A continuation of Part 1. One of our B2B thought leadership interviews with digital health entrepreneurs working to improve care of chronic conditions. We care particularly about chronic immunoinflammatory disorders (CIIDs), e.g., autoimmune and autoinflammatory diseases. This continues our interview with CEO of Oshi Health, Sam Holliday. Oshi Health is a virtual-first GI care clinic revolutionizing management of digestive health conditions through a technology-enabled, patient-centered, value-based care delivery model. Sam brings his deep perspective to the accelerating GI and digital health landscape and Oshi Health’s place in it.
From sick care to digital GI health care
Ellen: GI is specialty care. Tell us about Oshi Health’s view of unmet needs in GI: the roles of digital health, coaches, dieticians, psychologists, etc. How does Oshi Health coordinate GI with primary care?
GI as initial complaint and the PCP to GI handoff
Sam: GI is an interesting specialty. As I said before, many patient journeys start with GI symptoms in primary care. Estimates vary, but up to 20% of primary care visits include a GI symptom among the complaints. PCPs can rule out more common things and do some testing. For example, they can diagnose GERD and prescribe a PPI (proton pump inhibitor, e.g, famotidine). But if the problem persists or it’s not any of the obvious disorders, PCP’s refer patients to GI clinics. But here’s the rub. Average wait times to see a gastroenterologist are long. So, patients continue to suffer while they wait weeks or months to be seen.
The long GI diagnosis-to-treatment journey
Sam: Once the patient gets to the GI appointment, a more intense diagnostic process begins. There’s a set of well-recognized differential diagnostic pathways that gastroenterologists use. These are to figure out which combination of factors are triggering symptoms. This takes time and detective work because these are not as simple as, for comparison, diabetes. To diagnose diabetes, you take blood, measure glucose and A1C levels and get a number that says diabetes. Unfortunately, GI conditions are often murky. Many symptoms (e.g., bloating, diarrhea, pain) are common to several diseases, and thus harder to diagnose.
Once diagnosed, treatments that work for each patient differ, it may require trial and error to find the right one. There aren’t simple biomarkers (like glucose levels in diabetes) to measure response to treatments. It takes a deeper exploration of potential triggers of symptoms, tracking of bowel movements, pain levels, bloating, constipation, etc. The care team and patient must experiment until they find the right approach. This means a mix of medication, dietary changes, lifestyle adjustments and reduction in stress, maybe mental health treatment. This is an area where digital GI health care can help.
The challenges of GI case management
Sam: So, managing diabetes is pretty clear: insulin, other medications. Although there IS a dietary management/weight loss angle to type 2 diabetes that overlaps with chronic GI management. In general, though, GI conditions are more complex and nuanced to manage. Understanding symptoms, such as bowel patterns, means confronting stigmatized topics that people are uncomfortable talking about. Patterns of pain, constipation, bloating, are symptoms that could tell us whether treatment and case management are working or not. We do not yet have simple quantitative measures of results.
Remote monitoring, diet & psychology interventions, care teams
Earlier you mentioned Dr. K at SonarMD. A big part of what they do in IBD is remote monitoring to detect problems before they escalate. We’re building that piece in as well at Oshi Health. Digital GI health is going to include many of these pieces.
Triggering foods and dietary management – where digital GI health can excel
Another big gap is diet and behavioral psychology interventions, which are well studied and shown to be effective. If we can figure out if certain foods are triggering symptoms, then reorienting patients’ diets to minimize those foods can improve symptoms. For example, take low-FODMAP diets. There’s a lot of evidence that they work, but they are hard to execute on your own. Right now, practices give you a printout about low-FODMAP foods. But you, the patient, have to do your own research, eliminate foods and then reintroduce them in a structured way. All the while tracking symptoms and trying to connect the dots. Doing that on your own is overwhelming, especially if you are already feeling miserable. Taking a digital GI health approach, with a coach and tools for tracking, can make this more user-friendly.
You’d think that when you go to the gastroenterology clinic, they would pair you up with their dietician and get to work on your diet. But they don’t. Most clinics don’t have a GI-specialized dietician on staff. Maybe they give you a few phone numbers and you, the patient, have to coordinate. First try to find dietitians, then figure out if they are covered by your insurance. Maybe they do telehealth, maybe they don’t. That’s not a system designed to solve your GI problem, especially the dietary piece.
