Managed Care Strategic Briefing
`
`Challenge of CHF Management:
`A Culmination ot Precursors
`'
`
`Rot congestive heart failure, pharma-
`
`Office Visits at Home
`
`The questions to congestive heart fail—
`ure patients are customary, but the set
`ting is unusual: “Are your clothes get-
`ring tighter at the waist?" “Did you
`wake up short of breath during the
`night?" “Are your ankles more swollen
`than usual?" “Did you take your medica—
`tions today!" “How's the exercise pro;
`gram going?" The scene might not be
`the traditional office visit. More and
`more, such questions are being put to
`patients in their homes, through small.
`user—friendly network computers that
`"talk" to patients — in one case. a talk—
`ing scale. After weighing oneself, the
`patient responds to various questions by
`hitting :1 YES or NO button. The
`weight and answers are automatically
`dialed out to a central monitoring sta—
`tion. In another application of daily
`monitoring technology, the patient uses
`radiOvequipped home measurement
`instruments — a digital scale, a blood
`pressure cuff, and an EKG rhythm strip
`recorder.
`
`Such is one face of the brave new world
`of CHF management. Although the
`value of invhome data export devices is
`not universally embraced, giving
`patients control of sending in infarmav
`tion via unobtrusive monitoring devices
`at home apparently can benefit bath
`patients and their families.
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`EXECUTIVE SUMMARY
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`
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`system that accommodates DRG cote
`other than waiting tor a diagnosis
`
`gories. Physicians’ oiiice practices are
`usually not organized or statted around a
`lot at proactive followup. Disease man
`agement vendors claim to attend to those
`details, proactively.
`The value at
`in-home data export
`
`devices draws some skepticism. Will
`sick, elderly heart Failure Elients inter-
`act with daily monitoring technolggy?
`Yes
`in the case at a talking scale a
`small intuitive monitoring device tar use
`at home. The patient responds to non-
`iudgmental questions by hitting a yes or
`no button. The device automatically dials
`out to a central monitoring station and
`uploads that information.
`Some drug manufacturer-sponsored
`interventions are attracting more interest
`trorn provider groups than From health
`plans. One manufacturer has develofl
`a clinical mana ement s stem — a
`ro
`rieta
`software
`lattorm and the clini-
`cal
`r
`rams that run on the
`lattorm.
`Evidence-based guidelines,
`though nec-
`essarily broad, can be adjusted to indi
`vidual patients. lt's crucial that the client
`have a case management and cosetind
`ing infrastructure in place.
`' Health plans tend to be reluctant to
`link their care management programs to
`the prior ettorts of pharmaceutical com-
`panies, believed to emphasize product
`sales. Manutocturers are Erceived as
`ised to deliver ‘maiter'-
`r
`rams
`
`cy benelit management (PBM) lirms
`generally try to identity people at risk
`postrmyocardial
`intarction. Success has
`been reported from getting such Etients
`onto hypolipidemic or ACE inhibitor ther-
`apy or 53mg ocker use. Because CHF is
`such an integrated prob em, some PBMs
`are wary ot an external company man-
`aging CHF as a ‘carveout,’ thought to
`detach patients from needed feedback.
`HMOS are coming to realize they had
`better treat CHF patients, even though
`membership
`turnover means
`these
`patients may end up someplace else;
`chances are an HMO will get somebody
`else's patients down the line! A growing
`view is that it each HMO carria its Ear
`
`share ot the load, no one HMO would be
`hit hard with adverse selection.
`Health plans ask: Is there a return on
`investment in pumping additional dollars
`into CHF programs? Yes,
`it you get
`
`patients with severe CHF stabilized on
`
`medication. But putting another dollar
`
`toward trying to wring an incremental
`gain out at Enems who are stabilized is
`
`robabl not mone wells
`nt. Employ-
`
`ers, however, generally have a longer-
`term interest in employees, and may even
`
`see a role tor health promotion in culti-
`
`vating employee satisfaction,
`retention,
`and recruitment.
