The demand for home health is expected to increase to 15 million by 2020 due to the aging baby boomer population. The Visiting Nurse Health System (VNHS) case discusses the benefits of providing telemonitoring services to at-risk patients who were discharged from hospitals and need home care, and the difficulty quantifying those benefits.
Comment and build on what others say about VNHS, the services it provides, and whether you think home health systems like Health Buddy will increase medication compliance and reduce outpatient visits. Explain your thinking. Is it a benefit to the patients? To VNHS? You can speak to the case as well as other sources that speak to this issue.
The main thing I see as the driver for the popularity and success of VNHS as a company is the fact that hospitals are now being held accountable for re-admission rates. They would be held accountable not only in terms of ratings, but as well as financially. Also another point that I think made VNHS so successful was the fact that they created a new position, called the coordinator, that was responsible for setting up the patients with the tele-monitoring equipment. A primary concern amongst the nurses involved with the program was that their workload would increase due to being responsible for setting up these monitors. Since they were able to get someone else to set up the monitors and train the patients on how to use them the nurses didn't see that extra workload, and only had to change their workflow slightly.
ReplyDeleteThere is no doubt that home health systems, like Health Buddy, have a benefit to patients, physicians, and VNHS because it has shown to reduce hospital re-admission. They did a study where they had 20 patients on the monitor and 20 patients without it. They found that the group on the monitor only had 12 re-admissions, while the group without it had 22 or 23 which was higher than the amount of patients in the group since some of them were readmitted more than once. That proof right there is beneficial to the patients because it can help them to get better without costing them extra hospital bills, beneficial because hospitals will have more resources with people that actually need the care rather than dealing with re-admissions, and beneficial to VNHS because they can show their services actually do work and people will be more willing to use their services. (especially now as hospitals will be held more accountable for re-admissions)
There are multiple benefits that I see for the patients themselves: reduction of re-admission to the hospital, instant access to help when they need it, 24/7 monitoring of their condition rather than weekly or bi-weekly, and reduced need of leaving the home to go see doctors for post-hospital care. There was an example provided that showed a CHF patient keeping track of their weight every day with the Health Buddy, and that with CHF fluid build-up is a big issue. If they keep track of their weight every day the Health Buddy could notice a slight increase in weight over a 24-hour period which could mean they need attention, and therefore the right people could be contacted and the patient could be taken care of sooner rather than later and needing to go to the hospital again. Not to mention it is caught sooner because the Health Buddy sets reminders to keep track of such things. Also if there is something wrong the patient can talk to someone who already has access to all this information about their health and so it makes the consultation go faster and smoother.
There are also clear benefits to VNHS because they can reduce the number of house-calls nurses have to make on a day-to-day basis because the Health Buddy is doing the monitoring that they would normally be doing. It was shown that they could reduce patient house visits by as much as 2 visits per episode, and that means since VNHS gets paid per episode they have some cost savings as well.
Also I think Health Buddy is a quite useful tool in ensuring patient compliance because when trying it out everyone's first comment was how annoying the buzzer was, and so what patient could go ignoring that noise. It is an effective reminder to make them do something to make sure they are doing their part in the post-hospital treatments.
As Kyle Kwiedacz alluded to, the increased proliferation of the Health Buddy system must be analyzed from the standpoint of both the patient experience and VNHS business performance. It is easy to highlight the positive health impacts Health Buddy has had on VNHS patients, but from a business standpoint, the rewards are less apparent.
ReplyDeleteVNHS’s use of Health Buddy has been a success marked by high patient satisfaction. This satisfaction stems from studies proving that patients heal faster and have fewer complications when their care is administered at home versus a clinical setting. The VNHS Health Buddy telemonitoring system affords patients this luxury, by allowing them to heal in their homes, without the stressors of hospital admissions. In turn, VNHS is subsidizing hospitals and insurance companies because their care is reducing hospital readmission rates, which are both costly and inconsistent with CMS requirements. However, this one-way benefit stream is causing VNHS a degree of consternation as they decide whether or not to further invest in telemonitoring.
At a cost of $2500 per Health Buddy unit, and a $65 monthly charge per unit, the initial 50 units purchased cost VNHS $164,00 annually, not including the cost of the care coordinator. I highlight this not to show the insignificant cost of one year, but to extrapolate the cost if VNHS were to expand the use of Health Buddy. While not all of VNHS’s 20,000 patients are in need of the monitoring equipment, let’s assume that 40%, or 8,000 patients, could benefit. At this rate, the annual cost of implementing Health Buddy rises to $26,240,000, or 52% of annual revenues; VNHS cannot sustain the use of the system without being subsidized.
