 31 percent of Americans have self-rationed care due to cost for over a decade.

And, 19% of U.S. adults, roughly one-in-five people who are sick and dealing with serious conditions, also put off treatment due to costs, Gallup learned in its survey conducted the week of the U.S. mid-terms elections in the first week of November, 2018.

Underneath this statistic, it’s important to compare the payor mix of patients delaying care: nearly one-third of people with private, commercial insurance delayed care by 2018; 22% of people enrolled in Medicaid or Medicare put off care. So did 54% of people who had no insurance.

In another survey, conducted by NPR collaborating with IBM Watson Health, younger people had more trouble paying for care than older people, the survey found. One-third of people under 35 said that health care costs prevented them from getting care, compared with only 8% of people 65 and older.

Younger people identified the cost of prescription drugs as a problem: 38% of people under 35 said they had difficulty paying for medicines, versus 8% of people 65 and older.

Another survey from Earnin and the Harris Poll conducted in September 2018 found that over one-half of Americans delayed care in the past year because they couldn’t afford it. The analysis included the financial stress point that only 39% of Americans can cover an unexpected $1,000 expense with savings.

Health Populi’s Hot Points:  The average outpatient visit in the United States runs $500, and an inpatient stay, $22,000, a new study from the Institute for Health Metrics and Evaluation at the University of Washington on the global costs of medical services and how to fund universal health care.

The table shows that the U.S. has the highest inpatient admission costs, on average, about 50% greater than those in Switzerland, the highest-cost site for health care in this study which examined data from about 130 countries.

Switzerland’s outpatient visit ran about 5% higher than costs in the U.S. — $502 per visit compared with $478 in the U.S.

When considering how to fund universal health coverage, which this paper was addressing, identifying both quantity/utilization and cost/prices is key as total spending is a function of unit prices times volume.

The U.S. historically has had much higher prices for healthcare than other develop nations, prompting late health economist Uwe Reinhardt to tell us, “It’s the Prices, Stupid” when it comes to American health spending.

Any plan to move American health care toward universal coverage must get real about this phenomenon: that costs are part of the health economy in terms of healthcare workers’ wages and local economies. Lowering costs and prices means moving healthcare to less expensive sites of care (say, retail clinics, telehealth, and pharmacies providing primary care) and lowering utilization or allocating more self-care to patients at home.

Consider the 2020 Presidential elections and calls for universal health care. Any discussions about covering all Americans for healthcare must speak about the health economy, which is inextricably linked to the larger national macroeconomy for jobs, wages, and local economic development and health.

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How accurate are budget impact models at the national level?

That is the question of interest of a new study by Snider et al. (2018) in Value in Health.  The authors use six reviews by the Institute for Clinical and Economic Review (ICER) that forecast the likely national spend on specific drugs or drug classes as case studies.  Their study compares these forecast to subsequent real-world use. 

ICER’s uptake estimates exceeded real-world estimates by factors ranging from 7.4 (sacubitril/valsartan) to 54 (hepatitis C treatments). The “unmanaged uptake” assumption (removed from ICER’s approach in 2017) yields large deviations between BIM [budget impact model] estimates and real-world consumption. Nevertheless, in some cases, ICER’s BIMs that relied on current market estimates also deviated substantially from real-world sales data.

Note that this study was funded by the Innovation and Value Initiative (IVI), where I serve as the Director of Research.

Source:

• Snider JT, Sussell J, Tebeka MG, Gonzalez A, Cohen JT, Neumann P. Challenges with Forecasting Budget Impact: A Case Study of Six ICER Reports. Value in Health. 2018 Dec 14.

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Is Medicare delivering consistent messages to hospitals on quality?

