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ALDA & Associates International, Inc. Newsletter

2023 WINTER EDITION

Features & Articles in this issue

Breaking News

 

In this issue we look at the concept of At Home Hospital Care which may become a growing trend in the pursuit of lowering total healthcare costs and whether Artificial Intelligence is appropriate for use in healthcare or if healthcare is ready for the use of Artificial Intelligence.

A reminder about our Newsletter. Since we specialize in Healthcare, the feature article will always deal with healthcare. Its content will benefit all constituents-providers, insurers and patients so even though you may not work in healthcare you will benefit in knowing what is emerging which may affect your patient experience. The second article may also feature healthcare but may also focus on an aspect of business that will be of interest to all of our readers. Additionally, earlier editions of the Newsletter are archived on the website. Readers can find them by scrolling down to the bottom of the newsletter.

ALDA continues to add client engagements in the industry and is now working with a new company in the dental field developing software to streamline the front desk process and the patient experience. We continue to perform due diligence for a healthcare institution as they consider new investments. Our new clients continue because we performed successful engagements for them in the past or are former colleagues looking for our significant expertise and experience. 

Book News

   Essentials of Corporate and Capital Formation
   by David H. Fater
   ISBN (13): 978-0-470-49656-5
   ISBN (10): 0-470-49656-8
   Cost: $39.95
   Paperback: 224 pages


 

 
Brief Description: A simple and effective guide to the mechanics of finance and corporate structure.

About ALDA:

ALDA & Associates International, Inc. is a business and financial consulting firm committed to assisting companies with:

We help physicians, scientists, entrepreneurs and managements change the world. Our experienced professionals are dedicated to helping clients unlock inherent value and create new value. The real-world experience of the ALDA team is leveraged for each client's unique circumstances, challenges, and people.

Among ALDA's hallmark services:

Our experienced professionals can show you all the right steps. For additional information on how we can help, please contact us by email at dfater@alda-associates.com or rcohen@alda-associates.com.

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Is Hospital at Home a Viable Strategy for the Future?

Ever since the Affordable Care Act was passed in 2010 there has been a litany of strategies put forth to achieve the Triple Aims of (a) Improving the experience of care, (b) Improving the health of populations, and (c) Reducing per capita costs of health care. The Center for Medicare and Medicaid Services (“CMS”) has created an innovation center and experimental initiatives such as Accountable Care Organizations, Bundled Payments for Joint Replacements and other similar programs have resulted. Perhaps the most significant area for cost containment has been the movement of services to free standing outpatient facilities away from and not owned by hospitals. Examples of this (funded by private equity) include the proliferation of urgent care centers, consolidation of dental practices, dermatology practices and even ophthalmology. A significant effort is also being made, not only to move services to free standing facilities, but to substitute for the hospital in entirety by embarking on at home hospital care.

Health systems are increasingly investing in acute hospital-at-home technology to ease overburdened hospitals, reduce costs and improve outcomes. By equipping patients’ homes with biometric devices, along with tablets and other ways to communicate with clinicians, organizations aim to provide inpatient-level services to those who don’t need intensive care.

Some safety groups and unions argue the tools, data and operational efficiency are insufficient to justify the millions of dollars already put toward vendors and programs. But providers claim the technology, combined with in-person visits, has paved the way for a safe transfer of care from the emergency department or an inpatient bed to the home. Many have partnered with vendors to try to ensure seamless delivery of services, while implementing processes to train clinicians and identify the appropriate patients to participate.

One CEO of a 17 hospital system believes that this is an enduring strategy and has partnered with a hospital-at-home company called Medically Home. They are developing a strategy to deploy this concept across their entire system. (Interestingly enough, Medically Home has received a $100,000,000 investment from the Mayo Clinic and Kaiser Permanente.) This CEO has acknowledged that there are some regulatory and reimbursement issues to overcome, but is willing to take a little bit of risk upfront.

The COVID-19 pandemic kick-started some hospital-at-home programs while revving up others. CMS issued a waiver in November 2020 to establish a home hospital Medicare payment matching inpatient stays. Within a year, the federal agency approved more than 66 health systems and 144 hospitals to provide hospital services in a home setting. As of  November 2022, the number of participating health systems and hospitals has nearly doubled to 114 and 256, respectively.

