Article | December 18, 2021
“Health care is different, the data here is emotional! If you tell me you were buying a fishing rod online and were emotional about it, I’d say you are lying. But I do frequently see people helpless and confused when it comes to receiving health care, managing its costs, making sense of its data.”
- Senior Product Leader inOptum Global Solutions Pvt. Ltd.
Yes, health care is different, and so is product management in it. This piece highlights the top 4 product management trends that are specific to health care and serve beyond being just a list of technologies making their way into health care.
Health care consumerism
Lance broke his ankle in a bicycle accident and is now in hospital waiting for surgery. Which of these words would describe him more aptly— a ‘patient’ or a ‘health care consumer’? The fact that Lance holds a high-deductible health plan, manages an interactive relationship with his primary doctor, keenly monitors his fitness through his smartwatch, and learns about healthier diet plans and recipes online — I can say he isn’t just receiving health care, but making active choices on how to pay for and manage his health. This choice and responsibility that people demand, is ‘health care consumerism’. This trend has been growing since 2015 when value-based care started picking up in the US.
What does this imply for products/PMs?
These are challenging and exciting times to be a product manager (PM) in health tech. This is because people are now demanding an experience equivalent to what they’re used to from other products in their lives, such as e-commerce, streaming platforms, and digital payments, to name a few. Any consumer-facing product (a mobile app, a web-based patient portal, a tech-enabled service) needs to meet high expectations. Flexible employer-sponsored health plans options, health reimbursement arrangements, price transparency products for drugs and medical expenses, remote health care services, and government's push to strengthen data and privacy rights — all point to opportunities for building innovative products with ‘health care consumerism’ as a key product philosophy.
COVID-19 has tested health care systems to their limits. In most countries, these systems failed disastrously in providing adequate, timely medical assistance to many infected people. Prevention is of course better than cure, but people were now forced to learn it the hard way when cure became both inaccessible and uncertain. With lockdowns and social isolation, prevention, fitness, diet, and mental wellbeing all took center stage.
Wellness means taking a ‘whole-person approach’ to health care — one where people recognize the need to improve and sustain health, not only when they are unwell, but also when they’re making health care decisions that concern their long-term physical and mental health. A McKinsey study notes that consumers look at wellness from 6 dimensions beyond sick-care— health, fitness, nutrition, appearance, sleep, and mindfulness. Most countries in the study show that wellness has gained priority by at least 35% in the last 2–3 years. And wellness services like nutritionists, care managers, fitness training, psychotherapy consultants contribute 30% of the overall wellness spend.
So, what do health-tech PMs need to remember about wellness?
The first principle is, “Move to care out of the hospital, and into people’s homes”. A patient discharged after knee surgery has high chance of getting readmitted if he/she has high risk of falling in his/her house, or is unable to afford post-discharge at-home care with a physiotherapist. This leads us PMs to build products that recognize every person’s social determinants of health and create support systems that consider care at the hospital and care at home as a continuum.
The second principle is, “Don’t be limited by a narrow view of ‘what business we are in’, as wellness is broad, and as a health tech company, we are in health-care, not sick-care”. Wellness products and services include — fitness and nutrition apps, medical devices, telemedicine, sleep trackers, wellness-oriented apparel, beauty products, and meditation-oriented offerings, to name just a few. Recent regulations in many countries require health care providers to treat behavioural health services at par with treating for physical conditions, and this is just a start.
Last month, WHO released a report titled “Ethics and Governance of Artificial Intelligence for Health”. The report cautions researchers and health tech companies to never design AI algorithms with a single population in mind. One example I read was, “AI systems that are primarily trained on data collected from patients in high-income settings will not perform as effectively for individuals in low or middle-income communities.” During COVID-19, we came across countless studies that talked about the disproportionate impact on minorities in terms of infections, hospitalizations, and mortality. A student at MIT discovered that a popular out-of-the-box AI algorithm that projects patient mortality for those admitted in hospitals, makes significantly different predictions based on race — and this may have adversely moved hospital resources away from some patients who had higher risks of mortality.
