November 12, 2019

1. What is the potential of Online Care to revolutionize healthcare delivery? 2. What value do you see “Team Edition” creating? What barriers to its adoption do you foresee?

Answer these questions and write 3page case analysis . Attach data calculated sheets. American Well the Doctor Will E-See You Now 1. What is the potential of Online Care to revolutionize healthcare delivery? 2. What value do you see “Team Edition” creating? What barriers to its adoption do you foresee? 3. Which of the new market opportunities did you see as most promising? 4. Would you pursue any of the next-generation options in 2010, or would you just focus on the core platform with the core target market? Why and why not? DEFINE FROM THE ARTICLE: 1)Consumer 2)Competition 3)Market 4)Price 5)Distribution 6)Sales 7)Promotion 8)Product 1 American Well: The Doctor Will E-See You Now On a crisp morning in November 2009, Ido Schoenberg was walking briskly through Boston’s Logan Airport when he spotted his brother, Roy Schoenberg, standing in line to board a flight to Washington, D.C. The two brothers, cofounders of American Well, the Online Care company, were taking a flight to Washington to deliver a presentation at the World Health Care Innovation and Technology Conference (WHIT). With the debate over health-care reform raging in Washington and with Bill Clinton as the keynote speaker, this year’s conference was sure to be a big event. As the flight lifted off, the view from the plane’s window revealed the historic Boston cityscape, where many significant events leading to the American Revolution had taken place. But as they settled in for the short 90-minute flight, Roy and Ido had a different revolution on their mind. Just three years ago, Ido and Roy founded American Well in an attempt to forever change health- care delivery and improve the way patients interact with physicians. Traditionally, patients had two primary choices when seeking medical care—to show up at an emergency room or a similar acute- care facility, or to submit themselves to the schedule of their physician, which could result in weeks of waiting for an office visit. American Well’s vision was to use the Internet and telephony to connect physicians and patients, within minutes in real time. Since its founding, the company was successful in developing the necessary technology platform, and its efforts to market the vision to major health insurance companies (also called health plan providers) in the U.S. had started to yield results. In fact, Blue Cross Blue Shield of Hawaii was the first to roll out the service earlier in the summer on a statewide basis, and so far the implementation of the platform had gone well. American Well management faced several pressing questions regarding where the company should go next. Although focusing on a nationwide rollout and adding more health insurance companies to the service would be a monumental task for any start-up company, Ido and Roy were already considering new applications for their platform. Being well aware of the first-mover advantage that American Well enjoyed, they were thinking about the next service concept, called “Team Edition.” While the service offered in Hawaii facilitated connectivity 2 between patients and physicians, the next generation of service, if developed, would add connectivity between primary care physicians (PCPs) and specialists. Patients would no longer have to wait for weeks to see the specialist and then more time before coming back to their PCP for follow-up. Instead, Team Edition would connect the PCP and specialist instantly during the patient’s initial office or online visit. 510-061 American Well: The Doctor Will E-See You Now Ido and Roy were also contemplating new customer segments for American Well’s platform, including hospitals, retail clinics, and pharmacies. Having been approached by a number of non-U.S. health insurers, expanding into international markets was also a possibility worth exploring. Although Roy and Ido were confident that American Well’s platform had revolutionary potential even beyond the healthcare industry, they wondered: if they invested resources in new markets and product launches too early, would they undermine American Well’s opportunity to become the definitive leader in Online Care? Health-Care Delivery in the U.S. In 2009, U.S. health-care expenditures were estimated to top $2.5 trillion and were projected to reach $4.3 trillion, or $13,100 per resident, by 2018.1 This outlay represented 17.6% of gross domestic product (GDP)—a greater percentage than in any other country—and reflected the fragmentation and complexity of a system that was the subject of intense reform debate in public policy circles in 2009. Chronic diseases (e.g., cancer, diabetes, and heart disease) were leading causes of disability and caused 7 of every 10 deaths each year in the U.S.2 The prevalence of chronic disease made it a focal point for health-care providers, who were also bracing for the significant demographic shift expected to occur over the