Author: Hoby

In this ongoing interview series, we’ll be talking to leading clinicians, tech leaders, and entrepreneurs about their life, careers and professional experiences in the fields of heart care, cardiology and heart health as a whole.

Heartbeat in Conversation interviews are conducted by Heartbeat’s Chief Growth Officer, Brett Jansen.  

This past month, we spoke to Heartbeat’s Director of Operations, Kristie Servais. The following is an edited transcript from an email conversation on April 27, 2023..

Hi Kristie. Thanks for making the time on this beautiful spring day. Can you catch us up briefly on your career journey to date?

My professional path has been a unique one. I’ve always been interested in helping people so I initially pursued a degree in Social Welfare with an emphasis on gerontology. Unfortunately, after experiencing both a professional and personal loss as I was completing the degree, I quickly decided to change directions. I ended up working for a security company where I worked my way up to be the one and only National Account Manager for the organization. I enjoyed the experience and had an opportunity to influence a variety of organizations, including working on an installation project with Sprint and their retail stores nationwide.

Personal realities (this time for a very positive reason) again influenced my next step. In order to be with my now husband, I relocated from Kansas City to Minneapolis, where I continued to work in the security industry. But after seven years, I knew it was time to venture out and see where fate would take me.

After a stint at Target as part of their PMO team helping expansion into Canada, I embarked on my first healthcare opportunity and joined United Healthcare, as a Project Manager on the Clinical Business Enablement team. I learned about the complexities of health insurance – and after several years, I transitioned to the Medicare & Retirement Clinical value team where we worked to reduce the cost of United’s Medicare Advantage plans.

In 2022, I received a call from a friend who said she had an open role that would fit me perfectly. I told her I wasn’t interested in leaving United but after 30 minutes of hearing what Heartbeat was doing, I was hooked and couldn’t wait to become part of the team. To this day, I am so appreciative that she thought of me, and I’m thrilled to be working at Heartbeat and helping change the way cardiovascular care is delivered. My days are an array of activities that include problem solving, client launches, staffing, process improvements, workflow creation, capacity planning and platform management, just to name a few.

How would you describe your approach to customer service — which in the Heartbeat context – essentially translates to patient and provider experience?

My philosophy on customer service is based on the saying “treat others the way you would want to be treated”. Our team of Clinical Care Coordinators are called “Heart Heroes” because along with our providers — they are the face, voice and heart of patient care. The team’s interactions and care are based on the premise that the person they are interacting with could be one of their family members and are treated as such with a personal touch. It is such a pleasure working with this amazing team and watching their care and compassion for our patients.

Do you believe technology is making things easier or harder for individuals and how they navigate their health care choices and the care they need?

Technology in healthcare is a double-edged sword. Technology allows patients to be seen by providers in the comfort of their home and at convenient times, which can improve their engagement in their care. Unfortunately, those who need the most care and easiest care path sometimes don’t have access or a comfort level with technology which can create a barrier to utilizing tech-enabled clinical care support services. I believe it is imperative that emerging healthcare technology be built with an inclusive spirit so that diverse sets of populations can access and utilize these new services.

At Heartbeat, you are also now in charge of client implementations (that is working with Heartbeat clients to set up the processes and tools required to deliver virtual heart care for their populations). What do you think are the top secrets to a successful health-specific technology implementation?

Success for any type of implementation is dependent on details and relationships. In the Heartbeat Health context, launching a new client requires planning an end-to-end implementation that includes staffing, technology, credentialing, contracts, finance among a host of other details. A detailed roadmap is imperative to take into account upstream and downstream impacts and related inter-dependencies. Roadmaps can only get you halfway — you also have to have partners to support the effort. Building relationships cross-functionally is as important as determining the details and checking all the boxes. We’re lucky to have a great team of partners at Heartbeat who strive to achieve great things without ego.

Do you have an example of an implementation in your career that is memorable that you’d like to share?

At a previous employer, I was selected to create a National care program to reduce hospital readmissions. There were no blueprints and no rules so our team had to make it up from scratch. We worked tirelessly to design and implement a program in record time. It was challenging but I definitely learned a lot and I am proud of what we created. This program was unique because it placed nurses in hospitals to work with patients to create post discharge plans and reduce readmissions. Building programs from the ground up is my forte and something I always enjoy, which is why coming to Heartbeat was such an exciting career choice and continuing adventure for me.

Thanks again for your time today. Anything else you would like to share?