Still, some health systems have been wary of pursuing the programs without a guarantee of ongoing coverage. The Medicare waiver will stop at the end of the COVID-19 public health emergency, unless Congress passes legislation to extend it. And private insurers generally have been hesitant to reimburse hospital-at-home care because limited outcome data is available to adequately justify the expeditures. As you might expect, quality experts and nursing organizations are also waiting for more data to declare hospital-at-home care a safe substitute for in-person services.

 It goes without saying that health systems embarking on hospital-at-home care should consider the patients’ (and their families’) technology literacy, ruling out any potential candidates who aren’t comfortable with the tools. There are too many people that are incapable of using their smartphones, much less medical devices, and are not even suitable for remote patient monitoring services.

A registered nurse and assistant director of nursing practice at National Nurses United (a 225,000 member nurses’ union whose mission is to win workplace and health care justice by building the nation's most powerful union of direct-care registered nurses and by fostering a social movement of nurses allied with the patient public) is not a supporter of at home hospital care. She believes it shifts the burden of care to the patient and their family, while still charging the same fees as in the hospital environment. Furthermore, she believes that technology is not a replacement for a human being that has the knowledge and skill to treat acute patients.

Outside of payment and technology hurdles, legal risks may serve to deter health systems from adopting this practice. Few regulatory requirements exist when it comes to the safety and quality of hospital-level care in the home setting. Under the CMS waiver, programs must have a rapid response system in place to ensure patients can remain clinically stable in the home and receive equivalent, quick care for urgent or life-threatening issues. Between November 2020 and October 2021, the most recent data available, waiver recipients reported a 7.14% patient care escalation rate and a 0.43% unexpected mortality rate.

If the regulatory issues were not enough, each health system considering hospital-at-home care should reach out to their medical malpractice insurance carrier, which typically only covers clinicians on hospital premises. Health systems that have partnered with vendors should include contract provisions related to legal liability and provisions about proposed technology downtime or breaches and the related consequences.

 The director of the Mayo Clinic’s Advanced Care at Home program believes it takes 25 to 30 patients as an average daily census to at least break even or make this affordable. However, they are really pushing the care model to show that it works and it is a better way of caring for people. Mayo’s program started in January 2020 and works with Medically Home who, as mentioned previously, received a $100 million investment from Mayo and Kaiser Permanente
As part of all its partnerships with health systems, Medically Home helps identify the right physicians and nurses to participate in the model; installs devices such as Bluetooth-enabled blood pressure cuffs, scales and stethoscopes in patient homes; sets up performance and clinical outcomes dashboards; and ensures data are sent to patients’ electronic health records. The entire program implementation process can take up to six months.

A bedside tablet acts as a hub, displaying patients’ daily schedules, providing information on their conditions, and allowing them to take pictures of physical symptoms and communicate via video with nurses and physicians. Tablet data feed into a central command center, which the health system uses to coordinate virtual visits and dispatch on-staff clinicians to patients’ homes twice a day to administer treatment such as injections.

Over the past two years, the program at Mayo has served nearly 3,500 hospital-at-home patients, who have received about 7,500 days’ worth of at-home services. Around 85% of the patients are Medicare or Medicaid beneficiaries, whose care is covered by CMS’ current waiver. For those with commercial insurance, the health system’s payer relations teams try to make deals to cover their treatment, building individual relationships with insurers on a state-by-state basis.

The health system said its 30-day readmission rates for hospital-at-home care have been lower than rates at its brick-and mortar facilities, with quality metrics on mortality and patient safety equal to or better than those in the hospital setting. (A readmission from a hospital-at-home has not really been defined. Is it based on going back to the brick and mortar while still in the program at home or after being discharged from the at-home program). The health system reported that more than 90% of Advanced Care at Home patients report being satisfied with their care experience.

Some systems use simulations to try to preemptively address any issues concerning equipment set-up, connection, clinician response time and care quality. ChristianaCare requires its hospital-at-home team of nurses, advanced practice clinicians and digital experts to undergo three weeks of training. (Headquartered in Wilmington, Delaware, ChristianaCare is one of the country’s most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs. ChristianaCare includes an extensive network of primary care and outpatient services, home health care, urgent care centers, three hospitals [1,336 beds], a freestanding emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women’s health).

The health system launched its Hospital Care at Home program at the end of 2021, also in partnership with Medically Home. Most of the 200 patients it has treated so far are Medicare beneficiaries experiencing conditions such as COVID-19, chronic obstructive pulmonary disease, heart failure, sepsis and cellulitis. Patients in ChristianaCare’s Hospital Care at Home program use a tablet to communicate with clinicians about their care plan and access their schedule daily.