next two decades, by which time Americans over age 65 would comprise 20% of the population.3 (See Exhibits 1 and 2 for a breakdown of U.S. health spending in 2008.) Players The key players in the U.S. health-care system were patients, providers, public and private payors, and suppliers (of products such as 3 therapeutic drugs and medical devices). Other supplier subsectors included health-care information technology (IT) providers, private equity and venture capital (VC) firms that financed health-care ventures, and academic and other institutional researchers. Providers included entities involved in delivering care, such as hospitals, nursing homes, and health clinics, as well as physicians and other health professionals. Of the approximately 5,500 hospitals providing inpatient and outpatient services, close to 90% focused on acute care, while the remainder specialized in rehabilitation, psychiatric care, and other specialties.4 Institutional providers also included nursing homes, assisted-living facilities, home-based care providers, and others. Approximately 990,000 physicians worked in the U.S., 40% of which were PCPs:5 generalist physicians who served as the first point of contact for their patients’ physical and mental health needs. 6 Nonphysician providers included 2.5 million registered nurses, 74,000 physician assistants, 147,000 nurse practitioners, and others. 7 Some physicians were employed by hospitals, while others ran private practices comprising one or more physicians. On average, family doctors earned $168,000 per year (about $81 per hour), registered nurses earned $67,000 ($32 per hour), and pharmacists earned $107,000 ($51 per hour).8 Delivering and Paying for Patient Care The type and quantity of care delivered to patients depended on several factors, including health insurance coverage (if any) and geographic location.9 Patients with health insurance typically had a PCP who served as their chief contact for health concerns, and who referred them to specialists (e.g., cardiologists, dermatologists, surgeons, etc.) as needed. For patients without insurance, hospital emergency rooms often served as the main source of care. There were regional shortages of some specialists (e.g., mental health, obstetrics, and gynecology); as such, the patient experience of receiving care varied between and within states. Insufficient access to care was especially problematic 2 in rural areas, where provider shortages, low population density, and disproportionate reliance on self-employment and low-skill jobs—which 4 had low rates of employer-sponsored health insurance— created barriers to care.10 The U.S. system for financing patient care was a complex web of public (federal and state) and private-sector payors. Coverage requirements, premium limits, reimbursement levels, and other constraints imposed on insurers varied by state. As of 2008, 53% of health spending was funded by private payors, including health insurance companies, individuals, and philanthropic sources.11 Health insurance companies offered several types of health plans at different price and coverage levels. Individuals with private coverage either purchased plans independently or received coverage through their employer. Most firms with 50 or more workers offered health coverage; smaller companies were less likely to do so.12 The format of employer-sponsored insurance varied, but typically involved employees paying a portion of premium payments and employers covering the rest. In 2009, the average annual premium for employer-sponsored insurance was $4,800 for individuals (17% paid by employee) and $13,400 for family coverage (27% paid by employee).13 The balance of health spending (47%) came from public payors, chiefly Medicare (federal program for Americans age 65 and over) and Medicaid (state program for eligible low-income and disabled residents), as well as the Department of Veterans Affairs (for military personnel) and SCHIP (State Children’s Health Insurance Program). In some cases, public payors did not cover the full cost of care delivery, leading providers to rely heavily on revenues from privately insured patients. (See Exhibit 3 for community hospitals’ payment-to-cost ratios from different payors from 1980 to 2007.) Patients without health insurance—about 17% of Americans under age 65—paid for care out of pocket and, in many cases, went without: one survey found that 14% of Americans did not see a doctor due to cost concerns in 2008.14 This was even true of many who had insurance, because their plans had high deductibles—the required out-of-pocket payment before insurance kicked in—or had limits to the services or dollar amount that would be covered. Health-Care IT Background American Well’s novel service model, which the company termed Online Care, came on the heels of a number of developments in the use of telecommunications and computer-based tools to collect, 5 manage, and communicate health-care–related information and transactions. Examples included computerized decision-support and order-entry systems for physicians, electronic health or medical records (EHRs or EMRs), and tools for searching for health information (e.g., WebMD). Patients’ use of health-related websites increased through the 2000s, and by 2006, 80% of respondents to a survey of Internet users reported searching online for health-related information. 