How should I think about health equity as an AI health-tech PM?
Health equity means that everyone should have a fair chance at being healthy. As a PM, it’s my job to make sure that every AI-assisted feature in my product is crafted to be re-iterative and inclusive, to serve any community or subpopulation, and is validated across many geographies. To prevent any inequitable AI from getting shipped, it is important to ensure that the underlying AI model is transparent and intelligible. This means knowing what data goes into it, how it learns, which features does it weigh over others, and how does the model handles unique features that characterize minorities.
Integrated and interoperable
In every article that I read on topics such as digital platforms, SaaS, or connectivity with EMRs, I always find the words: ‘integrated’ and ‘interoperable’ therein. Most large and conventional health tech companies started by offering point-solutions that were often inextensible, monolithic, and worked with isolated on-prem servers and databases. To give a consistent user experience, leverage economies of scope, and scale products to meet other needs of their customers, started an exodus from fragmented point-solutions to interoperable, integrated solutions. The popularization of service-oriented architectures (SOAs) and cloud vendors like AWS, Azure, and GCP has also helped.
The what and how of integrated-interoperable solutions for PMs:
Integrated solutions (IS), as I see them, are of two kinds — one, in which as a health tech company, we help our customers (health systems, insurance companies, direct to consumers) accomplish not just one, but most/all tasks in a business process. For example, a B2B IS in value-based care contract management would mean that we help our customers and health systems by giving an end-to-end solution that helps them enter into, negotiate, plan for, manage, get payments for their value-based contracts with health plans.
In the second type of IS, we offer products that can be easily customized to different types of customers. For example, a health management app that people can subscribe to for different programs such as obesity, diabetes, hypertension, cholesterol management, as needed. The app works with different datasets for these programs and uses different analyses and clinical repositories in its backend, but still delivers a consistent user experience across programs to a user who enrolled in multiple programs, say diabetes and weight management.
‘Interoperable’ simply means that one product should be able to talk to other products both in and out of the company. For example, if product-A can alert a doctor about any drug-drug interactions or allergies a patient might have, while she is writing prescriptions for the patient in product-B (an EMR), then product-A does talk to product-B, and hence, is interoperable. This trend is picking up further with the growth of IoT devices, and industry-wide participation in adopting common standards for data exchange.
Though the article derives much of its context from US health care, I have tried to keep a global lens while choosing these topics. For developing economies like India, digitization is the number one trend as much of the health system is still moving from manual records to digitally store patient and medical data in EMRs. The good news is that India is booming with health-tech innovation and that is where consumerism, wellness, and equitable AI make sense. Once companies develop enough point-solutions for different health system needs and use-cases, Indian health tech will see a move towards creating integrated, interoperable (IGIO) systems as well.
There are some other trends such as — use of non-AI emerging tech such as Blockchain in health information management, cloud infrastructure for health tech innovation, big data and analytics to improve operational efficiency in areas such as claims management and compliance reporting, Agile product management for co-developing with and continuously delivering to clients etc. — but I see them either as too nascent, or too old to feature in this list.
Finally, as a health tech product manager, you can use the following questions to assess your products against the above trends — (Consumerism) do the products that I manage, empower consumers with choice, information, and actionability? (Wellness) Does my product emphasize keeping them out-of-hospitals and healthy in the first place? (Equitable AI) Am I sure that my product doesn’t discriminate against individuals belonging to underserved populations? (IGIO) And finally, is my product scalable, integrated and interoperable to expand to a platform, in the true sense?
Article | December 18, 2021
Artificial Intelligence or AI has attained continuous evolution over the years and witnessed widespread adoption across major industries of the globe. The Forbes report of December 2021mentions that the number of AI startups since 2000 has increased 14 times, and investments in AI startups have grown six times. It underlines the fact that the AI industry, powered by its path-breaking developments and innovations, has always been an attractive and trending option in the market.