The gut-brain connection and psychological support
Beyond that, there’s the gut-brain connection and the known impact that stress, anxiety, and depression have on GI symptoms. Again, there’s lots of evidence around cognitive behavioral therapy (CBT). This is psychodynamic therapy that improves symptoms in cases of irritable bowel syndrome (IBS). So you’d think, okay, GI practices must have psychologists. But they don’t. The standard system wasn’t designed well.
There are Australian studies that have shown significantly better patient outcomes and care experiences with an integrated care team. But in the US, very few places outside of academic medical centers offer integrated care teams. Most private practice clinics don’t have the financial incentives or even the bandwidth to make investments and redesign their approach to include dietary and psychological services and support. I’ve had GI doctors tell me they tried dieticians and psychologists, but they weren’t generating enough revenue. They were basically overhead for the practice. For these reasons, the sad reality is most US GI clinics do not offer all these services in one place. Far better to offer one shared care plan, communicate in a continuous way and use remote monitoring tools to provide data-driven digital GI health care.
The GI care payment-incentive disconnect
When you look at the evidence that those interventions improve outcomes, then you look at the payment dynamics, you see the disconnect. Patients get a fragmented experience of GI care. We’ve largely left it up to them to navigate all this. They have to find dieticians who know about GI, find GI psychologists. Worse, if patients do find those practitioners, they aren’t working off the same plan or even talking to each other. Also missing is symptom tracking and remote monitoring feedback to tell your care providers how you’re doing to prevent escalations. Are the interventions we’re trying: medication, diet, behavioral psychology, working or not? Instead we put it all in one place on a shared care plan.
Redesigning GI care: patient-centered, virtual-first and value-based
As I said above, not all care can be virtual. Our goal at Oshi Health is to build good local market partnerships with endoscopy centers and gastroenterology clinics. Then we can coordinate closely with them to get patients in-person care and procedures when needed. However, we take the work off the patient’s plate. We can ensure shared decision making around when, where and how to get needed in-person care.
For example, take an employer that offers virtual care options for other specialties plus Oshi Health for GI. We’re not going to provide, for example, diabetes care. Thus, referring somebody into that diabetes program is good for us. It’s good for our patient and it’s good for the employer to get value from their investments in different conditions. I think this is the long-term plan exemplified by mergers like Teladoc and Livongo, to create multi-specialty footprints. It’s going to be interesting to see how it evolves.
Virtual and digital can support more personalized care
There’s a personalized medicine angle here too. We want to quickly iterate and test until we find the right answer for each patient. Because even if all of us had IBS, your genetics and microbiome and other factors will be different than mine. We likely have different trigger foods. Or one of us is stressed and another has anxiety, a third is depressed. It has to be a personalized approach. My opinion is you can only do all of that if you’re doing much of it through telehealth. Virtual care is a perfect delivery platform for integrated digital GI health care. That’s really the inspiration for Oshi Health.
Digital support is key for remote monitoring, tracking and coaching
Bonnie: Do you see remote monitoring and continuous tracking as part of a virtual specialty clinic? Or are they part of a primary virtual clinic? Or both? All under GI digital health, of course.
Sam: First, most people don’t want to track everything forever, it’s work. Tracking needs to be connected to patient care in a very obvious way, like weight loss. They need feedback loops and accountability partners to support tracking. Is there someone, a coach maybe, helping them gain insights from it? Is it a seamless day-to-day experience of interacting with that person? I think virtual care is great for that. I don’t think primary care clinics have the GI specialization to do this. Having a dietician is not the same as having a dietician who specializes in GI conditions. I don’t think generalist dieticians or psychologists are going to solve GI problems. That’s why we want to build, train and become the employer of choice for dieticians and psychologists who want to focus on GI and digital health.
Digital helps build speed and efficiency, coaching and specialized understanding helps produce insights. The long game is that we will automate that more over time using machine learning, AI, analytics. That will make more insights available to patients for self-management through the data that we collect. But for now it’s a human-to-human interaction enabled by technology.
Coordinating with adjacent non-GI specialists
Ellen: Since GI problems overlap with so many other diseases, how does Oshi coordinate with non-GI specialist care? For example, many GI patients need other specialty care (e.g., dermatology, MSK, neurology). Oshi Health’s core care team is centered around the patient. However, it’s not practical to have every specialty be part of that core team. How do you see seamless referral emerging? In a larger sense, where do you think cross-silo care is headed in the GIdigital health arena?
