Redefining digital health: From Chronic Management to Empowered Self Efficacy

Kate Wolin and Christina Farr have written some thought-provoking pieces over the last few weeks and I’m going to be unpacking my thoughts here over a series of posts.

Some of the questions that informed our development of Nightingale Virtual Respiratory Care:

In digital health, are we merely managing illness, or are we empowering individuals to take charge of their health?

Is the issue with current digital health approaches really because of an overemphasis on constant engagement when we should be focusing on empowerment and independence instead?

My thoughts on the topics threshold effects and dose response that Kate describes so well in her March 8th article: the most effective digital health companies will have and should depend on a threshold effect, and doses AND payment should be adjusted accordingly.

Here’s a story about one of our members:

She has been a member for more than 2 years now. She became an expert at managing her condition within 9 months of starting Nightingale, even though she had been having attacks every month before Nightingale. After 2 years:

• Does she talk to a Respiratory Therapist or a Wellness Coach every month? No. Does she call or send a text when she has a question? Yes.
• Does she still avidly read all of personalized our self-management tips as we send them out? Yes, even to the point of engaging with our frankly corny April 1st joke text. If you know me, you’ll know that I rarely meet a corny joke I don’t like, and my team fortunately (or unfortunately?) is like me … Shoutout to Sarah Morgan for this year’s joke.
• Does she wear ADAMM every day? No. Does she wear it most days? Yes. Does she absolutely put it on every time she’s feeling less than okay? Yes. That’s how her Respiratory Therapist was able to tell her something seemed different from her personalized baseline – turned out she had COVID but didn’t know it, so was able to deal with that before it got worse.
• Does my team feel invigorated to know that they’ve helped someone, don’t need to chase people who don’t need them anymore just to meet some engagement metric? Very much yes.
• Does this mean my team can focus their human touch on the people who need it at any point in time while the digital does the rest ? Yes.
• Does that in turn help us scale? Yes.

The way I describe it simply – just because asthma and COPD are chronic conditions, our full Nightingale offering shouldn’t also be “chronic”. We’ve always viewed our role as helping our members to become experts at living well with their condition – emphasis on living well and developing expertise.

I agree with Kate and Chrissy – PMPM being largely gone is good for the sector. We need to stop rewarding doing things (“engagement" as it is currently defined) and move towards rewarding outcomes (health and cost). We need to move the industry forward by rewarding efficacy, ROI and re-focusing how we think about engagement so we can reduce costs. In an economic sense – we can’t add new digital health solutions ad nauseam to continue to extract utility from the system when there is no more utility to be extracted from the patient.

Our premise – if we do our job well, and we overwhelmingly do, then most members will not need our full offering after a while - they “graduate”. And that’s okay with us.

What that looks like:

• We have a great partner who helps us help our clients measure baseline spending, and we track progress over time.
• We use clinically validated tools to measure outcome improvement.
• When a member achieves a certain improvement threshold and sustains it for 6 months thereafter, we adjust our expectations of what their “dose” or engagement should be.
• And we expect our payment to decrease accordingly, or go away if we aren’t being effective.

It’s why we make a “graduation” promise to our clients - we guarantee that a certain proportion of their members will graduate within a specified time frame. Our customers see reduced costs, our members are happy no one is hounding them but they know we are there if anything goes wrong, and we get to help more people. We call that a win for everyone.

What are your thoughts on the threshold effect, dose response and payment methods?