To monitor performance, ChristianaCare collects metrics from patient surveys and clinician reports on care access, equity, cost and affordability, along with patient safety, engagement and experience. Measures of success include improved patient health, satisfaction scores and positive feedback. The health system’s 30-day readmission rate for hospital-at-home is 8.9%, which is lower than the national hospital readmission rate average.

Patient vetting is a key part of ensuring the success of programs, health system leaders say. OSF HealthCare stations one advanced practice provider per shift in emergency departments to screen patients. The goal is to evaluate how clinically stable the patients are and how safe their home is for medical care according to the  manager of digital care at OSF OnCall, the system’s acute care at home program.

To address any issues of technology literacy, the at-home kits are designed with the typical “92-year-old with fever” in mind. Patients can interact with their care team in a variety of ways, including by pressing a button on a wrist device. in the virtual setting, what’s going on with the patient has to be carefully thought through, triage the situation, ask the right questions and really be observant of how the patient is appearing on video and what they’re saying. OSF said it has had no readmissions since launching the program roughly four months ago.

Connectivity can be a concern, particularly in geographic areas with incomplete broadband infrastructure. Around half of the patients served through hospital-at-home vendor Current Health don’t have internet access at home, so the platform provides Wi-Fi through its Home Hub, which allows for continuous monitoring of vital signs and other metrics relevant to a patient’s condition. Current Health, which was acquired by Best Buy in 2021, dispatches Geek Squad tech support employees to patients’ homes to assist with device setup and troubleshooting. It uses information about risk factors to help health systems prioritize their resources and identify which categories of patients could benefit from care at home; creates dashboards for providers to track patient metrics; provides clinical oversight via a remote command center; and integrates data into electronic health records.

When it comes to the future of acute care at home for adults, many health systems are advocating for an extension of the CMS waiver to continue coverage for services. This is the way care is going to move and ultimately insurers and regulators will come around, even though there might be some hesitancy now.

In the meantime, systems are seeking feedback from physicians, nurses and patients on areas for improvement, such as reducing the number of caregivers sent to the home or finding better ways to sift through remote patient monitoring data.

In the next one to two years of its Advanced Care at Home program, Mayo Clinic plans to acquire more non-invasive devices and wearables that can capture several patient metrics at the same time, while also tapping into patients’ existing smart devices. Over a three-to five-year range, the clinic will be looking at advanced camera technology and smart Wi-Fi to make gathering patients’ blood pressure, oxygen saturation, heart rate and breathing rate data more seamless.

Mayo also intends to partner with other health systems and hospital-at-home programs, with the aim of sharing resources and expanding treatment. Mayo believes that it can build a healthcare delivery ecosystem that’s decentralized and that the future of all this is building the ecosystem together and treating patients wherever they are, across a continuum, not siloed in institutions as is the case right now.


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To explore ways in which we can provide assistance  with your  strategy or adding additional services, please contact David H. Fater at dfater@alda-associates.com or Richard M. Cohen at rcohen@alda-associates.com

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Is Artificial Intelligence Appropriate for Healthcare Or is Healthcare Ready for Artificial Intelligence?

Artificial intelligence (“AI”) has become the current fad. You cannot pick up a magazine or watch the news without some mention of AI. It started with IBM’s Watson which now offers a suite of solutions for Advertising, Business Automation, Customer Service, IT Operations, Financial Operations, Risk and Compliance and Security as well as Healthcare. ChatGBT has been grabbing headlines because of its skill at composition and high school students are submitting papers authored by it. Another application will produce artwork and Dall E2 is now available to the public. Microsoft recently announced it is investing billions into AI building on its existing partnership with OpenAI. The investment could be as significant as $10 billion.
 
Healthcare companies are being formed and funded to process thousands of patient interaction data (HIPAA Compliant) to diagnose and prepare personalized medicine/patient specific treatment plans. We know this is being done in cardiology and oncology with significant funding being raised at substantial valuations even when profitability is not expected until 2025 or 2026. One company, Moterum Technologies, Inc., is developing a new paradigm for caring for stroke survivors. Using a combination of smart proprietary devices and AI driven algorithms they are able to alter the gait in stroke survivors which improves mobility, lowers blood pressure, increases patient engagement and reduces fall risk-- all of which lowers the total costs of that patient with improved outcomes. As health systems and insurance companies ramp up adoption of AI and machine learning technology, experts fear clinical algorithms are not ready for prime time—with potential consequences for patient safety and outcomes.
 