An interesting descriptive analysis by Meddings et al. (2018) finds that CMS is delivering somewhat different messages on quality based on whether the message is conveyed to patients (via Hospital Compare) or to hospitals directly (via the hospital readmissions reduction program [HRRP]).  They find the following:

Of the 2956 hospitals that had publicly reported HF [heart failure] grades on Hospital Compare, 91.9% (2717) were graded as “no different” than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as “better” than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI [acute myocardial infarction] data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions.

Although this result may be seen as inconsistent, statistically, one can view this as simply a different definition. Hospital Compare reports grades based on a risk-adjusted 95% confidence interval that the hospital’s unplanned readmissions differ from the 30-day national average.   On the other hand, 
the hospital readmissions reduction penalty (HHRP) program uses the actual risk-adjusted readmission rate–rather than the 95% confidence interval–to determine payment. 

Why would these similar programs use different methods?  

I would argue that they aim to answer different research questions.  For HHRP, the goal is to retrospectively evaluate how well a hospital did on readmissions.  Here, there is no statistical uncertainty–all readmissions are observed and they prior performance is known with certainty.  It may be the case that small hospitals had a year with bad luck, but the though is that if that is the case, these penalties would even out over the years. 

The research question asked for Hospital Compare by consumers, on the other hand, is likely not how well a hospital has done in the past but how well they are likely to do in the future.  Consumers use Hospital Compare to measure past quality only in able to predict future quality.  Although future quality is not known, there clearly is more uncertainty and Hospital Compare takes this into account.  

Thus, while the headline of this article may make it appear that CMS is doing something non-sensical, the respective approaches do make sense conceptually.  How CMS makes these predications (e.g., should they have used a Bayesian approach for Hospital Compare using the national average rate as the prior to create credible intervals and reported those?) I will leave for another post.  

Source:

• Jennifer Meddings, MD, MSc; Shawna N. Smith, PhD; Timothy P. Hofer, MD, MSc; Mary A.M. Rogers, PhD, MS; Laura Petersen, MHSA; and Laurence F. McMahon Jr, MD, MPH. Mixed Messages to Consumers From Medicare: Hospital Compare Grades Versus Value-Based Payment Penalty. American Journal of Managed Care. 2018;24(12):e399-e403

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Dental Crowns—What You Probably Don’t Know

As we head into the new year, many of our patients have expressed interest in learning more about specific dental topics. And, well, there are some topics that affect more patients than others. More than 40% of Americans have a dental crown, and that percentage only goes up the older you get. And so, since many of our patients might need crowns in 2019, we wanted to offer information on what different types there are and all the benefits of popular options, like porcelain crowns.  

 

If you are faced with needing a dental crown next year, then keep reading to learn more about the crowns used in Dr. Ku’s office. 

 

What is a dental crown? 

 

Simply put, a crown is a cover or “cap” that Dr. Ku can put on a tooth. The crown restores the tooth to its normal shape, size and function. The purpose of a crown is either to make the tooth stronger or improve the way it looks. Crown restore your bite, too, which will help minimize jaw and head pain if you suffer from this.  

 

Since the mouth is linked to most systems in your body, a crown can positively impact your whole heath. For example, people who suffer from missing teeth may have problems eating crunchy, high-fiber foods. This can lead to both malnourishment and cause an individual to rely on soft, high carbohydrate food that ends up causing weight gain.  

 

Crowns are made by taking an impression of the tooth or teeth they’ll be covering. Before this impression is created, your dentist must first reduce your tooth’s size so that the crown can fit properly. Your dentist may also place a temporary crown while the permanent one is being made, so don’t worry—you won’t be stuck with funky dagger teeth. 

 

Are there different types of crowns? 

 

You bet! There are many different types of dental crowns to choose from. Since it can be overwhelming to parse through an overload of information in the office, we wanted to share this as your low-stress reference guide: 

 

• Base metal alloy – This metal is rarely used to make full-metal crowns. Instead, it requires the least amount of healthy tooth to be removed prior to fitting. But once it’s on, metal crowns can withstand biting and don’t wear down as easily. These qualities make them a popular option for many patients. 