15 Other electronic exchanges included bill-pay services, appointment scheduling, and communication of lab results. Many of these innovations aimed to reduce the administrative burden facing providers and payors. (See Exhibit 4 for private insurance administrative cost data.) Electronic Patient-Physician Interaction By the mid-2000s, patients and physicians were becoming more comfortable communicating electronically through e-mail and secure messaging. In 2006, a survey found that 74% of respondents wanted to communicate with their doctors using e-mail, but only 4% were actually doing so, largely because such a service was not offered. 16 Concurrently, physicians’ use of online communication was on the rise: one survey of Internet-using physicians in the U.S. noted that from 2001 to 2008, physicians who communicated with patients online increased from 23% to 36%.17 Some data 3 510-061 American Well: The Doctor Will E-See You Now suggested online communication created efficiencies; for example, a 2007 study of Kaiser Permanente, a large health-care system, found that e-mail-using patients were 7% to 10% less likely to schedule an office visit, and physicians offering e-mail communication received about 14% fewer phone calls.18 (See Exhibit 5 for consumer attitudes about e-mailing their PCP in 2009.) Yet, many doctors were reluctant to engage patients via e-mail, as an April 2008 article noted: Some [physicians] say they worry it will increase their workload, and most physicians don’t get reimbursed for it by insurance companies. Others say they fear hackers could compromise patient privacy—even though doctors who do e-mail generally do it through password- 6 protected Web sites. There are also concerns that patients will send urgent messages that don’t get answered promptly. And any problem raises the specter of legal liability.19 HIPAA The market success of health-care IT innovations depended on their compatibility with HIPAA (Health Insurance Portability and Accountability Act), enacted in 1996 to address privacy and security risks stemming from increasing use of electronic channels to transmit patient information. The act applied to providers, insurance companies, group health plans, and government payors.20 HIPAA’s Security Rule set national standards for protecting electronic health information, and its Privacy Rule dictated how patient information could be used and disclosed.21 Since 1996, HIPAA had been revised in light of technological advancements, but users of new health-care IT remained wary about HIPAA compliance and malpractice risk. Payment Physician adoption of new technology was also contingent upon payors’ willingness to reimburse for electronic communication with patients. Physicians were typically reimbursed on a fee-for-service basis. For classification and billing purposes, services were “coded” by the American Medical Association (AMA) in conjunction with federal payor agencies. AMA assigned a descriptive phrase and numeric code to each medical service, and issued new codes periodically as the nature of services evolved. Payors would not reimburse services without a code. As such, the issuance of codes was critical to the success of new health-care IT innovations. In 2009, codes had been issued for some forms of health-care delivery via IT platforms. However, most insurers remained reluctant to cover online services due to concerns over security, privacy, and uncertain patient demand.22 Recent Developments in Health-Care Provision Tele-Medicine Services The term “tele-medicine” described a range of programs and services that involved health-related electronic exchanges with the objective of improving patient care. A number of companies offering such services are described below. RelayHealth Founded in 1999, RelayHealth offered online solutions for facilitating patient- physician communication.23 Through 7 RelayHealth, patients could schedule appointments, update their health records, and request lab results, prescription renewals, and referrals. For nonurgent issues, patients could complete interactive online questionnaires describing their symptoms;24 this information was then transmitted to the patient’s physician, who determined whether an in-person office visit was necessary. 