Within a very few years, AI has taken over different segments of healthcare like wellness, early detection, diagnosis, decision making, treatment, research, training, public health functions (surveillance and outbreak response), virtual care etc. A study by Accenture claims that AI-enabled devices and gadgets meet 20% of the clinical demands, and this has reduced the unnecessary visits to hospitals by a great number.
Applications of AI in healthcare is broadly categorised into 3 segments, namely, Patient-oriented AI; Clinician-oriented AI; and Administrative-oriented AI. The transformative role of AI in healthcare is undeniable, as it scripts new journey for patients and practitioners, alike.
According to Healthcare IT News, 63% of the research subjects agree to the observation that the devices and machinery enabled by AI have provided excellent value to the specialty healthcare divisions like radiology, generic pharmacy, pathology, etc.
The rapid growth of AI in highly delicate domains like healthcare calls for great promise to accelerate diagnosis and treatment. At the same time, it also puts ethics, patient safety and privacy concerns at the heart of it; thereby calling for a framework of governance. Gartner report of July 2019 predicted the application of AI in more than 75% of the healthcare delivery organizations (HDOs) around the globe.
Since most of these HDOs are new to adopting and applying AI-enabled machinery and services, AI governance is crucial to prevent the actions that may lead to errors, misjudgements and further chaos. Moreover, the degree of variance in the application of AI is high, and therefore it is not advised to implement the AI mechanisms without proper guidance or governance.
From AI-enabled smart bands to pacemakers, the range of devices and gadgets offered by the AI industry is simply remarkable. The implementation of AI in the healthcare sector has proven to be highly effective in drastically reducing the scope of slipups. Moreover, AI has also facilitated early detection of illness with the help of daily use gadgets and devices in a smart way.
At this juncture, it is equally important to create data governance framework that ensure ethical principles are applied to patient, providers and payers’ data. Further, AI initiatives by healthcare providers should be created using transparent protocols, auditable methodologies and metadata. These technologies should do no harm, reduce biases and help patients make informed decisions about their care.
A significant part of AI governance also lies in change management. To build trust towards AI’s adoption across the healthcare ecosystem, there should be a dialogue between clinicians, scientists, technologist and end-users. Such discussions will address the opportunities, value and investment, including concerns across the stakeholders.
In fact, prominent think tanks suggest healthcare providers to establish an AI Governance Council to monitor the value, investment and use of strategic AI capabilities. Some of the crucial roles and responsibilities for the Council include addressing legal and regulatory compliance; clinical evaluations; ethical usage guidelines and organisational deployment of AI across the system.
AI is indeed a revolutionary technology that has huge surprises up its sleeves for the future. But exploring new frontiers comes with its fair share of challenges. Establishing appropriate governance over AI implementation and initiating a conversation around the ethical implications and regulations as well, will play a fundamental role in the introduction and scale-up of AI in healthcare.
Article | November 2, 2021
The fall is a time of renewals and choices. It is also a time of so called “open enrolment” for health plans. It is the one time of year we can study and learn about the options offered through employers or government sponsored plans. Individuals and small business owners alike are also are faced with a myriad of choices with confusing and often contradictory language promising lower premiums with higher out of pocket costs for covered services subject to deductibles. What does it even mean anymore when your monthly premiums exceed your pay check and you still have to pay for your colonoscopy or your insulin? Where is it all going?
Let’s imagine you twist your ankle playing basketball. You might go to an urgent care, receive an X-ray, probably be examined by a non-physician, and then referred to your primary care, who can’t see you for a few weeks but eventually sends you to an orthopaedic who takes another X-ray and treats your injury. Weeks have passed, multiple visits, time out of work, and co-pays, not to mention the out-of-pocket fees associated with imaging and perhaps a $100 ace bandage. What stops you from going straight to the ankle specialist in the first place? First, we have become conditioned to follow the directions dictated by the insurance companies, even when restrictions are not in place, patients have been convinced that stepping out of line will make all insurance promises null and void resulting in catastrophic bills and financial ruin. Second, the doctors and their office staffs have been conditioned to deny entry to any patient who does not have the proper referral, authorization, or identification. There are dire consequences for both if the insurance rules are not followed and fear keeps both sides aligned.