 

• All ceramic – These crowns provide a better natural-color-match than any other crown type and are usually the most suitable for people with metal allergies. All-ceramic crowns can be used for front and back teeth. 

 

• All porcelain – The most popular type of crown are those made from porcelain since they not only replicate the original tooth in function, but can be designed to look like the original—or even better. Patients have reported that all-porcelain crowns feel the most like their real teeth since they can be molded to any size and shape. 

 

• Gold alloy -This crown is a mix of gold, copper and other metals. In addition to providing a strong bond to the tooth, it doesn’t fracture—and it doesn’t wear away the tooth itself! 

 

What is it like to get a crown? 

 

Proper preparation for a crown is important to ensure your smile and teeth appear natural and function right in the end! First, your dentist will remove a fine layer of enamel from the front of the tooth, then take an impression of your teeth. Sometimes it can take a couple of weeks for this crown to be completed. And because of this, your dentist may fit you with temporary crown to protect your teeth after the enamel was removed.  

 

When the crown is ready, your dentist will check it to ensure the color, shape and size are spot-on. Dentists have the ability to fine tune crowns after they arrive to ensure they blend in perfectly.  

 

After prepping your teeth the day of placement, the crown is bonded to your teeth using a dental cement. The cement is allowed to harden with a curing light which sets the teeth in a matter of minutes.  

 

While the whole process can take several weeks (due to making the crown), putting them on to your teeth can be done in a couple of hours! 

 

 

If you are looking for a dentist to help improve your smile, look no further than Dr. Ku’s office! For the second year running, Dr. Ku has been voted the #1 Dentist in Fort Worth by the Star Telegram. Ask Dr. Ku to rejuvenate your smile today!  

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Is physician judgement overrated?

Would you trust the judgment of a machine or a physician?  That is a pretty simple question.  A seminal paper by Dawes, Faust and Meehl (1989) claim that you should trust the machine.  The compare statistical or actuarial methods that are not based on human judgement against physician’s own decisions.
In reviewing the literature, they find:

Eliminating research that did not protect sufficiently against inflated results for actuarial methods, there remain nearly 100 comparative studies in the social sciences. In virtually every one of these studies, the actuarial method has equaled or surpassed the clinical method, sometimes slightly and sometimes substantially

The statistical methods outperformed physicians even when physicians were provided additional information.

However, it is still possible that physicians may be superior to machines. How so?

• Information advantage. Physicians may be able to gain information from patients tone of voice and better extract information from patients to improve decision-making.
• Factoring in treatment experience. When picking between treatment A and B, treatment A may be superior on average. However, if a physician has extensive experience using treatment B–and say, has better experience knowing how to control side effects–a physician treatment decision could be the ‘wrong’ decision from a global perspective but the right one based on their experience.
• Better defining what the ‘right’ decision is. The right decision for the average patient may differ from the right decision for an individual patient. For instance, some patients may prefer more effective treatment even if there are more side effects; other patients may prefer treatments with fewer side effects even if the treatment is less efficacious. While machines could potentially weight outcomes if patients entered their preferences, physicians may be able to better understand patient preferences. Further, physicians may understand patients may up-weight or down-weight certain types of outcomes. Alternatively, some errors in judgement may be more severe than others and thus physicians may place different weights on Type I vs. Type II errors.
• Rare facts and the broken leg problem. “In psychology this circumstance has come to be known as the “broken leg” problem, on the basis of on an illustration in which an actuarial formula is highly successful in predicting an individual’s weekly attendance at a movie but should be discarded upon discovering that the subject is in a cast with a fractured femur…The clinician may beat the actuarial method if able to detect the rare fact and decide accordingly.”

Source:

• Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74.

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Holiday HWR

Peggy Salvatore has posted Have a Holly, Jolly Health Wonk Holiday from Health Wonk Review at  Health System Ed Blog.  Check it out!