This lack of subsidization and the inequality of cost savings make the use of telemonitoring equipment a poor business decision. Even considering the savings VHNS may realize by reducing patient visits by two in a 45-day episode of care ($280), the savings are miniscule compared to the savings experienced by the hospitals and insurance companies due to reduced ER visits and admission costs. Based on this, expanding the use of telemonitoring equipment by VNHS will be contingent upon hospitals and insurance companies sharing the cost.
As hospitals continue to pursue Accountable Care Organization (ACO) models, they are capitalizing on the shared savings experienced. For VNHS, they should position themselves to be a partner in the ACO, and benefit from the savings as well. This is especially true with hospitals such as Piedmont, who refer 75% of their acute patients to VNHS. Even if Piedmont is not part of an ACO, their savings through reduced readmission costs, and government subsidizes for meeting CMS metrics, should be shared with VNHS. Additionally, as mentioned in the case, VHNS must further petition insurance companies to cover a portion of the cost of the Health Buddy system. Because insurance companies are likely experiencing higher benefits than even the hospitals due to VNHS’s use of telemonitoring. Considering Medicare is unwilling to sponsor the use of telemonitoring systems currently, these two avenues offer the best chances of reducing the costs bore solely by VNHS, and allow for further expansion of the system.
In conclusion, the use of telemonitoring is a benefit to the patient and that should be the driving force behind increasing usage. Patients are being afforded the opportunity of not only spending more time away from the hospital, but as the case detailed, actively involved patients are increasing their level of education of their own health. This increased health literacy offers an even higher rate of return, as patients are able to understand their ailments better, and further limit their use of medical facilities.
Anthony
Rimer, Sara, “The biology of emotion – and what it may teach us about helping people to live longer,” Harvard School of Public Health, http://www.hsph.harvard.edu/news/magazine/happiness-stress-heart-disease/ (accessed November 17, 2014).
I'm going to make the link that Anthony posted linkable, and then I'll add to both of your comments. Rimer, Sara, “The biology of emotion – and what it may teach us about helping people to live longer,” Harvard School of Public Health, http://www.hsph.harvard.edu/news/magazine/happiness-stress-heart-disease/
ReplyDeleteA couple of comments. Kyle makes some good points that if a hospice or any tele monitoring system is to succeed, they do need to create a position to act as a coordinator, for the reasons mentioned, but one that stands out: Clinicians are too busy, and this is full-time job. I do not, however, think that VNHS is doing this just for the good of their patients; there has to be a financial incentive, and a sustainable one at that, to continue. For these reasons, I think that Anthony shows quite convincingly that VNHS may be too expensive to expand. Of course, we don't know what incentive HealthBuddy is offering, and they are in the business of making money (see their website as proof).
ReplyDeleteWith that said, I don't think elderly patients without a caregiver or partner/spouse will be able to monitor their activities alone. Insurance has to be involved to make it "affordable" to patients. My dad bought a high end motorized wheel chair to move around the house; it was sold to him by a vendor, and though expensive, insurance covered most of it. So it's a mixed bag. You can bet that hospices and hospitals offer these tele monitoring devices as a way to keep patients from returning (and there is a financial reward for doing so), but other, cheaper options may not even be considered because of the financial incentives involved. We learned this from many readings. Great comments. Maybe others will chime in.
I agree with Anthony, the highlights of the Health Buddy had a very positive impact on VNHS patients, but the business aspect, totally trumps the rewards from a patient care aspect. The use of the Health Buddy by VNHS is a success due to the high patient satisfaction. But Anthony is correct when he said “satisfaction stems from faster healing and fewer complications when their care is administered at home versus a clinical setting”. The VNHS telemonitoring system gives the patient the luxury of self-healing in their home and spending more time away from the hospital. But that brings me back to the business aspect. I read an article from the U.S. Department of Health and Human Services that read not all telehealth costs are reimbursed. That is, Medicare will cover telemedicine services that mimic normal face-to-face interactions between patients and their health care providers. Come to find out that Medicare only reimburses for telehealth services that originate where the patient is in a Health Professional Shortage Area (HPSA) or in a county that is outside of any Metropolitan Statistical Area (MSA). To put is simpler the patient must be at a medical facility and not the patient's home.
ReplyDeleteSo from a business standpoint, I feel VNHS future investment in telemonitoring is not good. Without financial reimbursement from insurance providers VNHS will put themselves in a deep financial hole. Some insurance companies see the value of telehealth and will reimburse a wide variety of services, pending Medicare guidelines.
As Kyle was saying, telemonitoring has been proven effective in reducing readmissions of patients. This paper mentioned that telemonitoring brought down re-hospitalization rates by more than 38% for CHF patients and by 50% for ER admissions. These are amazing numbers, and a great introduction as to the benefites of telemonitoring. Along with the readmission rates, the nurse visit rates have fallen as well. Kathleen Coughlin is quoted saying, “I would say 5, 10 years ago we were doing 18 to 20 skilled visits for episodic care. Everybody’s down to 14 now”. Because of telemonitoring, the nurses can monitor a patients condition remotely. This allows for the nurse to only make a visit when it is necessary based on the patient condition.