I’ve recently celebrated my one-year anniversary at Heartbeat. I am so thankful to be part of this team. Cardiovascular health impacts everyone, either directly or indirectly – and I believe we can change the script on care delivery and outcomes for years to come. Our challenge as a growing organization is to select a strategic path that will have the greatest impact for patients everywhere — and thereby enabling a friction-free delivery of services that produces great outcomes for patients, providers and at-risk healthcare organizations alike.

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A closer look at how cardiovascular care is changing across the country.

Throughout my career, I’ve witnessed a lot of changes in healthcare. One constant over my thirty years of experience is that things do not stay the same. I’ve worked with hospitals, provider groups and payers – trying to help drive the right type of access, care, and value across the healthcare continuum. One of the biggest challenges I’ve observed is access to high-quality and timely rural healthcare. 

Rural communities face a two-pronged problem. One on hand, there continues to be an ongoing physician shortage in much of the United States. According to Health Resources & Service Administration (HRSA), there are over 3400 Medically Underserved Areas (MUAs) designated by HRSA, which each have a shortage of PCPs and specialists serving their communities. For example, there are far fewer cardiologists in the  Midwest and Western States – as little as 25% of the number of cardiologists per 100,000 residents ages 65 and older – compared to more densely populated areas.¹  That problem is exacerbated by the lack of access to acute care:  Since 2011, two-thirds of the hospital closures in the U.S. have been in rural areas.²

The second element at play is that there are ingrained social determinant barriers that ultimately prevent access to quality care, most notably with transportation and finance. Rural patients often have to drive farther to get care than the people who live in urban areas – and they often can’t afford to do so.  A recent Pew Research Center Study found that the average travel time to reach an acute care facility is 34 minutes. That trip is often longer in more rural locations. which often suffer from higher poverty rates, too.³ Access to timely quality care becomes more and more of a challenge for too many rural communities – and hospitals and payers continue to look for solutions to address this intractable problem.

Specialty Demand

Certain specialties, focused on conditions like cardiovascular disease and diabetes, also have rising demand, as the baby boomer population ages and becomes higher risk. The demand for cardiovascular care, for example, continues to grow at an almost exponential rate. According to the Journal of the American College of Cardiology, cardiovascular disease has nearly doubled in prevalence since 1990, with deaths due to cardiovascular disease increasing by over 50%.⁴ Conditions such as Ischemic Heart Disease, Atrial Fibrillation, Hypertensive Heart Disease, and Ischemic Stroke make up almost 75% of the deaths due to cardiovascular disease.⁵ These conditions, if detected and addressed early and appropriately, can be treated and prevented. 

What is clear is that the combined supply and demand for speciality care we are seeing will not be solved by historic approaches and processes.

Specialty Solutions

The question then is: how do we prepare for and address the problems that rural communities are facing across the country? The pandemic taught us that telehealth, virtual care, and innovative diagnostic technology enable providers and caregivers to expand capabilities, regardless of location. Doing so also helps address socio-economic barriers. 

So what is the way forward? I’d like to suggest three discrete paths to help provide better access, care, and outcomes for rural America.

1. Empower local Primary Care
   There is, of course, a shortage of primary care providers in rural geographies. PCPs are stretched thin and often have to refer their patients to specialists hundreds of miles away. Between travel, time, money and fear, many of these patients don’t make it to the appropriate care provider under current conditions. Specialists need to partner with local primary care clinicians – using technology to meet patients where they are – to reverse this reality.  That work might include virtual visits as well as provider-to-provider consults with specialists.  
   
2. Leverage technology
   Employing ground-breaking remote diagnostic devices, such as the Zio patch by iRhythm, changes the game. By enabling remote atrial fibrillation detection, virtual cardiologists can work with the local PCPs to read, diagnose and prescribe, allowing for the appropriate triaging of the patient — while still keeping the patient under the care of the PCP according to guideline-based protocols. 
   
3. Enable virtual cardiovascular care
   Most non-invasive cardiovascular care aligns well with virtual and telehealth capabilities. Patients don’t have to travel from their home to see a specialist, and access to care is improved.  Virtual cardiologists can work with both local providers and patients to help manage chronic conditions and diseases like atrial fibrillation, vascular disease, and heart failure.  CDC studies, in fact, have demonstrated the safety and effectiveness of home-based cardiac rehab is equal to the care delivered in facilities.^5.

The Ultimate Impact

Evolving and improving how we collectively care for individuals with heart conditions across rural America will differ depending on the individual or stakeholder. 

• For the Patient: With earlier detection, better diagnoses, and improved access, patient care can be drastically improved in areas where access and care are now lacking. Early detection saves lives, improves quality of life, and enables equitable cardiovascular care regardless of location.