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The end of Obamacare?

As reported in NPR:

A federal judge in Texas issued a ruling Friday declaring the Affordable Care Act unconstitutional, apparently setting the stage for another hearing on the health care law by the U.S. Supreme Court.
The ruling by U.S. District Judge Reed O’Connor invalidates what’s commonly referred to as Obamacare nationwide, and casts into doubt the survival of the law on the eve of the deadline for tens of millions of Americans to sign up for health care coverage in 2019.

So are the Obamacare health insurance exchanges closed?  The answer is, not yet.  Kaiser Health News reports:

Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, which oversees those insurance exchanges, said in a tweet: “The recent federal court decision is still moving through the courts, and the exchanges are still open for business and we will continue with open enrollment. There is no impact to current coverage or coverage in a 2019 plan.”

Clearly, more to come on this story.

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What evidence does NHS need for reimbursement of digital health technologies?

This week, the UK’s National Health Service (NHS) and National Institute for Health and Care Excellence (NICE) released a document titled Evidence standards framework for digital health technologies.  An accompanying piece in The Lancet by Greaves et al. (2018) aims to describe the goals of the document at a high level.

The authors state that key principal used to inform these guidelines is that the level of evidence that should be required is proportional to the risk to the patient. 

For example, digital tools that provide diagnosis or treatment are in the highest level for which the minimum evidence requirement will be a high-quality experimental or quasi-experimental study with comparative data on patient outcomes. Support services and technologies designed to simply communicate information are lower in the hierarchy and the requirements are therefore designed around the credibility and accuracy of the content, including whether they meet established standards for the quality of the information provided.

Greaves et al. 2018.

The authors note that because digital health technologies tend to be iteratively developed, new techniques may need to be used such as Multiphase Optimisation Strategy (MOST) and sequential, multiple assignment, randomized trials (SMART) [see Collins et al. 2017]

Yet in general, the guidelines impose a similarly high standard of evidence on digital as compared to conventional technologies. 

However, there should be no lowering of the quality bar and experimental or quasi-experimental studies using traditional or innovative methodologies need to conform to high standards, including transparency of methods, a-priori analysis plans, and full publication of all results.

Greaves et al. 2018.

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Americans End 2018 Worried About Healthcare Costs

Nearly one-half of Americans are quite concerned they won’t have enough money to pay for medical care, according to the latest Gallup poll.

Health insurance in-security is mainstream as of November 2018, when Gallup polled U.S. adults about views on healthcare costs. It’s a major concern among six in ten people that their health plan would require they pay higher premiums or a bigger portion of their healthcare expenses. It’s also a big concern for four in ten people that someone in their family would be denied health insurance covering for a pre-existing condition, or that they might have to go without health insurance at some point.

Gallup conducted this survey among 1,037 U.S. adults in early November, as American voters headed to the polls and voted Democrats into the majority of the House of Representatives.

Gallup notes their October 2018 poll learned that voters were most concerned about healthcare, immigration and the economy as key midterm voting issues.

The second chart details responses to the survey by demographics. See that women are overall more concerned about healthcare finances across the different categories than men are: paying higher premiums is a major concern to 67% of women compared with 56% of men, for example.

Paying higher premiums is also of major concern to more Independents and Democrats that Republicans.

But those premiums are also a major concern to majorities of people at all income categories, even those earning over $75K a year.

Not having enough money for health insurance is a major concern for most people with lower incomes, and people enrolled in Medicaid or Medicare.

Having to go without health insurance is a major concern for nearly one-half of Democrats and Independents, but only 29% of Republicans.

Health Populi’s Hot Points: New data from the Center for Financial Services Innovation (CFSI) profiles Americans’ financial health at the end of 2018. Only one in four people say they’re financially healthy, with another half just “coping” financially. 42 million people, 17%, believe they’re financially vulnerable.

By income, even 50% of folks with over $100K a year in earnings are just financially coping or vulnerable, CFSI learned.