For example: comorbidities, e.g., GI + diabetes
Sam: Here’s a specific example around dietary interventions. GI patients may be living with diabetes as well. So looking at the whole patient with multiple conditions, how do we create a dietary approach and meal plans? That diet should take into account patients’ different socioeconomic situations, cultural food norms, likes, dislikes and beliefs. We’re building our own protocols for co-managing diet in patients with diabetes. Because someone with diabetes and a GI issue that comes to us likely doesn’t already have access to a dietician. In the future we may be able to help them on both problems through our dieticians.
Sam: Also, patient behaviors, like smoking, impact GERD and other GI conditions. We’re not going to build smoking cessation into our platform. There are plenty of other companies that already offer such programs. Our job is to help patients understand how smoking affects their GI conditions, figure out what’s available through their benefits and then refer them into those programs. Maybe support sticking with that program by tracking how it’s positively impacting their GI symptoms.
Behavioral and mental health
Sam: On the behavioral health side, there are specific GI-related psychological interventions. But for someone with severe clinical depression, that’s not what we’re here to tackle. There are already many behavioral and mental health options available to patients through their health plans or employers. We will refer into those, while the Oshi Health care team will focus on how mental health influences patients’ GI care. We’ll seek to understand and coordinate with other specialties, for instance, through sharing records. Our technology enables us to easily share records with other providers, like an endocrinologist treating comorbid diabetes. Right now we focus on coordinating non-GI care with the patient’s other providers.
Ellen: What about sleep as another example, how would that work? Many people with GI symptoms also have disturbed sleep. And vice-versa, poor sleep is associated with overeating and other GI problems. How can digital GI health help?
Sam: Yes. Or their sleep is influencing their GI symptoms. Sleep is certainly one of the lifestyle factors that we cover with our coaching, to see if sleep is influencing their GI symptoms. We will focus on it for GI reasons. If that helps them more broadly on sleep, great. If they need more intensive intervention around sleep, right now we would refer them out as for smoking cessation or diabetes control.
Multi-specialty virtual clinics – seamless care coordination
Sam: Over time, we want to see multi-specialty virtual clinics emerge that, either by acquiring or building out all the different specialties, create an integrated virtual care model so that the patient can go to one place. So co-morbidities are managed seamlessly through systems that enable providers to talk to each other, coordinate with each other. Something like a Slack conversation so that communication becomes easy. Give employers one place to get most of the care needs of their patients handled.
We see a future where virtual specialty care companies combine or partner to form multi-specialty virtual clinics on larger platforms. That will make things easier for patients. It’s also easier for employers and payers that don’t want to contract with many different vendors for specialty virtual care. The Teladoc-Livongo combination is the largest example of this trend. Another is Omada Health expanding the conditions it covers and other major players starting to explore new areas. These are the next steps in expanding digital health to GI and other specialties.
As more virtual care companies emerge in different specialties and primary care, we aim to enable seamless referral processes. That way, our patients can move easily between virtual care providers to get the care they need with less coordination work on their shoulders.
The impact of IMPACT on virtual-first care
Sam: To enable this future of virtual-first care, Oshi Health is a founding member of IMPACT, the virtual-first medical provider collaborative recently launched by the Digital Medicine Society (DiMe) and the American Telemedicine Association (ATA). We have brought together virtual-first care companies with payers, patient advocates, investors, consultants and other key stakeholders to advocate for policies, regulations and reimbursement approaches that support this care delivery model and improve patient outcomes at lower overall cost. We’re really excited for this group’s launch in 2021 and our work ahead.
Which specialities will lead for autoimmune patients?
Bonnie: Could immunology lead for autoimmune patients as oncology does for cancer? But there are so few clinical immunologists. So far, we haven’t seen anyone even begin to think this way. How might immunologists fit into the Oshi Health model?
Sam: We have tremendous work to do still just to get GI ironed out. But we are starting to think about the characteristics that indicate that a condition area is a good fit for expansion for us. And that goes, no doubt, for others in the industry. There are white space areas, as you point out, conditions where provider resources are scarce. When there’s too few specialists, costs are high, waits for appointments are long, the patient experience is slow, fragmented, inefficient.
Even though there are evidence-based interventions that work, they are not yet scalable. That’s where I classify GI dieticians and psychologists, too. Today it’s only a small pool of people in those specialties. How do you scale access when it means building a workforce trained specifically for those roles? But that’s a great thing about virtual care, you can scale access by taking geography out of the question. Aside from, as we’ve seen, existing barriers of state-by-state corporate practice, telemedicine and licensure laws and regulations.
