The previous articles in this series showed how payers, providers, and digital health companies try to prove that they’re helping to create healthier patients. Sara Shanti, a partner specializing in health care at law firm Sheppard Mullin, says that organizations in the wellness space are searching for strong algorithms. But they also want to ensure that technology leads to, and clearly reflects, improved and worthwhile outcomes. This is not likely to emerge for some time. But this final article looks at how some organizations are filling the gap.
Rigor at a Weight Loss Clinic
Dr. Brett Osborn, author of the book Get Serious, is a cynic regarding most wellness measures, particularly those offered by apps. Vital signs are hard for wearables to measure accurately, and popular measures such as the number of steps you take each day don’t clearly correlate to ultimate patient health.
But Osborn’s main point is that health measures such as blood pressure are multi-variable, depending on a mix of activities and personal demographic traits. Furthermore, activities depend on each other. For instance, an improvement in your mood might lead you to exercise more. “You would need to track 50,000 people to establish clear effects for most interventions,” he says.
Osborn’s clinic offers four health supplements: only the ones that have measurable effects. The clinic suggests that some patients use a continuous blood glucose monitor, because it’s immediately actionable: It helps then see the effects of something they just ate.
They also use an app for food tracking, because they can see what eating habits help people get leaner. Generally, Osborn says, one can measure nutrition much more easily than exercise.
Measuring the Ineffable: Psychological Evaluations
Because psychological states of minds don’t create observable statistics like A1C levels, how can the effectiveness of psychological interventions be measured? Jessica L. Schleider, a clinical psychologist who is now associate professor of medical social sciences at Northwestern University, says that simple questionnaires can turn up depression, one of the most common mental health conditions. You might well have been handed one of these questionnaires during a routine PCP visit: the Patient Health Questionnaire-9 (PHQ-9) or the Generalized Anxiety Disorder 7-item (GAD-7) scale.
Schleider says that these two questionnaires build on standard text used in the psychiatrists’ Bible, the DSM, and were evaluated by comparing their results to standard, comprehensive, diagnostic interviews that often take three hours. Schleider’s teams have used the PHQ-9 and GAD-7 to show the effectiveness of an innovative one-session counseling service.
As background, it’s worth stating that the insurance industry has settled on a ten-session course of therapy for most conditions (which of course was seen as ridiculously inadequate by the classical Freudian psychoanalytic movement, who could treat patients for years at a time). In actuality, most people—particularly young ones—never get through more than four of the ten sessions they’re allowed.
For many, Schleider finds, her one-session treatment, delivered in-person or online, can improve their symptoms. She says that this could be of critical value, because 80% of youth in the U.S. with significant mental health have no treatment currently.
Proem Behavioral Health also deals with states of mind that have no objective measures. CEO John Letter points out the chosen course of treatment must be customized for each patient, and that Proem seeks to replace the “trial-and-error method that many patients face” with reliable tools for patient assessment and for measuring outcomes. They measure outcomes “meticulously” at the symptom and functional levels, using tools created by globally renowned psychiatrists.
Proem’s licensed digital tools ask patients to rate their symptoms through short assessments. The ratings are used to measure outcomes for 17 adult and 24 pediatric mental health conditions.
Proem also uses a tool called the Sheehan Disability Scale (SDS) to measure improvement in a patient’s functional impairment. Letter says, “The SDS asks three questions about how well a patient is functioning at work/school, social/life, and family life/responsibilities, as well as how many days in a particular timeframe the patient missed school or work or was unproductive at school or work.” The PHQ-9 and GAD-7 are also offered because providers are accustomed to them.
Proem includes a short survey to measure the patient’s relationship with their therapist or provider, showing the patient’s “therapeutic alliance,” which behavioral health experts have found to be a key indicator of treatment success. Proem can also measure important traits of patient behavior, such as anger or aggression, and track the ups and downs of these traits in comparison with the use of therapy and medications over time.
The Midwest Institute for Minimally Invasive Therapies (MIMIT) handles a number of conditions, such as peripheral artery disease, arthritis, and fibroids, that can be treated without invasive surgery or with minimally invasive procedures. As part of follow-up, MIMIT uses both remote monitoring tools and patient-reported feelings.
Standards and Regulations
Dr. Kate Behan, Chief Medical Officer of Arcadia, gave me a whirlwind tour of standards and how they are evolving.
CMS has historically incorporated a patient-centered focus into numerous programs through patient experience measures that assess effectiveness and guide improvements in the patient experience: Comprehensive Primary Care Plus (CPC+), the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model, the Merit-based Incentive Payment System (MIPS), and the Hospital Value-Based Purchasing Program (HVBP).
CMS is now building on its learnings from patient experience measures and incorporating patient reported outcomes measures (PROMs) into recent value-based care models. These go beyond measuring how patients episodically perceive their healthcare experience to measure disease symptoms, health-related quality of life, and behaviors that affect health. Behan also points to research on PCOMs at the Patient-Centered Outcomes Research Institute (PCORI) and adoption of Patient-Oriented Evidence that Matters (POEMs) by professional societies like the American Academy of Family Medicine, as indicators that the healthcare industry is advancing patient-centered measures.
Behan also says that CMS’s new Making Care Primary (MCP) model is exploring “whole-person health,” incorporating social determinants of health such as housing and nutrition. Just to confuse us, CMS calls these SDoH issues health-related social needs (HRSNs). These initiatives also pay more attention than before to mental and behavioral health.
Another organization trying to create meaningful health measures is the Peterson Health Technology Institute (PHTI). The introductory document for their assessment framework says: “The selection process for which technologies are evaluated will be based on several factors, including market relevance, disease burden, level of spend and claimed savings, and evidence quality and availability.”
The Digital Medicine Society (DiMe), a nonprofit, helps digital app companies and their clients evaluate the effectiveness of their interventions, as part of DiMe’s mission to promote digital interventions into health. In a paper published in Nature, the DiMe team turned up 78 wellness measures that have been applied to digital health interventions. According to one of the authors, CEO Jennifer Goldsack, there are now more than 80. This is clearly too many measures, leading (as Goldsack says) to confusion about which measure to use when designing and evaluating a digital product.
DiMe augments the wellness measures with other important issues in product design: “patient experience, provider experience, product design, cost effectiveness, interoperability, etc.” Their Evidence Defined framework guides the developers and payers in choosing measures.
DiMe is highly committed to diversity, equity, and inclusion (DIE). Here, too, they offer a that lays out the stages of design and development where DIE needs to be considered and shows the expected cost benefits of designing for inclusion. Goldsack says that well-designed inclusion efforts always have an enormous payoff for the insurer, employer, and patients using the digital interventions.
Measuring Where We All Are Heading
This series has looked at the ever-shifting, sometimes surprising definition of “wellness” and what we consider to be the truth in striving for it. While some of us measure wellness as completing a hundred-kilometer bike ride or just getting up the stairs in our house, payers and providers are measuring totally different things.
The wellness space is not just a matter of touchy-feely encouragement and taking walks in the woods (although those are definitely worth doing). Many objective and well-tested measures are being collected by organizations that want you to be a healthier and happier person.
Wellness, of course, is also the goal of value-based medicine. Over time, improved measures of success will allow more robust and fair value-based programs, bringing us closer to the goals of health care reform.