The past two decades have seen an explosion of healthcare costs. Health insurance has become the single biggest line item second only to payroll for most businesses. It is no coincidence that as the government increased its role as payor with state subsidies, the prices have gone up. Much like college tuitions, when loans are easy to obtain and guaranteed by federal support, there is little to deter those in charge from increasing the price. After all, everyone is doing it, it must be OK, and even if students end up in debt, it will be repaid because they have received the value of a great education. Right? But unlike higher education, healthcare is a necessity. We cannot avoid it, and there needs to be a reliable mechanism in place to guarantee access.
Ironically, as charges and prices have continued to escalate, payments to doctors have diminished. Why medicine is the only service industry where there is no transparency is truly astounding, especially since the there has been no increase in so called “reimbursements” for decades. As physicians, we have been complicit, being fully aware of the discrepancies between what is charged and what a patient’s insurance will pay. Even as patients began to have higher deductibles, and therefore higher out of pocket expenses, we continued to follow the rules, asking insurance permission to collect payment from the patient. It is not surprising that bad debt accounts for over 50% of most account receivables and why over 70% of doctors are now employed by hospital networks or private equity, who not only go after patients, but benefit from the repricing that occurs when insurers pay a negotiated amount as opposed to the charge. In other words, we pay more not just for less, but for nothing.
But what if we twisted our ankle and went directly to that specialist and paid out of pocket a transparent price? What would it take for that to happen? Not much, the cost of care is predictable, and because payments have always been decreasing, most physicians have learned to be economical. Plus, out of pocket costs are capped by federal law, so no patient is really responsible for catastrophic bills. Charges inflate to cover overhead, but if payments were guaranteed and immediate, then the cost of doing business goes down. Add technologies like telemedicine to a practice and you have increased patient access to a doctor without adding more personnel. Direct pay doctors are emerging all over the country and have consistently offered better access and more affordable care. The bar is also being set by independent surgery centers and imaging centers who offer better outcomes at lower costs. Perhaps motivated by prohibitive pricing, better options have emerged that have moved patients away from expensive operating rooms to safe, office-based procedures. Even cutting-edge cancer therapies can be delivered at home, preserving more of the healthcare dollar for medical care rather than the complex system built to manage it.
Competition and choice inevitably drive prices, but in a monolithic system the price is not negotiated, but instead it is set by only a few, in this case the big insurers. Small businesses cannot compete when bigger companies come to town. Eventually, the local hardware store gives way to a national brand, and the consumer is left with fewer choices and eventually higher prices. Amazon disrupted this equation by creating a marketplace for individual buyers and sellers. The convenience of finding a trusted brand, no longer available locally, is irresistible and the reason why we became loyal consumers. Healthcare is no different. Trust exists implicitly between a physician and patient, because it is an authentic, empathetic, and logical relationship. Trust does not exist between a patient and their insurer, on the contrary it is an unsympathetic business relationship without transparency or consistency. Few doubt the insurance company’s top priority is the premium, not the patient. Creating a direct relationship between the doctor and patient is a common-sense approach that serves both stakeholders well, and requires merely a fair and affordable price. But do doctors have the capability or the will to do it and if so, can the rest of the system follow?
Never in the history of modern medicine have physicians been more dissatisfied. US healthcare used to lead the world in innovation and outcomes, now we struggle to break the top thirty. We may have the most brilliant doctors and scientists with access to the best resources, but the need to maximize profits while catering to special interests, be they commercial or political, has led us to favour certain therapies over others despite marginal proven benefits. Doctors have little autonomy and less authority; prescribed treatments are routinely denied by insurance companies without a second thought or appropriate peer review. In fact, insurers even renamed us “providers”, a term used to by Nazis when referring to Jewish doctors to devalue them professionally. Over 56% of physicians are burned out, nearly all report moral injury and as hospitals have systematically replaced doctors with non-physicians with limited training, we have watched the standard of care deteriorate. It is no wonder we have witnessed the single biggest loss in life expectancy since WWII. The prognosis is grim, but there are solutions.
