Telemedicine for Diabetes

Telemedicine (TM) is becoming increasingly established as a part of mainstream medical care. ¹ With the development of new wearable devices, portable sensors, and wireless communication devices used for mobile health, there is increasing demand for medical care to be available remotely. Just as shopping, financial transactions, education, and training are now being conducted electronically with no apparent increased cost to the consumer, remote medical care is becoming a commodity that is increasingly available within the cost constraints of current health care, and TM care to remote locations is becoming a routine part of medicine.

TM Contexts Affect Economic Outcomes

TM can be delivered in many different contexts. Therefore blanket statements about financial costs of TM, effectiveness of TM, or the popularity of TM among patients or health care professionals (HCPs) are often not helpful if the context or type of TM is not clearly defined. In one context or for one type of patient, TM can be cost saving and in another it can add to costs. Furthermore, the perspective of the stakeholder is important because TM can lead to increased costs for the payer but increased revenue for the provider or it can lead to decreased costs for the payer and decreased revenue for the provider. In some cases TM has no direct financial effect on payer or provider revenues, but when this intervention is linked to patient outcomes, TM can result in time saving, greater satisfaction, or preferential selection of health care.

TM can be sensor-based or non-sensor-based, and if sensor-based can be linked with mobile or immobile sensors. Furthermore a TM app for mobile health can be linked only with 1 proprietary sensor or it can accept data input from an open system of other sensors or there can be a hybrid of open source whereby 1 type of measurement can be made only by a single sensor and other types of input can come from a variety of brands of sensors. TM can utilize automatic or nonautomatic data uploading. Furthermore, the setting of use can be in a fee-for-service environment or an accountable care (or single payer) environment, where the financial incentives and treatment outcomes can be very different from each other. The purpose of TM can be either to treat acute disease or chronic disease. The timing of message delivery to the patient can be synchronous (in real time, such as by phone, video, or text message), or asynchronous (by delivering information or advice some time after the original request for information or advice) such as by an email or posted message on a secure web portal, whereby there will not be immediate back-and-forth between the patient and HCP. The TM can be provided by a hospital-based or clinic-based HCP or by a freestanding HCP who is not part of a patient’s usual care system. The recommendations from a TM system can be automated and delivered directly from a cloud computing system, or it can be from the HCP based on decision support capability.

Economic Winners

Because TM can be delivered in various contexts, there can be economic winners and losers when TM is initiated, depending on the type of TM that is delivered and the needs of the stakeholders (which are generally considered to be patients, HCPs, and payers). ² Economic winners can include patients who will save time by not having to spend money on driving and parking or lose work time for visits to the office of a HCP. ³ Accountable care organizations (ACOs) save money from TM visits being faster than in-person visits because they will be spending less for providing each visit. ACOs will also save by being able to more efficiently allocate specialists to the patients who need them the most, rather than provide in-person visits for patients who might be located geographically close to the specialist and do not greatly need this visit, but not be able to provide in-person visits to other patients who live far from a specialist and who might go on to break down for lack of this visit. ACOs can design TM programs that use up only small amounts of resources (or even lose a small amount of money) for specific types of communications with HCPs but result in an enhanced reputation and greater numbers of patients signing up for their plan, resulting in greater revenue. Finally, hospitals, clinics, and ACOs will save by not having to build, staff, heat, or clean waiting rooms. Walgreens, the nations’ largest pharmacy chain, now provides a free app for gathering health-related information from a suite of proprietary sensors that are only sold at their stores. Presumably, the cost of providing this service is more than recouped by increased sales of these sensors as well as sales of other products that are purchased when customers come to Walgreens to purchase sensors. On October 28, 2015, The US Department of Health and Human Services (HHS) acted to make it easier for ACOs providing TM to qualify for Medicare incentive programs. ⁴ This policy shift was made because HHS believes that the use of TM can help reduce costs for the Medicare program. ⁵

Economic Losers

Conversely, there will economic losers with some forms of TM. The costs to ACOs can increase if TM care is not rationed and the utilization of this service becomes excessive. Patient access to HCPs might decrease if TM is rationed to avoid overuse. Fee-for-service (FFS) HCPs currently receive less reimbursement for synchronous TM visits than for in-person visits and far less reimbursement for asynchronous TM visits than for in-person visits. The general perception among many HCPs is that the biggest barrier to widespread adoption of TM is poor reimbursement. In fact, TM is gradually becoming established in spite of poor reimbursement for FFS HCPs, so new economic models will be required to accommodate this service to create economic winners and not losers. ⁶ The general population could lose out if the nation’s inventory of acute care facilities should decline with increasing adoption of TM, in the event of a disaster that requires widespread acute care. The benefits to each hospital or health plan of shrinking its facilities must be balanced against the common good of maintaining elasticity in the supply of in-person acute care.

The Value of TM Health Data

Compared to obtaining data through non-sensor-based methods such as clinical trial outcome data, TM offers an opportunity to create value by enhancing traditional data sources for health care. Better analytics of cloud aggregated big data from digital sensor adds value to the data and mobile sensors decrease the cost of obtaining valuable data. Compared to traditional health data collection methods from immobile sensors, delivering analog input based on patient-entered observations, TM delivers data automatically from mobile digital sensors that is more valuable at a lower cost.

Ownership of Health Data

TM applications are beginning to move beyond storage and reporting to delivery of interventions and predictions. TM app companies for diabetes will soon be in a position to sell contextualized blood glucose (BG) data sets (including responses to meals, exercise, and treatments) to blood glucose monitor (BGM) manufacturers, pharmaceutical companies, and payers. Possession of big data will lead to business opportunities. ⁷ A combination of analyzed BG data from apps along with claims data from payers, clinical trials research data from pharmaceutical companies, and patient preference data from surveyors could be valuable to BGM manufacturers and pharmaceutical companies. The former would want to determine how BGMs are actually used in the real world and the latter would want to analyze these types of data to discover benefits and risks that were not evident during clinical trials of their diabetes drugs. Analysis of BG data sets accumulated by developers of these apps will be able to help inspire the creation of new products and new indications for existing products. ⁸ In the past year, the two largest continuous glucose monitor companies in the US, DexCom ⁹ and Medtronic ¹⁰ , have formed alliances with Google and IBM, respectively. I expect that novel analytics for management of glucose data streams will be developed by these two alliances of a device company and a software company. Analysis of data from wearable devices will also help payers to stratify patient risk and inform earlier interventions to improve outcomes and lower costs. ¹¹ Who will be designated as the owner of this potentially profitable data? Will it be the TM app developer, the sensor company, the payer, the hospital, the health care provider, or the patient?

Conclusions

TM is part of the new digital age that is transforming the world. There is more to TM than not doing the same thing as in-person medicine, except doing it remotely. This practice actually represents a new paradigm in medical treatment and can bring financial gains when applied wisely. Economic opportunities in diabetes TM require proper matching of patients, technology, and payment. In the next decade health care researchers will be searching for the settings where specific types of TM have the most to offer, both clinically and economically for diabetes and other diseases. These settings will be identified and TM will become increasingly adopted.