ReplyDeleteAnother great device is the Health Buddy. Patients tend to heal better at home than they do with all the stress of the hospital. The Health Buddy allows for the patient to heal at home and set their own goals, all while being monitored. The initial cost of a Health Buddy is only $2,500 per unit and then $65 hosting fee a month. Nurses are able to determine which patients best qualify for this at home monitoring remedy.
The Health Buddy has a demo so that people can see how it works. After just five minutes with the demo, it is obvious how beneficial this could be. Not only does the Health Buddy sync with measurement tools such as scales, and blood pressure machines, it also asks all the right questions. The questions can determine if a person is staying on track with their regimen, if they are getting worse, or better. I could personally see this being adopted nationally and being able to harvest big data from this. It is possible that if enough of these were in use, patterns would show up in the data. Different seasons or different medications could have effects we only see on patients when they use this daily. Another nice thing is if the Health Buddy deems it necessary, it tells you to call your health provider and explain what your symptoms are. I think they system is much better than what many Americans currently do, log onto the internet and self diagnose and create even more unneeded anxiety.
Patients with chronic diseases such as CHF often needed to constantly monitor their weight, blood pressure, salt intake, and glucose levels. The Health Buddy made all of these things much more manageable and centralized. Patients also often were readmitted to hospitals for incorrectly taking their medication. At a certain point some patients have a litany of medication to take each day and this can become a job in itself. The Health Buddy again was a centralized system and made this easier. In summary, I think this Health Buddy will increase patient compliance and decrease patient visits. I think that something in the home giving people a constant reminder is a great motivation. I also think this could prevent unneeded revisits, as well as help people stay on track so that they don’t need to go back to a hospital. Lastly, the Health Buddy provided the ability to monitor these patients remotely, which was a huge benefit to everyone involved.
Nurses initially were worried about loosing part of their job. But, nurses are still needed for visits, this just makes the visits and the care more efficient. To help facilitate the use of this monitoring, a coordinator position was created to coordinate the care between the nurses and the monitoring. I believe VNHS has proven that telemonitoring is truly a feasible and efficient method of patient care. It allows patients to receive better care from their own home, saves costs, has proven to prevent readmissions, and functions rather well all together.
The cost of the unit is exorbitant and prohibitive if insurance didn't help subsidize some big part of it.
DeleteI believe Justin did a great job at pulling the important information out of the case, making an example out of the percentage decrease in rehospitalization and amounts of visits during an episode. It is clear that this technology has shown a positive impact, but the one thing I found unsettling was the sample sizes. For the people with CHF and their rehospitalization numbers, the sample sizes was just 50. Being statistically minded, I believe that these results can just happen by luck, so going off this case alone isn’t going to be something that sells me on this technology right away.
ReplyDeleteNow as with all cases in this class, I tend to look at these cases and articles from multiple points of view, as a business student, and as a medicine student. As in the past, I see things that are very relevant to both sides of my interests. Starting from the business perspective, the VNHS is a non profit, but in order to keep operating, they need to keep getting their money. The case does a good job at explaining the benefits, especially compared to times before telemonitoring and with people who weren’t using it, but they only briefly mentioned the cost justification. However, they did mention the potential long-term benefits of telemonitoring which was basically centered around the savings from avoiding rehospitalizations and how it could lead to insurance companies helping out with the costs, which I see benefitting everyone in the long run.
Now from the medicine point of view, I believe that this is very exciting technology. As someone who has always been interested in health, one of the strongest positives I see coming from technologies like Health Buddy is the education aspect. As we saw in class, the health buddy is very interactive and rather simple. It allows people to see what is important at which times and that opens up countless doors for people to go explore and learn about their health and health in general. On top of that, it benefits physicians and nurses as well by getting them accurate, real-time information so they can make better quality decisions. If the research being done is correct in that this technology reduces hospital visits and required nurse visits, then these trained professionals can spend their time on more important issues such as research or helping patients who actually need a lot of face to face care, essentially helping to wipe out the “doctor shortage” and ridiculous wait times in hospitals. Not to mention, the Health Buddy is only the tip of the iceberg in telemonitoring, with plenty more interfaces being developed every single day that could have unimaginable benefits in the future.
Good points. I appreciate you pointing out that Health Buddy is only one of many, many other telemonitoring devices.