`
`Provider groups operating under undile
`
`terentioted capitation needed outside
`rather than tailoring care plans to indi-
`help in designing costetlective disease
`vidual needs,
`interacting with phfii
`
`management programs. Capitation may
`cians, trackng p_atients, and having a
`home health camEnent.
`be tadifl, but likely to be replaced by a
`
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`1
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`Bosch Ex. 2053
`Bosch EX. 2053
`Cardiocom v. Bosch IPR2013-00468
`Cardiocom V. Bosch IPR2013—00468
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`

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`Cost—effective methods of managing CHF are taking on
`greater urgency as CHF case management becomes more
`labor intensive. Owing to the aging population, CHF is the
`only area in cardiovascular medicine for which all expendiv
`tures throughout — medical, pharmaceutical, laboratory —
`are increasing in the aggregate. CHF is the largest cost cen—
`ter for senior care. Three—quarters of the money spent on
`heart failure goes for hospitalization. One irony is that as
`other cardiovascular conditions —— hypertension, myocardial
`infarctions —— become amenable to better treatments, sur—
`vivors are at the highest risk for congestive heart failure.
`CHF will loom larger down the line.
`
`The problem is, a large number of health plans don't have
`the mindset to look at downstream clinical outcomes. And
`
`physicians’ office practices have never really been organized
`or staffed around a lot of proactive follow—up. Hence a role
`for pharmacy benefit management firms. disease manage
`ment vendors, informatics units, telephonic demand man—
`agement organizations, monitoring device/service firms, and
`drug manufacturer initiatives. The perspectives of leaders in
`those fields were gleaned through interviews by The Genesis
`Report/Mex and are presented here as Part II of a tw0vpart
`article on CHF management. Part I, in the September issue,
`highlighted views from clinical and academic settings and
`managed care organizations.
`
`”Health Buddy Personal Information Appliance extends beyond congestive heart failure. But CHF is probably the
`
`number one application because it’s the largest cost Center for senior care. it’s also one offering the greatest possi-
`
`Health Hero Network, inc »
`
`bility of preventing hospitalizations by having iust a little information a little sooner.”
`
`Steve Brown, CEO
`
`Health Buddy/Health Hero Network:
`An Information Appllance for the Kitchen
`Steve Brown is CEO of Health Hero Network, Inc (Moun-
`tain View, CA), a privately held e—health company that
`provides a flexible Intemet—based communications platform
`that enables disease management companies, inthuse man—
`aged care providers, and informal caregivers to communicate
`daily with their patients at home. About his communica«
`tions platform, he said there are two parts: Health Buddy,
`the patient interface, and Health Hero on—line service, used
`by the nurse or the case manager.
`
`“Essentially, Health Buddy focuses on wiring the senior pop’
`ulation to healthcare services over the Internet through our
`extremely simple information appliance. The idea is finding
`a way to get to the point of selfvcare in the home, where
`patients are making decisionsabout their health, or taking
`their medicine, or doing some kind of self—care routine. At
`the touch of a button, the appliance sends information to a
`
`care manager.
`
`“Health Buddy Personal Information Appliance extends
`beyond congestive heart failure. But CHF is probably the
`number one application because it's the largest cost center
`for senior care. It’s also one offering the greatest possibility
`of preventing hospitalizations by having just a little informa—
`tion a little sooner.
`
`“The Health Buddy information appliance for the patient’s
`home," Brown continued, “can go anywhere from the
`kitchen countertop to the nightstand. It plugs into a phone
`line, and has four buttons and a display screen. It turns itself
`on, it lights up, and it asks you questions about how you‘re
`feeling. It collects data about symptoms, and it gives you
`educational information or feedback. To collect more data,
`it also has (pending FDA clearance) the capability of being
`an interface to a wide range of medical devices, whether
`that's a weight scale, a blood pressure cuff, or a blood glua
`case meter. It's a platform for focused, protocol—based comr
`
`2
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`

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`own programs. Whatever
`customers want to create
`
`protocols for, they can
`use Health Hero. We are
`
`creating the platform on
`which one can create
`one’s own disease man—
`
`agement program.