• For the Primary Care Provider: By supporting the PCP in the diagnosis and treatment of cardiovascular disease, the PCP can treat more of the community appropriately, triage only those patients truly in need of in-person visits, and support earlier detection and care.

• For the Risk Bearing Entity e.g The Health Plan or Accountable Care Organization (ACO) Today, the outcomes for patients (or members) with potential cardiovascular intervention continue to be what risk-bearing entities ultimately care about. And the day-to-day care challenges I’ve outlined remain a real threat to change e.g.
  • If an individual lives over 200 miles away from the specialist, will they end up making it there?
  • Will non-emergent transportation be needed to an appropriate facility?  
  • Has the individual had the right diagnosis and oversight to validate a costly visit to the specialist?
  • Could some of these visits have been diagnosed at the PCP office, with the appropriate support? 
  • Could an ER visit have been avoided? 

Yet, there are signs of the status quo shifting. Heartbeat’s most recent clinical study⁶ showed that appropriate virtual care and support reduced cardiac-related  hospital readmissions by 53%. By meeting members where they are — access to care, quality, and outcomes can be dramatically improved, and all stakeholders will benefit. 

¹ https://www.healthgrades.com/pro/8-things-to-know-about-the-cardiologist-shortage

^2. https://www.healthaffairs.org/do/10.1377/forefront.20220222.972908

³ https://www.macpac.gov/wp-content/uploads/2021/04/Medicaid-and-Rural-Health.pdf

⁴ https://www.jacc.org/doi/10.1016/j.jacc.2020.11.010

⁵ https://www.cdc.gov/chronicdisease/resources/publications/factsheets/telehealth-in-rural-communities.htm

⁶ http://www.heartbeathealth.com/wp-content/uploads/2023/03/ACC23-poster_web.pdf

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In this ongoing interview series, we’ll be talking to leading clinicians, tech leaders, and entrepreneurs about their life, careers and professional experiences in the fields of heart care, cardiology and heart health as a whole.

Heartbeat in Conversation interviews are conducted by Heartbeat’s very own VP of Marketing, David Mait.  

This past month we spoke to Heartbeat Staff Cardiologist, Edward “Ted” Gibbons. The following is an edited transcript from a live conversation on Jan 26, 2023.

Hi Ted. Thanks for making the time on this lovely Thursday morning. Can you catch us up briefly on your career journey to date?

My forty years in Cardiology have been exciting and have changed dramatically every 5-7 years of my career. I actually wasn’t interested in medicine until after I finished college, because I was more interested in biochemistry. But then I ultimately got into some medical research, and then was encouraged to go to medical school — and it turned out to be a very good decision. I went to the University of Chicago, and did very well there. I really liked medical school. And then I did my training after medical school in medicine and Cardiology at Harvard/Mass General Hospital. Then, after seven years of doing that, I moved to Seattle, and have been in three institutions since that time, including two large group practices with hundreds of doctors and many specialty clinics. I was then asked to go over to the University of Washington to one of their main teaching hospitals to start a heart failure program, which I did, and then got roped again into a lot of administrative things, and so quickly became chief of cardiology, and started this and started that. So a lot of what I’ve done is actually me taking stock and asking “Well, what’s going on here? How can we make it better?” So I’ve started lots of programs. I also did a special fellowship and echocardiography at Mass General. I’ve always been interested in cardiac imaging. I was also an invasive but non- interventional cardiologist. I like doing things with my hands, and the manual dexterity that it takes to do things like that.

How would you describe your approach to diagnosing and treating heart disease?

Patient context and experience are essential to understand. I like to know how a subject has spent their life, and what their goals are. Diagnosis is in many ways developing pattern recognition skills–piecing together symptoms, physical signs combined with a direct review of test results, especially imaging. But always, it is important to challenge assumptions: what don’t I know? Is there data on the problem I am trying to solve? How can I intervene, and how can I translate my process into patient teaching and define the course of therapy?

Can you discuss a particularly challenging case you have treated in the past and how virtual-cardiology has changed your approach?

We recently saw a heart failure patient who was “packaged” as a 65 year-old man with routine hypertensive heart failure. But the more we looked at the data, it became clear that this man had a complex systemic disease that required specialized blood and imaging tests. So, virtual cardiology provided an opportunity to turn on my “pattern-recognition” radar with a clinical team that shares that approach.. Again, the more data we have, the better and faster this process can go.

Where do you see virtual patient care going in the next 5-10 years?

I think the biggest advance will be in some secure cloud-based data repository that includes all medical data and imaging on a patient. We need to develop ways of examining patients, perhaps with breakthroughs in defining and using biometric data we have yet to gather. We also need to understand virtual care better (benefits and drawbacks) and accordingly educate patients and practitioners about the results.