The White House Office of Science and Technology Policy released a blueprint for an “AI Bill of Rights” in October to help healthcare and other sectors navigate the potential perils of the technology. But the development of AI in healthcare has greatly outpaced fledgling government efforts to control it. That leaves providers and health systems to develop their own “guardrails” to protect patients’ well-being as well as themselves from malpractice liabilities. While the framework does not have an enforcement mechanism, it includes five rights to which the public should be entitled: Algorithms should be (i) safe and effective, (ii) be nondiscriminatory, (iii) be fully transparent, (iv) protect the privacy of those they affect and (v) allow for alternatives, optouts and feedback.
 
Interestingly enough, a Deloitte survey performed in June indicated that 85% of healthcare leaders expected to increase their AI investments in the next year but only 57% say their organization is prepared to handle failure or bad decisions stemming from the use of AI. Nearly half are not prepared to handle new or changing regulations concerning AI. One critic has likened it to the “Wild West” and, unfortunately, it is becoming embedded in every organization.
 
We certainly acknowledge that the promise of AI is significant, but we often forget that the algorithms being used are programmed by humans who are making assumptions which could lead to faulty information being used as input for the models. The old term for this is still relevant, GIGO or Garbage In-Garbage Out. Guidelines should be enacted around how an AI model is introduced, tested, and applied to various demographics, and health systems should publicly clarify what protocols are in place when something goes wrong.
 
 In 2021, researchers at the University of Michigan Medical School published a peer reviewed study that found a widely used sepsis prediction model from electronic health record giant Epic Systems failed to identify 67% of people who had sepsis. It also increased sepsis alerts by 43%, even though the hospital’s overall patient population decreased by 35% in the early days of the pandemic.
In the absence of robust regulation or legislation, larger health systems at the leading edge of deploying algorithms are creating their own safety and efficacy standards.
 
HCA Healthcare, the Tennessee based for-profit health system operating in 19 states, has developed AI models for administrative tasks, physician documentation and sepsis detection. Dr. Michael Schlosser, senior vice president for care transformation and innovation, said the system does not prioritize what he sees as higher-risk AI applications. Those are that are true clinical decision support, in which algorithms determine therapies and diagnoses which are those areas we identified earlier as being extensively developed by startup companies that are attracting significant investor funds.
 
HCA maintains that it is not that they are not interested in those applications but they are very much focused on the lower-hanging fruit which eliminates redundancy, automates tasks that are not those high level decision-making tasks, but simple, administrative tasks to make the hospital run more efficiently.  HCA employs a dedicated staff member to advise the system on ethical ramifications. It has also worked with Deloitte and Google to develop best practices and ensure algorithmic quality. They acknowledge that this is a relatively new space for healthcare, but they can learn a lot from others that have gone before. HCA resists the idea of governmental oversight believing that norms will be developed over time. Dr. Schlosser believes that the industry groups coming together, combined with the regulation already in place, will provide sufficient guardrails.
 
While many providers are focused on developing models that prompt care teams to consider addressing certain conditions, others are taking the technology a step further. Mayo Clinic has developed diagnostic algorithms that can more effectively detect polyps on colonoscopy images. Nationally, the rate of physicians misreading results is around 20%. But the model developed at Mayo improved the miss rate to around 3%. A peer-reviewed study published in the Journal of Gastroenterology found the use of AI at eight facilities halved the miss rate of colorectal neoplasia, such as polyps. The authors, who included a gastroenterologist at Mayo Clinic Jacksonville, supported the use of AI in reducing human errors for detection of small lesions.
 
Mayo has also developed cardiology algorithms to predict future heart disease progression and we know of one company that is doing that in connection with high-definition imaging.
 
Other health systems have also attempted to bring AI further into care delivery. Phoenix Children’s Hospital developed a model using patients’ medications, lab results and visit history, in addition to their body mass index, to help detect malnutrition and order a consult with a nutritionist. After running the model in stealth mode, in the background away from physicians, the health system found it was between 60% and 80% effective at identifying patients presenting with malnutrition. Clinicians, other executives and the hospital’s legal team agreed it should be deployed, so long as it continued producing similar results. Consequently, they are letting the AI order the consult as if it was the physician, The nutritionist doesn’t know either way and they just show up. The health system has  been retaining that 60% to 80% accuracy. The full scale implementation of AI has led to malnutrition diagnoses for an additional six to eight children per week, out of an average 25 to 30 weekly cases. They theorize that malnutrition is one of 5,000 diagnoses made at the hospital so how could it always be top of mind to a human physician.
 