25 Most providers replied within eight business hours. RelayHealth pioneered the use of secure (HIPAA-compliant) e-mail between patients and providers. In 2006, McKesson Corporation, a health-care IT and automation supplier acquired RelayHealth. By mid- 2009, 50 health-care systems and hospitals had contracted with RelayHealth.26 4 American Well: The Doctor Will E-See You Now 510-061 Medfusion Founded in 1996, Medfusion facilitated online physician- patient communication through its Virtual Office Suite, a secure, HIPAAcompliant web-based platform through which physicians could connect with patients by phone or online.27 This included appointment requests, bill payment, and prescription renewal. Medfusion also offered virtual office visits, employing an interactive questionnaire similar to that used by RelayHealth.28 In 2009, Medfusion served more than 28,000 physicians in various specialties across the U.S., and had over 1 million patient accounts.29 “[Medfusion offers] a self-service technology providers want to make available to their patients so that patients can be more involved in their care,” noted Medfusion CEO Steve Malik in 2009.30 TelaDoc Founded in 2002, TelaDoc offered patients year-round, 24- hour by 7-day phone access to a network of physicians in a call center model.31 In a 2007 interview, TelaDoc CEO Michael Gorton described the question that had driven the creation of TelaDoc: “What percentage of primary care visits could be handled with just a telephone and an electronic medical record?”32 The company suggested patients use the service when their PCP was unavailable (e.g., after normal office hours), when traveling, for short-term prescription refills, and to obtain physician advice to supplement that provided by their PCP. To request a medical consultation, which cost $38 or less, TelaDoc’s more than 1.6 million “members” could access their online account or call TelaDoc. 33 After reviewing the request and the patient’s EHR, a physician licensed to practice in the patient’s home state phoned the patient, typically 8 within one hour.34 After the consultation, physicians updated the patient’s EHR, which could be viewed online by the patient and her PCP. Cisco TelePresence Founded in 1984, Cisco was a leading global provider of networking technology.35 Cisco’s TelePresence, which enabled live video conferencing and collaboration, was adapted to the health services setting to create HealthPresence, which combined TelePresence with medical devices to enable real-time interaction between health-care providers and patients. Using HealthPresence, patients could interact with physicians over video conference while also sending data (e.g., blood pressure) collected from medical devices to the physician, enabling a real-time evaluation. At a specific time and location where the HealthPresence technology was set up, trained professionals operated the medical equipment and helped the patient communicate with the remotely located physician. In 2009, Cisco was creating a nationwide network based on HealthPresence technology in collaboration with UnitedHealth Group, a large U.S. health insurer whose provider network included nearly 600,000 physicians and 5,000 hospitals.36 Convenient “Offline” Care Nurse Practioners (NP) The idea for NPs was conceived in the 1960s to address the problem of PCP shortages in rural areas. NPs underwent more training than registered nurses and were licensed to perform many of the same tasks as physicians.37 In 2009, NPs worked in numerous settings, including hospitals and emergency rooms, private practices, retail clinics, nursing homes, and schools. In addition to clinical care, NPs engaged in health promotion and education, disease prevention, and counseling. Each year, NPs engaged in approximately 600 million patient visits.38 MinuteClinic MinuteClinic was a provider of walk-in health clinics based primarily in large pharmacy or grocery chains (e.g., CVS, QFC, Cub Foods), as well as malls and corporate and government offices. In 2009, MinuteClinic had locations in 25 states offering medical care for nonemergency needs, as well as preventive care and vaccinations. 39 Clinics were open seven days a week, including evening hours, and patients were not required to make an appointment. In a visit that typically lasted no more than 15 minutes and cost $62, a physician assistant or NP could examine a patient for issues stemming from a 9 minor illness or injury.40 Patients often paid out of pocket, though many health insurance companies covered MinuteClinic services. 5 510-061 American Well: The Doctor Will E-See You Now RediClinic Like MinuteClinic, RediClinic was a walk-in, retail-based clinic offering treatment for routine health issues, as well as vaccinations and certain health tests and screenings. RediClinics were located in the stores of Texas-based grocery and pharmacy chain HEB and staffed by physician assistants and NPs.41 “Research over the past 30 years has consistently shown that the primary care provided by nurse practitioners is comparable in quality to that provided by physicians,” said Webster Golinkin, CEO of RediClinic. 42 Several insurers covered RediClinic visits—treatment of conditions such as ear infection and common cold cost $79—though many patients paid out of pocket.43 Golinkin noted that, “research shows that as many as 50% of the people who seek care at overburdened emergency rooms could be treated much less expensively in convenient care clinics.” 