`
`less Slippage
`Through the Cracks
`“Health Hero has cus‘
`tomers that are assessing
`the outcomes as they go
`along," Brown added.
`“Since we have only
`anecdotal results so far,
`we haven’t published any
`data yet. Last week I
`talked to the medical
`director of one of our
`
`munication with the patient in the home, and it can work
`for just about any disease and any patient, depending on the
`kind of protocol assigned to it.
`
`“It’s kind of a little four—button consumer appliance. It’s the
`simplest computing device in the world right now. A big
`part of this is making it extremely convenient for patients,
`not interrupting-their daily routine. It's like E—mail. You’re
`getting a little message on a display screen that says, ‘How
`are you feeling today? Good? Bad? Did you have difficulty
`breathing last night? Yes? No.7 On a scale of 1 to 10, how
`difficult was your breathing?’ And you can press in an
`answer.
`
`Website for Stratifying by Risk
`
`“The Health Hero on»line service,” explained Brown, “is
`essentially an Internet‘based communications platform that
`tells a nurse the status of her patients. The data are all
`graphically presented, so you see who’s in the red zone, the
`yellow zone, the green zone, by different categories, like
`symptoms, behavior, or knowledge. Every time the patient
`answers a question, a risk score is attached to that answer, so
`the nurses have daily data on their patients, organized and
`risk stratified.
`
`“A case manager has an account, and within that can create
`a protocol to assign to patients or groups of patients. Case
`managers can type in questions, or they can use the protocol
`that the medical director or perhaps a third party has creatr
`ed. So the case manager can say, ‘l have 100 patients with
`congestive heart failure whom I want to enroll in our CHF
`program.’ When the nurses want to add a new patient, they
`go to the Internet and push a button. We automatically ship
`to the patient and get them set up.
`
`“It's an open system for communicating with patients, using
`a protocol. With 600,000 doctors and 2 million nurses in
`this country, there are a lot of different ideas about the right
`way to communicate with patients. So we made a flexible
`system that every doctor and every nurse can use to create
`their own protocols if they want to.
`
`“We have the same customers, the same sites, using the
`same system for congestive heart failure, cardiovascular CllSv
`ease, coronary artery bypass, hospital discharge, diabetes,
`even transplants. Besides that, there’s mental health, the
`frail elderly, disability, and shorttterm disability. Protocols
`for all those kinds of things are being developed by different
`groups. We have a library of sample dialogues, so you could
`give people a head start. But some groups are creating their
`
`”I think the big thing that’s going to
`
`happen in the morket is that medical
`
`groups are going to start doing dis-
`
`eose‘monogement themselves rather
`
`n=k that ultimately
`than outsource. lt
`..7.
`‘
`.
`.
`.
`t -
`*
`i
`. he doctors and the nurses in this
`country will be the disease mon—
`
`ogers, and wont to do that. But we
`
`need to help them get reimbursed
`
`appropriately for it; we're working
`
`on that.”
`
`Health Hero Network, Inc
`
`Steve Brown, CEO
`
`customers and got forr
`warded E—mail from
`another. One said,
`‘We’ve prevented anothv
`er hospitalization by
`detecting a problem
`sooner and just scheduling an office visit.’ The other said,
`‘We've saved the first life using Health Hero because it was
`somebody who had really slipped through the cracks and
`was identified with their Health Buddy.’
`
`“We have about 15 organizations that signed up for it so far,
`and we think we’re going to have a number more soon. And
`all those organizations are developing their own programs
`based on the platform. How many Health Buddies get out
`there depends on how far those groups take their disease
`management programs.” Brown noted that a Health Hero
`customer may be a managed care organization or a medical
`group as well as an employer.
`
`“I think the big thing that’s going to happen in the market is
`that medical groups are going to start doing disease manage—
`ment themselves rather than outsource. I think that ultimately
`the doctors and the nurses in this country will be the disease
`managers, and want to do that. But we need to help them get
`reimbursed appropriately for it; we're working on that.”
`
`3
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