Healthcare Access, Equity and Affordability Challenges

The past several years at Harmonize Health have given me a unique perspective on US healthcare. Harmonize helps manage complex, chronic illness remotely. Our main goal is to stabilize the health of the patients we monitor so they can avoid acute care. Along the way we hope to make US healthcare more cost effective, convenient and efficient for patients and providers. And in particular, we try to address the substantial gaps in healthcare equity and access. I thought these insights might be helpful.

Wellness Works. When we started, we thought the target was vital sign collection, assessment and alerting. We weren’t wrong about the importance of vitals – we were wrong to think vitals were the end game. Vitals are trailing indicators - results. High or low vitals mean the patient needs to change something: diet, activity, medications or medication adherence, stress, sleep, alcohol or tobacco use. In essence, their wellness. Specific changes made the most difference immediately. But we also observed a “health halo” once patients began using our platform: the volatility of their vital signs declined. They were out of range less often and overall had more stable vitals. When we asked them, they said that taking their vital signs helped reinforce their personal responsibility for staying healthy and they paid more attention to the factors that impact health. Wellness works.

Value Based Care Will Be Here Someday….Maybe. We planned the platform to fit best in a value-based care (VBC) environment, where in one way or other providers had a financial interest in patient outcomes and long-term health. This was a big bet on the direction that healthcare needed to go and was based on (I thought) sound financial assumptions and demographic trends. But we were way ahead of the curve and found the providers we serve primarily interested in generating revenue in the traditional fee-for-service construct. From the most macro perspective, VBC is clearly a smarter financial strategy, since it covers whole health and is outcomes oriented. As that macro strategy is disaggregated down to the patient level, it’s more difficult for providers to embrace. The explanations for this are straightforward (patients switch plans, incentives are too low, it’s all too difficult to track, etc). The focus on procedures instead of outcomes is an unintended consequence of the healthcare payment and delivery systems that have operated for the past 60-70 years. In a market that consists of providers, patients, payers and pharma/device providers, no one participant is to blame. But until there’s a comprehensive way to incentivize health, wellness and outcomes, VBC is going to be a slow walk. And if you want to stretch the explanation, this is the reason we spend 150-200% as much as citizens of other countries for health care that is generally no more effective (and on some metrics, worse ).

Health Equity Is In Crisis. Access to healthcare in the US is terrible if you’re not wealthy or don’t get good health insurance from your employer. Just how bad? Ok - numbers - but stay with me. Using constant dollars to remove the impact of inflation, healthcare in 2020 was 6.6x as expensive per capita as it was in 1970. Then, it cost just under $2,000 per person, per year; now it costs almost $13,000, implying a 3.9% annual growth rate. If you look at averages, we’re all spending much more of our income on healthcare: in 1970 the average person spent 7.7% of their income on healthcare and by 2020 it was 20.8% (about 270% higher). That’s the average, but if you were in a lower income bracket, you got slammed: healthcare as a percentage of your budget was more than 6x as large in 2020 as it was in 1970 (Your budget, which includes food, housing, transportation and incidentals, likely doesn’t have room for healthcare to cost 6x as much as it used to). Cost is but one measure of health equity. Others – 60% decline in hospital beds per capita , rural hospital closures , ER and clinic closures, a shift to ambulatory care that leaves out rural populations, the reduced availability of family medicine/general practitioners, the increased reliance on pharmaceuticals and a variety of other factors make access to healthcare very unequal. In the US, 43% of respondents report being dissatisfied with the healthcare system compared with 30% who are satisfied with it (and we are a rarity in this respect – developed economies with a higher percentage of dissatisfied consumers.).

Technology Can Help (But It Takes Work). Healthcare is hard. Providers don’t always have the answer, patients don’t always do as they’re asked, medications and devices aren’t always effective. None of that is changed by technology alone. Technology can often help (a) enable new ways to do things, (b) broaden access, and (c) reduce costs. But it’s not automatic. Providers, patients and payers need to work through the inevitable learning curve before technology can provide any advantage. And most of the advantages should reduce or eliminate mindless tasks, human error, time delays from manual processes, etc as opposed to “doing medicine.” Take our platform – by 10am, we can show a nurse or doctor more information on patients than they could ever collect, record and organize manually in a day. They can literally start the day working with patients that need them most, rather than playing phone tag. There are scores of technologies that are like this. We never found a provider that didn’t “get it” but we seldom found one ready to jump in feet first. Resistance to organizational change is high in healthcare. But we need to find a way to make this work, because technology is how we close the gap on health equity and make healthcare more affordable, convenient and effective.

The past several years have been difficult for everyone involved in healthcare. High costs, reduced access and provider burnout top the lists of challenges. A majority of US hospitals lost money last year. Doctors and nurses left the practice because the stress was too high and they couldn’t make ends meet. Patients paid more for healthcare than they ever have. Most insurers struggled with single-digit operating margins. Vertical economies flourish, stagnate, evolve and ultimately succeed or fail by delivering what people need at a cost they can pay that the providers can reasonably profit from (don’t be misled – NFP hospitals still need revenue to exceed expenses). The dynamics I’ve described have been building for decades. The solutions are complex but involve known avenues: increasing incentives for outcomes, improving access, incentivizing smart use of technology. Onward - to a better future!