Patient-centered care for rare diseases with digital GI health as a model
Ellen: How would a patient-centered approach work for rare diseases, for example, the non-marquee autoimmune diseases, undiagnosed conditions, conditions Bonnie and I are particularly attuned to. They fall through the gaps in the current system and it’s been a serious challenge addressing that. How could GI digital health help?
Sam: Off the cuff, I think a model would look something like this. Start with a care coordination and navigation platform that supports such people through the exploratory process. Use apps, coaching, remote monitoring to capture data around what the patient is suffering: symptoms, flares, diet, sleep, all the things we’ve discussed. And then feed that data to an analytics engine for machine learning. Put the data to work to figure out what might be going on. You could build that into an app or network: here are providers that specialize in teasing this out, and make the referral. But such providers are mostly in big academic medical centers, few and far between at that. A lot of people don’t have access to them. Maybe virtual consultations could improve the geographic reach.
Evolving value-based payment models
Bonnie: How do changing payment models affect Oshi HealthOSHI’s strategy? Are GI practices beginning to consider more value-based payment approaches, especially post-COVID? What drives payer adoption? What is Oshi Health’s fundamental value-based attitude?
The VBC challenge in GI practice
Sam: So far there is not much activity toward value-based payment for GI conditions. There has been some focus on negotiated price or bundled payments for procedures like colonoscopy, but there has not been strong pressure toward broader value-based care outside of Medicare ACOs. I’ve spoken to some of the larger GI players and they’ll say, yeah, we have value-based contracts. When I inquire further, it’s one payer, one contract and they couldn’t figure out how to reconcile it. It didn’t move the needle and they’re not really investing resources behind it.
Where you have seen VBC activity, like Dr K mentioned, is in the medical home concept for IBD. How do we apply remote monitoring? We’ve haven’t seen payment models built around capitated payment where it’s up to the practice to manage the outcome, to not exceed a certain cost. At the end of the day, that’s what it will take to get traditional providers to really rethink things. New models of digital GI health can lead the way.
Moving GI from fee-for-services to value-based care
What we’re seeing in our conversations with GI providers is most of their businesses are still driven by fee-for-service. The FFS incentives around procedures, pathology and infusion are too strong to enable much focus toward value-based payment models or the technical infrastructure and integrated clinical teams that GI practices will need to participate seriously in VBC. Today, GI is a very profitable practice area, which is why there are a growing number of private-equity investments in GI clinic rollups across the country. But there’s not a lot of investment in rethinking the whole model around how to actually take cost out of the system.
For example, as I mentioned, we have heard many GI practices refer to care providers like NPs and PAs, as well as dietitians or psychologists as “overhead”. They are viewed as resources needed to support patients so the physicians can spend more of their time in the endoscopy center doing procedures. It’s a sad reflection of the payment incentives in place and how misaligned they are with the evidence that integrated care generates better outcomes for patients.
Starting from scratch with value-based care in GI digital health
On the other hand, at Oshi Heath, we’re free as a new GI digital health entrant to start with VBC. I don’t have to worry about navigating from a cash-cow FFS model into a murky emerging value-based approach. We can say, “We are going to bundle all the care you need for a fixed price, manage cases and show you that we get great outcomes and we’re going to share together in the cost savings.” In building Oshi, we started with care models already shown to generate the best outcomes for patients and the payer or employer that sponsors the benefit plan. We then built a payment model that is not driven by volume of services or visits, but rather on generating outcomes through higher-touch, continuous, data-driven and relationship-based care. That’s a fresh model for digital GI health.
And then in Year 2 or 3, we’ll be able to start assuming risk, because we’ll be informed by the data and results. We see the opportunity to manage a population’s GI needs so that we do well when we take cost out of the system and give patients access to everything they need to get their GI problems under control. That’s how healthcare should work. Everybody knows it. It’s just hard to transition. Because we’ve started from scratch we’ve built what we think GI care should be in the future. We are early in our journey, but we will demonstrate in 2021 that this integrated, virtual-first care for GI conditions drives higher patient satisfaction, improved quality of life and workplace productivity, all at a lower overall cost.
Contact Dr Bonnie 360
We approach these interviews, as we do all our work, from two different multi-lens perspectives:
- DrBonnie360: clinical dentist, Wall Street analyst, patient advocate, and digital health consultant.
- Ellen M Martin: evolutionary life science, finance & investor relations, marketing, communications and writing/editing.
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