Nearly one-half of Americans are spending more than or up to their income, and over one-third are unable to pay bills on-time. Nearly one-half also don’t have enough savings to cover three months of living expenses, and a third have more debt than they can manage.

Healthcare costs as a basic need take a toll on financial wellness in America. People who struggled to afford healthcare were nearly ten times less likely to be financially healthy.

And that lack of affordable healthcare leads to self-rationing behavior: in the past year, someone in the respondent’s household did not get needed healthcare because they couldn’t afford it: 50% said this happened often, and one-fourth said “sometimes.”

Reflecting back on the Gallup Poll results, it’s clear why voters brought their financial health care stress to the voting booth in November 2018. With greater financial burden forecast on healthcare consumers in 2019, no doubt we’ll see healthcare rank highly on voters’ minds in the 2020 Presidential election.

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ACA Individual Market and State Re-insurance programs

A number of states have re-insurance programs to support the Affordable Care Act (i.e., Obamacare) marketplaces in the individual and small group markets.  Re-insurance occurs when the state offers to pay a percentage of patient costs if they exceed some threshold.  This may lead you to ask a number of reasonable questions.  For instance:

Why do states have reinsurance programs?

According to Schwab, Curran, Corlette (2018), the answer is: 

1. Stabilize individual market premiums and mitigate future rate increases;
2. Increase consumer enrollment;
3. Maintain insurer participation and attract future competition; and
4. Generate federal savings to fund state-level innovation, while ensuring a financially sustainable program.

Do reinsurance programs actually reduce premiums?

The answer seems to be yes. 

The reinsurance programs in all three states have directly reduced individual market premiums…One insurer noted that the program had a “tremendous immediate impact,” allowing them to reduce their proposed rates by over 20 percent. In Alaska, the state’s only insurer initially proposed 2017 rate increases of over 40 percent, on average, prior to approval of the [reinsurance] 1332 waiver.

https://ift.tt/2rxEdnw

Do reinsurance programs increase the number of health plans entering the individual market?

The answer to this question is unclear.  Practically speaking, if the government guarantees to pick up a share of your cost, entry is bound to happen. In practice however, none of the states saw additional insurers join the individual market after the reinsurance program was introduced. However, current market insurers did not that reinsurance decreased their chance of exiting the market. 

Will reinsurance programs continue?

Insurers like them because they reduce business risk.  Patients like them because they subsidize insurance premiums.  The key question, however, is whether States will continue to pour money into these re-insurance programs.  If there is an economic downturn and state budgets sour, then re-insurance programs may soon be at risk. 

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How good is your mental health care? Depends where you live

Access to physician services and pharmaceuticals is vital–particularly among patients with serious mental illness–to insure patients receive the care they need. However, the likelihood patients receive this care depends on where they live. A paper by Manchester (2018) examines a cohort of patients eligible for both Medicare and U.S. Social Security Disability Insurance (SSDI) and finds: 

The number of services for SSDI beneficiaries ranged from almost 48 per capita in Minnesota to 23 in Arkansas. Services for musculoskeletal impairments averaged 4.6 per capita, ranging from 6.7 in Minnesota to 2.5 in Hawaii. The greatest variation occurred in services for mental disorders, averaging 3.2 for the U.S. but ranging from 9.1 in Massachusetts to 1.4 in Alabama.

As the saying goes: location, location, location.

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Retail Health Ends 2018 With Big Plans for 2019

As the CVS + Aetna merger crosses its last regulatory hurdle at the close of 2018, we enter 2019 facing a fast-growing and -morphing retail health landscape.

I brainstormed retail health yesterday with Patrick Freuler, CEO of Audicus (developer of hearing aids sold direct-to-consumer over-the-counter) and Shai Gozani, CEO of NeuroMetrix, maker of the Quell device for pain management. The three of us will be on a panel addressing retail health disruption at CES 2019 on 9th January 2019 at the Digital Health Summit.