We need to reinvent healthcare by removing the middleman. We don’t have to set the price, but we can make it transparent so patients can decide for themselves if it is worth the inconvenience, the delay, and the co-pay to use insurance or just pay directly. Health savings accounts are tax deferred and can cover an out-of-pocket maximum in just a couple of years. Paying for care means there are no surprise bills or out of network costs, because there are essentially no networks and therefore no need to follow restrictions. You’d be hard pressed to find a doctor or hospital unwilling to accept an immediate cash payment, especially when it costs nothing more than the service provided. There are no billing cycles, or claims to prepare, no up coding, or authorizations. Doctors free to care for patients, patients treated individually and not subject to protocols designed to maximize charges. There are literally thousands of direct pay primary care and specialists now available all over the country and they are building alliances with likeminded people providing imaging, ancillary services, surgery centers, and prescriptions all at fair market prices. More and more employers are moving toward medical cost sharing plans that not only lower the cost of care but the cost of administration. Even the biggest payor, namely the government, sees the benefit of price transparency and is piloting models of direct contracting.
We will always need coverage for those unexpected events, emergencies, or hospital-based services, but all the rest - doctor visits, screening tests, and outpatient procedures - are easily affordable. After all, do we use our car insurance to pay for an oil change? If we did, the cost would be prohibitive and few of us would drive. But health insurers have lost our trust, they no longer cover necessary services and no longer honour contracts with physicians or patients. It is time to offer another option and let the patients and doctors get back to the real business of medicine.
FUTURE OF HEALTHCARE
Article | October 25, 2021
In today's uber-fast-paced world, the human race, in general, has gotten highly comfortable running on all cylinders in the rat race of life, especially people in India. Our country is a land where opportunities are aplenty, and competition is ever-present, which makes every day life so tedious and constant that taking a breather is something that people can rarely afford. This has led to increasing cases of anxiety, depression, high blood pressure and insomnia. These cases rose to such high numbers that it gave way to one of India’s most prominent industry sectors: The Wellness Industry.
Though the industry captured global attention between 2015 and 2017, a study conducted by McKinsey & Company found that the wellness industry is currently valued at $1.5 trillion globally. This sudden boom can be attributed to the realisation that it is more important to remain healthy than getting healthy. Furthermore, the report, produced after analysing 7500 consumers in six countries (including India), has offered keen insights into consumer behaviour. When it comes to wellness consumers, their trends can be grouped into six categories:
Health: People are now investing in many remote medical devices that can constantly monitor their state of well-being. With the increase in popularity in digital wearables, telemedicine, and remote patient monitoring services, this trend is bound to increase.
Fitness: People are exercising more. Whether it’s jogging, going to the gym, investing in a pedometer, FitBit, etc., there has been a steady increase in people exercising more.
Nutrition: Dieting has always been a significant part of being healthy. An increase in dietary food, supplements, nutrition coaches can be observed in recent years.
Aesthetics: With a major chunk of India’s youth population getting invested in their social media, notably the pictures that they post, aesthetic well-being has seen a sharp increase. This includes investments in specific Athleisure clothing apparel (Nike, Addidas, Puma), skincare products (collagen supplements, face masks), and plastic surgery.
Sleep: Burning the midnight oil is counterproductive. There has been a steady increase in consumers willing to invest in sleep medications, specialised mobile applications that track their sleep and the state of their sleep, ASMR generating devices, White noise devices, and other products that can enable a consumer to maintain a healthy sleep cycle.
Mindfulness: Introspection, understanding the body and its processes to the molecular level, and figuring out ways to implement clarity of thought and methods for improving focus have been huge draws for the wellness industry. Furthermore, with central government’s schemes like AYUSH and the introduction of International Day of Yoga by the United Nations, this particular trend has seen enormous growth.