44 Take Care Clinic Part of Take Care Health Systems, a wholly owned subsidiary of convenience and pharmacy chain Walgreens, Take Care Clinics were located inside certain Walgreens locations throughout the U.S. Take Care Health Systems also managed workplace-based health services through its Take Care Employer Solutions division. In 2009, there were more than 340 Walgreens-based Take Care Clinics and some 370 workplace-based health centers.45 Offering walk-in appointments starting at $65 for treatment of common ailments, Take Care Clinic claimed to “deliver healthcare that fits your life.” 46 Walgreens pharmacies and Take Care Clinics began offering walk-in vaccinations for the H1N1 flu virus in December 2009. 47 The Entrepreneurial Roots of American Well Before becoming an entrepreneur, Ido Schoenberg was trained as a physician at the University of Tel Aviv Sackler School of Medicine in Israel. In 1996, Ido and his wife, Phyllis Gotlib, cofounded iMDsoft, a health-care enterprise software company. iMDsoft was among the first to recognize the opportunity for IT to have an impact on the nature and quality of critical care. Initially focusing on adult, pediatric, and specialty intensive care units, iMDsoft developed an expert system that monitored critically ill patients. Previously, doctors and nurses had to 10 continuously observe several monitoring devices and integrate the information on the fly in an attempt to translate independent clinical measurements into a comprehensive clinical assessment. The software of iMDsoft integrated the separate measurements, enhanced the quality of decision making, reduced errors, and improved the financial performance in one of the most high-cost units of any hospital. In 2000, Ido left the company but continued to serve as chairman of its scientific advisory board. Gotlib stayed on to lead the company in becoming a global leader in hospitalwide acute care information systems. In 2001, Ido became CEO of CareKey, a provider of electronic health management systems that his brother Roy founded the previous year using capital raised from angel investors. A graduate of Hebrew University Medical School, Roy had worked as an internal medicine physician in Israel before pursuing a research fellowship at the Center for Clinical Computing and a master’s of public health degree from Harvard University. As a fellow, Roy published a scientific paper in the British Medical Journal that described a hypothetical online system of personal health records (PHRs). The brothers envisioned CareKey as a model for enabling more direct interaction between patients and health insurance companies. CareKey was first to provide patients with Internet-based PHRs coupled with a comprehensive personalized set of tools to self-manage certain health and wellness issues, as well as communicate effectively with nurses and other staff members at their health plan. CareKey’s platform greatly assisted health insurance companies in transitioning from the episode-of- care model—simply paying for each covered service an insured member received—toward an advanced care–management model, which sought to minimize members’ long-term health costs through prevention and early detection. In the typical approach to care management, in which nurses 6 American Well: The Doctor Will E-See You Now 510-061 phoned patients when they were due for a test or checkup, patient compliance was poor. CareKey helped narrow this compliance gap by giving patients access to a personalized, on-demand platform for selfmanagement and transactional communication with health plans’ staff 11 and resources. After growing CareKey over the next five years, Roy and Ido sold the private company to the TriZetto Group, one of CareKey’s early corporate partners. By the end of 2009, more than 45 million people were using the CareKey system (renamed CareAdvance). After selling CareKey, Ido and Roy frequently met to discuss the remaining gaps in health care and ways IT could help bridge those gaps. In the summer of 2006, Roy returned to Israel for a few months. He recalled: I settled in an apartment in Herzliya, Israel, overlooking the Mediterranean, and got into the vacation routine of relaxing on the beach in the morning, enjoying long lunches, and hanging out with friends. The problem with taking time off in your thirties is that all your friends are working during the day and available only at night, so I had lots of time on my hands. I started to reflect on all that we had learned through our CareKey experience about health-care IT. Of all the ideas Ido and I discussed, the issue of affordable, convenient access to quality care, particularly in terms of place and time of delivery, was an area where technology could really make a difference. I thought about my own experience as a clinician. Health care for p…
November 12, 2019

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Describe the legal and ethical dilemma discussed in the case study. Analyze the key ways in which a patient ’s right to die relates to this specific case.

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