DeleteI tend to agree with what Kervin said. So I went on this big long rant and then the comment didn't post!!! So here is my redacted comments. I am not a proponent of them rolling out these telemonitoring devices largely because of feasibility and scalability issues. At $50,000 for 50 devices without any incentive for the insurance companies to help subsidize cost, this places a significant cost burden on VNHS to acquire these devices. I’m a big proponent of what telemonitoring can do for patients and how fantastic of an alternative it poses to the traditional health check up approach. But for a company that is entirely patient-based, it doesn’t seem feasible to continue acquiring these $2,500 devices without real proven research on the effects they have on re-admittance. If all of their patients are determined to be in need of these devices, what then? Will they go out and buy enough to account for all of their patients? The small sample sizes reported in the case are not adequate to warrant an additional $50,000 on perhaps another 50 devices. Mr. Oshnock has to recognize that there is a decent level of pessimism that must exist in rushing out to buy more of these devices. Sure there is an incentive for the hospitals to use them as they demonstrate actionable proof of reducing readmission. However, there is no definitive link that I see between these devices and hospital readmission – what I see is a small sample set with reasonable coincidence.
ReplyDeleteAdditionally, the nurses have clearly voiced their concerns with the possibility of additional hours to train patients and setup these devices. This was addressed with the creation of the Coordinator position, but from what I gathered this was just one person filled in the role. So is this person expected to be in charge of visiting all patient homes and setting these up and training them? I sure hope not because this doesn’t seem to scale too well for VNHS.
Finally, my last concern is about accountability and medical error reduction. We talk so much about methods of reducing medical error nowadays and yet we want to go so far as to place critical medical diagnostic functions in the hands of the patients themselves? What is 80-year old Sally doesn’t weight herself correctly or incorrectly takes her own blood pressure? If that becomes the case, you’ve not only voided the purpose of telemonitoring reducing re-admission but you’ve now got quite a messly lawsuit on your hands!
I mostly took a pessimistic approach here to try and stir some debate. What do you guys think?
I agree with Kyle in that a key factor of VNHS' success was the decision to create the new coordinator position. This eliminated the nurses concern that their workload would increase and only mildly changed the workflow. However, I understand there may have been alternate incentives other than just patient concerns for implementing this position.
ReplyDeleteHealth Buddy seems to have benefits as well as disadvantages depending on who is using the system. It can certainly decrease outpatient visits but in some cases could cause re-admission. For patients with chronic diseases, Health Buddy would act as an excellent device to continuously monitor these patients and can do it remotely- decreasing patient visits. The decrease in patient visits benefits both physicians and the patient. Physicians and nurses can also use Health Buddy to their advantage in that it provides them accurate and easily accessible information on their patients. As far as disadvantages go, I fully agree with the argument that elderly patients will not be able to properly monitor their activities without the presence of a caregiver. The advanced technology may be difficult for them to understand/operate and could lead to the patient taking incorrect measurements- increasing medical error. The inaccurate measurements are not only dangerous when determining the patients state of health but will most likely result in the patient having to come in and be seen in order to obtain the correct measurements. Ultimately, Health Buddy can both help and hurt VNHS in terms of hospital re-admission rates.
--I just looked and noticed that my post was never posted, luckily I had emailed it to myself, because I was afraid of the submission process the first time; here's my take:
ReplyDeleteI think a major part of what makes VNHS so compelling, that seems a little glossed over is the fact that it educates patients. When patients know what is going on with their health they will become more motivated to take care of because they understand the consequences of what will happen if they don't! As mentioned by most of the other posters, especially patients with chronic diseases need to have an understanding of what their disease and why certain measures must be taken if they are truly to be motivated in doing it. It can also help in avoiding that terrible feeling that many patients (including myself) have after leaving a doctor's appointment of not knowing what just happened or what your next steps are, will overall enhance the patient experience.
Financially, though, I think as of right now the system of VNHS does not make sense to upscale. As the concluding paragraph of the case states, making the argument of overall system savings as of right now is not affecting the way that they are getting paid by CMS. Until real savings are being shown and proven and the cost of these devices/practices is changed accordingly, it cannot be sustained. Furthermore, I'm not sure from the data given in the case that it can be definitively stated that there is of yet significant cost savings that would impel insurance companies, CMS, etc to make the change. Looking at Anthony's calculation of the costs of the 50 devices costing $164,000 annually, that cost is definitely prohibitive when looking at expanding the service--at least as the incoming "saved" costs are still being realized. Part of this also is that there truly is not yet a direct link that is tied between device usage and hospital readmission/healthcare costs saved. Once it can definitively be shown that these devices are making patients healthier and avoid readmission and ultimately decreasing their healthcare costs, AND insurance and Medicare, etc. start paying out accordingly, then it will make sense for the purchase and usage of more of these devices.
One really interesting topic that Kyle Somers brought up was that of accountability of medical errors made because of incorrect data from the devices. What happens when a patient accidentally inputs the wrong data unknowingly? Even the Health Buddy demo online didn't make it too obvious in showing ways to backtrack if a mistake was caught. Especially considering that the target demographic of the users are older, and presumably less tech-savvy folks, this might prove to be a major obstacle in the effectiveness of these devices and their ultimate medical worth.