Impact of these trends on the future of Indian wellness industry
Organic Products: According to APEDA, India has become one of the largest producers of organic products. A growing number are actively investing monthly in organically grown produce, meat that is organically processed, oil that is wood-pressed or cold-pressed, cosmetics made from organic materials, and clothes made from pure cotton instead of manufactured materials. People becoming more conscious of what they put in their bodies has led to a steady increase in organic shops across India.
Exercise, Dieting & Nutritional Supplements: From using simple Calcium supplements and energy drinks to adhering to a strict diet regimen, today’s consumers are genuinely worried about falling sick. This has led to an increase in purchasing supplements. Another trend can be observed where an increasing number of consumers have started buying vitamin, Zinc, and iron tablets, to shore up immunity. Furthermore, Indians have begun consuming gluten-free cereal, cold-pressed juices, Kale products, Avocados, and other food products recommended to be healthier alternatives. Indians have also become BMI-conscious, and an increasing number of them have started to invest in gyms, yoga/cardio classes, exercise-wear, sports wearables, and other products that can enable a person to work out more effectively.
Constant Increasing Demand for Oxygen: Even before the second wave of the COVID-19 pandemic, getting access to 99% breathable oxygen has pure oxygen was a necessity considering the rising concerns of pollution in Indian cities. As per the ‘World Air Quality Report, 2020’ prepared by Swiss organisation, IQAir, 22 of the world’s 30 most polluted cities are in India, with Delhi being ranked as the most polluted capital city globally.
Moreover, people who indulge in extreme physical workouts exercise, or suffer from high-altitude sickness, need oxygen handy to maintain their wellbeing. In India, prominent wellness companies like UCS Wellness Pvt Ltd have made significant strides to ensure that every individual has access to oxygen through their innovative specially outfitted 18-litre aluminium-bottled oxygen cans of 18 litres under their brand gO2therapy. With the pollution rate showing no signs of slowing down, and the steady increase in demand for oxygen, it would be no surprise to find every household medical kit fitted with a portable oxygen cylinder.
Transitioning to Digital Platforms: With the increase in popularity of Telemedicine and Remote-patient monitoring, healthcare and the wellness industry are gaining an aggressive online presence. There are many online exercises/online videos, fitness apps, meditation apps, motivational apps, power coaches, and so much more. Indians find it easier to use these online tools combined with a digital wearable to keep their well-being in the best of conditions.
Investing in Social Media Influencers: With the increase in online dependence, the voice of social media influencers is soon to be gospel when it comes to maintaining a fit body and healthy mind. Much like how mainstream celebrities endorse various products, the wellness industry has seen great rewards in deploying online influencers to support their products. Typical examples can include a famous workout specialist advertises particular apparel, gadget, energy drink, or brand of Whey Protein distributors as part of their video.
Alternatives to Allopathy: In the Indian market, the wellness industry has seen a shift in paradigm where an increasing number of consumers opt for Siddha, or Ayurveda substitutes, instead of conventional medicine. This is seen more in the age group of 40+. This particular age group has patients with a long history of high BP, high cholesterol, and other ailments that require continuous monitoring and medication. They feel that the healthier choice is in traditional medicine or treatments like Panchakarma, Ayurveda, or Siddha. Conventional medication provides them with little to no side effects, which is the primary reason for its increasing popularity.
India is expected to become a wellness hub in the global community following a 12% growth per annum. The Make in India initiative is expected to bring in more investments and opportunities in this sector. The Ministry of AYUSH, with a separate department for Yoga, has been exempted from service tax. A budget of around ?3,400 crores has also been earmarked to be spent over the next five years to help set up and strengthen Ayush Wellness Centers under the National Ayush Mission. This has sparked an increase in startups and businesses focusing on the wellness sector.
Meanwhile, the global pandemic is also giving rise to a new consumer behaviour called wellness rebound where they are becoming more health-conscious and striving towards regaining their health soon after recovering from an illness. Considering the aftermath of the pandemic, the aggressive implementation of technology, and the constant consumer market in India, it can be inferred that the wellness industry will evolve and expand further with little to no backslide.