How will these dynamics impact the cardiologist community?

I think that we also have to realize that the American College of Cardiology keeps emphasizing that at least 25-30% of cardiologists are between the ages of 50-55, and that there might not be enough cardiologists in our aging population for the future. So, we have to be able to work in teams in order to leverage the expertise of each of the team members, the nurses, and the medical assistants, technicians, as well as the cardiologists. The only way we can do that is to be able to do quick evaluations with comprehensive information. And if you don’t have the information, you’re going to make mistakes. The key is having a comprehensive medical record stored in the cloud that is secure — and giving patient’s confidence that it’s secure. These two dynamics acting in parallel are essential. And I’ll reiterate again – it must include every single piece of medical information.

Thanks again for your time today. Anything else you would like to share?

I cannot emphasize enough the need for having comprehensive data. It improves care, promotes credibility with patients and caregivers, and sets a standard for superior care. That includes clinical information, but also a full profile of the patient’s social, socio-economic and philosophical milieu. Then heart care becomes something living, breathing and evolving.

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The History

The first recorded mention of the term “Accountable Care Organization” was by Dr. Elliott Fisher during a 2006 public meeting with the Medicare Payment Advisory Committee (MedPAC). 

Then, six years later in 2012, The Patient Protection and Affordable Care Act (ACA) authorized the use of Accountable Care Organizations (ACOs) to improve the safety and quality of care and reduce health care costs in Medicare. ACOs are defined as groups of doctors and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. They matter because their member bases are growing fast, and they’re driving both better outcomes and lower costs.

As of January 2022, there are 483 Medicare ACOs serving over 11 million beneficiaries across the country (per the National Associations of ACOs). There are many flavors of ACOs — including hospital-based ACOs, independent ACOs that offer what tends to be called “facility-based primary care” (that is, they build and run their own centers), and “over the top” players such as Aledade, Evolent, and Privia that collaborate with existing independent primary care practices. This network dynamic from Aledade et al enables independent practices to participate in the ACO model when otherwise they probably would or could not.

These days, it’s significant that The Center for Medicare and Medicaid Innovation has clearly expressed that they want every Medicare beneficiary in an accountable care plan by 2030. And their newest program, called ACO Reach, has attracted hundreds of applicants, as CMS seeks to ensure historically underserved patients are fully included.

Primary and Speciality Collaboration

Over especially the last two decades, primary care in America has been limited in what it can or will do in regards to specialty care, such as for categories such as kidney, cardiovascular or GI. But now, given the economic incentives that are baked into the ACO model, along with the rise of advanced diagnostic devices, the specialty line in American primary care is being redrawn much higher – that is, the lower ~40% of acuity in any specialty such as cardiovascular disease will be addressed in the ACO, and only the top ~60% of acuity will be referred out to specialists. 

This has led to a “hub & spoke” effect – the idea is that ACOs employ advanced diagnostics and curated clinical data to identify gaps in care. In cardiology, that diagnostic is commonly a cardiovascular echo. What happens next is a partner such as Heartbeat Health conducts a same day read, and if the patient has low-to-moderate cardiovascular disease (CVD), the ACO typically keeps the patient and treats their heart issues face-to-face. If the patient has high-to-acute CVD, the spoke is invoked – the patient is referred to, as an example, virtual cardiology team for ongoing heart care, given the convenience that virtual visits represent for the patient. This “hub & spoke” effect is transforming how primary care tied seamlessly to speciality care work together across disciplines.

The ACO REACH Model

To make matters more nuanced, the new ACO REACH model is now here. REACH stands for Realizing Equity, Access, and Community Health. It replaces the Global and Professional Direct Contracting (GPDC) Model. The GPDC was launched during the Trump administration, with the aim of allowing traditional and non-traditional risk-bearing entities to take on risk for lives across an entire market beyond the normal attribution method for other ACO models.

A major focus of the Biden administration’s ACO REACH program is health equity. A new benchmark adjustment prominent in the REACH rubric is to positively incentivize ACOs covering underserved communities and beneficiaries — or at least avoid inadvertently penalizing them for doing so.

The ACO REACH Model accepted applications in April 2022, and will officially launch next year, likely with known players from the ACO and GPDC realm, and new organizations as well.

All ACOs in the REACH model will have to develop a plan for how they will identify health disparities in their respective communities and then take specific actions to address those disparities. This is a requirement that does not exist currently in Medicare. 

Virtual models will also be key in regards to health equity. Medicare patients have proved far more facile with video visits and HIPAA-compliant texting than prognosticators imagined, especially when no smartphone app is required. Since there’s increasingly appreciated “value in the visit,” web and mobile web video encounters appear to be especially effective with seniors, and lead to a level of appointment adherence far greater than what is seen in the face-to-face model.