It has been predicted that clinical and administrative AI will happen in the background, without hurdles, at many health systems. But the road there could be complicated. Providers seeking to expand their AI capabilities are the same ones stricken by rising labor costs. Many find themselves in a battle over expensive employees who can work to implement high-quality models and ensure patient safety.
 
Beyond finding talent and forming partnerships, experts said building support for technology—by explaining its tangible benefits to the teams who will be working with a model, for example—is paramount to deploying an AI tool that can improve outcomes. The typical difficulty of changing physician practice patterns is amplified with AI. The biggest overarching challenge is gaining provider trust, or clinical trust. Ultimately, you can have the best technology in the world, but if [care teams] don’t trust it, it will not be used and no benefits will be realized.

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To explore ways in which we can provide assistance  with your  strategy and impementing AI in yor organization,  please contact David H. Fater at dfater@alda-associates.com or Richard M. Cohen at rcohen@alda-associates.com

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Representative Engagements

Our experienced professionals are dedicated to helping clients unlock inherent value and create new value.

The ALDA Team includes, among others:

David H. Fater - Chief Executive Officer

Strategy, capital markets, restructuring, and mergers and acquisitions experience with public healthcare companies focused on physician management, rural healthcare, nursing homes, HMO's, diagnostic imaging and medical devices. Deeply involved in the implementation of the Affordable Care Act with Accountable Care Organizations, Independent Practice Associations and Management Services Organizations. 

Richard M. Cohen - Senior Operations and Business Development Executive

Healthcare operations and worldwide sourcing experience. Skilled in healthcare (physician management, clinical trials, medical and patient process flow, diagnostic imaging and life science) operations as well as in issues dealing with importing, exporting and manufacturing operations in South America, Far East and Europe. 

Thomas J. Bohannon - Senior Financial Executive

Accomplished, creative CPA, outstanding analytical and technical abilities. Has experience for over 40 years in public accounting and private industry including nursing homes, medical device companies,  hospitals, not-for-profits, retail, manufacturing, import/export and natural resources.

R. Brent Miller, Ph.D. Senior Research Executive
Focused on advancing Chemistry, Manufacture, and Controls (CMC) activities of small molecules from discovery through development. with more than 30 years of drug development experience. working with start-ups, mid-size, and large pharma companies. Throughout this experience, he has led a wide variety of operational departments, including Technical Strategic Alliances & Due Diligence, Project Management Office, Pharmaceutical Sciences (Formulation Development/Analytical Development), Bioanalytical Development, Quality Control and Stability.  .

A. Ronald Turner - Senior Healthcare Executive

Senior healthcare industry executive with strong entrepreneurial focus including CEO and COO positions with start-up hospital companies and a publicly-traded hospital company. Extensive and successful operations experience for more than 50 hospitals and 9 nursing homes, and senior reimbursement experience for a major publicly-traded hospital company and a national accounting firm. Experienced in mergers and acquisitions, led operational turnarounds and debt restructurings that created significant value.

Mark W. Caton – Senior Healthcare Executive

Senior hospital executive with over 30 years experience in operating not-for-profit and investor-owned rural/community hospitals as CEO or COO, and Regional COO with several national hospital companies.  Skilled in strategic planning and business development, operations management, revenue cycle management, medical staff development, and quality/resource management.

Daniel N. Weiss, M.D., F.A.C.C. - Chief Medical Officer

Medical devices and healthcare practice experience, engaged in a private medical electrophysiology practice where he performs numerous invasive cardiac procedures and has served as a consultant for several Fortune 500 Medical Device Companies including Philips, Boston Scientific/Guidant, St. Jude and Medtronic, as well as for several medical device and drug start-up companies. 

David Bott - Senior Information Technology Executive

Systems and network support solutions experience, proviedes analyis of strategic business needs and assessment of business models and their integration with technology.  

Santiago Guzman - International Executive

Experienced in new project development for companies in a variety of industries from start-up to Fortune 500. Client relations management, fluent in English and Spanish. Skilled facilitator for introductions with influential leaders in South America including those in the health care industry. 

With offices in:

For additional information, please contact:
David H. Fater, Chief Executive Officer
ALDA & Associates International, Inc.
4772 N Citation Drive Suite 103
Delray Beach, FL 33445
(877) 845-4657
dfater@alda-associates.com

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