I explained to Shai what I’m going to say in my talk about retail health at the Summit: that once considered the purview of the pharmacy, today “retail health” broadly write covers all consumer-facing touch points for health, not just healthcare. So that includes the many so-called “front doors,” as Oliver Wyman’s team coins them, that provide on-ramps to people seeking wellness, healthcare, holistic therapies, and medical services.

Several big-companies with strong brands have announced plans to go big in retail, consumer-facing health in 2019, falling under my expansive umbrella.

On the pharmacy front, Walgreens and FedEx launched a next-day (or sooner in some markets) delivery service for prescription drugs direct-to-consumers’ homes. This works via a Walgreens mobile app where patients can opt-in to text alerts and be notified when their scrip is ready for pick-up. Instead, she can choose delivery on the app menu, for a $4.99 fee.   Patients enrolled in text alerts will receive text notification when qualifying prescriptions are ready.

Walgreens had more retail health developments, opening a new store concept with Kroger, the grocer, called Kroger Express. The pilot brings together grocery, pharmacy, health and beauty, testing out first in 13 stores in Northern Kentucky. Kroger’s chairman and CEO believes this idea, “rethinks convenience and redefines the way America shops for food,” explained in the press release for the project. The smaller-footprint stores will curate/select a fraction of the number of products sold in typical food markets. In the meantime, Kroger acquired Home Chef, the food subscription service, and offers Home Chef Express kits at Walgreens stores in metro Chicago to start.

Another grocery, Giant Eagle, is moving its pharmacies further into medical services through an agreement to channel DarioHealth’s Digital Diabetes Education and Rewards Program. Giant serves 4.6 million customers in Maryland, Ohio, Pennsylvania and West Virginia each year, who can enroll into the Dario program and receive diabetes education through a mobile app, and earn rewards as people manage the condition. This is the largest deal DarioHealth, an Israel-based company, has struck in terms of potential patient reach.

Another food-focused venture in the retail health world was announced this week: Tivity Health is acquiring Nutrisystem,  the weight-loss brand. Tivity Health has a portfolio of fitness, wellness and healthcare programs and with this acquisition, can expand its healthy living franchise along with programs like SilverSneakers, Prime Fitness, and flip50.

Walmart, already a major force in retail health through its pharmacies, retail clinics, health and beauty aisles, and groceries, is growing in telehealth. The company announced a collaboration with the Department of Veterans Affairs along with Philips and T-Mobile to expand healthcare access to veterans via telehealth. The Anywhere to Anywhere VA Health Care Initiative was launched in 2017 to build a national telehealth network to reach veterans especially in rural and remote areas. This alliance will fill in some of the gaps in the national network.

Walmart is also testing operating mental health clinics in retail stores, beginning in Carrollton, Texas. Walmart’s working with Beacon Health Options from Boston, which already serves 40 million patients across the U.S. The clinic will be staffed by at least one licensed professional and deal with anxiety, depression, grief, stress, and relationship issues, according to the announcement.

To round out these stories, we turn to Amazon, which continues to add accomplished experts from the healthcare system to various health-related projects brewing inside the ecommerce giant. You can’t get more consumer-facing that advertising on the Hallmark channel during the holidays, and I note that as I am in holiday baking mode with the kitchen TV on for background entertainment, PillPack — Amazon’s direct-to-consumer prescription service — has been frequently advertising this season.

Health Populi’s Hot Points:  As patients continue to grow their consumer muscles, retail health is playing a growing role — through the growth of services offered in the community, closer to home, to workplaces, to school, to play and entertainment, to shopping.

It’s not just about convenience but about experience and value-added services. The ventures described here are reshaping what the consumers’ health experience is, pressuring legacy healthcare providers — hospitals, doctors, pharma, health plans, et al. — to grow their own consumer-facing muscles in 2019.

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