Patients in ACO REACH – and other ACO models – actually receive more benefits than those in traditional Medicare. Broad use of telehealth is very much allowed, as is the waiving of a requirement for a three-day inpatient hospital stay before an admission to a skilled nursing facility. Patients can receive cost-sharing support to help with copays, as well as rewards for managing their chronic diseases. REACH also allows much more generous use of home visits after patients leave the hospital.

This home visit component is important, because the “Last Mile” is being paved at a rapid rate in America, whereby a nurse with advanced diagnostics can get to the patient’s home in a growing set of major markets in less than 4 hours. Then, the visiting nurse can stream diagnostic data in real time to relevant providers, typically specialists. Prominent “Last Mile” firms include Dispatch Health, Medically Home, MyNexus (owned by Anthem), OneHome (owned by Humana), Livio (owned by Blue Cross of Minnesota) and Emcara (owned by Florida Blue). And there are many dozens more.

The hub for any ACO, traditional or the new ACO REACH model, appears to be face-to-face primary care. The spokes, however, are likely to be increasingly virtual as a function of patient convenience and achieving lower costs of care. And the recasting of the specialty line will mean “V1Cs” (Virtual-First Care companies, as named by the Virtual First Medical Practice Collaboration) are operating in every specialty, representing a rich menu of choices for ACO and ACO REACH players alike.

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Scheduling an in-person visit with a cardiologist is downright difficult. Nationally, it takes upwards of 45 days to see one and the prospect of getting yourself there can be a challenge for many. For PACE plans (Program of All Inclusive Care for the Elderly) who manage care for thousands of individuals in their network – this reality is an incredible challenge and extends beyond one speciality area like heart care. The responsibility that falls under a program providing all inclusive healthcare for the elderly includes so much more than standard primary care. The all inclusive aspect of care in the PACE model is also one of the greatest assets to its participants, but what happens when specialty care becomes too complex for the participant to reap the benefits? 

As background, PACE programs provide the entire continuum of care and services to seniors with chronic care needs while maintaining their independence in their home for as long as possible. Services are all inclusive, a participant relies on the PACE organization to provide all care, inclusive of transportation and social services related to care. Programs receive a set amount monthly from Medicare and Medicaid to provide nearly everything for people over 55 whose needs qualify them for a nursing home but who don’t want to enter one. This includes doctors’ visits, tests, procedures, physical, occupational and speech therapy, social workers, home care, transportation, medication, dentistry and hearing aids. Participants typically visit a PACE center several times a week for meals and social activities as well as therapy and health monitoring.

So the question arises – are there ways to simplify specialty care, like heart care, for PACE plans?

At Heartbeat Health, we provide an opportunity for a primary care provider in a PACE facility to easily refer a patient directly to a Heartbeat virtual cardiologist. The participant can set up a virtual visit instantly or on another day that they will be back in the PACE facility, or even at home if they choose. This simplified workflow eliminates scheduling headaches, transportation coordination burdens and the visit itself is lower cost than an in person visit. Not to mention, this simplifies the experience and lowers stress barriers reduction for the participant as well.

Additionally, given the barriers that participants face, such as the need for translation services or access to a laptop or WiFi, there are concerns among some that Virtual-First care will exacerbate the digital divide. Fortunately in the PACE model, an interdisciplinary team of health professionals provides PACE participants with coordinated care and assistance. For most participants, this opens a door for simple virtual visits, with their care team in the facility to help if needed. Furthermore, Heartbeat’s virtual visit experience (televisits) takes those issues into account and as a result, systematically improves access to treatment. 

Lastly, given the at-risk nature of the payment model for PACE, cost reduction also becomes a very important piece of the puzzle. With facility fee costs eliminated, the average savings can be ~$200 per visit across most markets. This coupled, with a reduction in costs in eliminating transportation costs, presents a great opportunity financially for a PACE program. 

Additionally, Heartbeat can conduct cardiovascular risk assessment across the entire PACE population. This can be done either through chart review or in-person diagnostics or remote diagnostics, to identify participants with rising risk or existing CVD. This may allow the PACE plan to adjust risk scores and potentially increase reimbursement per participant. 

PACE plans are responsible for some of the widest variety of services for any healthcare organization taking on risk. The complexity that each plan faces to ensure their participants receive high quality specialty care is just too much. The time is now to untangle the logistics, scheduling burden and cost for specialty care for PACE plans – and deliver better clinical outcomes for PACE participants at scale.

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