In an era where nearly every consumer good and service — from books and groceries to babysitting and shared rides — can be purchased through an electronic transaction on a mobile device, it seems reasonable to think that more and more of our health care can also be managed using apps on mobile devices. Proponents of these apps see the potential of digital technologies to shift care provision from physicians’ offices and hospitals to the patient’s home or anywhere with reasonable Wi-Fi connectivity.
The potential benefits of digital health seem particularly compelling for managing chronic conditions such as diabetes and hypertension. In these cases, providers typically prescribe multipart protocols — including medications, dietary restrictions, and exercise — whose success depends on patient compliance and choices that take place on a daily basis outside of the formal health care system. Chronic diseases are prevalent, affecting roughly 120 million Americans, and take a large toll on public health. The Centers for Disease Control and Prevention estimates that chronic diseases account for 70% of U.S. deaths and 75% of U.S. health care spending.
While chronic disease management (CDM) apps have had some initial success, they have not yet lived up to their potential. This shortcoming is not due to the technologies, which are quite impressive; the problem is the incentives and institutions of the delivery system into which the technologies are being introduced. To succeed under these circumstances, developers of CDM apps must first consider who the primary (that is, paying) customers will be for their technologies. They must then develop an approach for ensuring that a customer’s willingness to adopt their app translates into the sustained use of the app. Only with sustained use will CDM apps have a chance of improving patient outcomes and reducing costs for the treatment of the conditions they target.
The Current Hurdles
One challenge facing digital health apps is that they are difficult to sell directly to patients, making this group an unlikely source of paying customers. Given that individuals are not used to paying for chronic disease treatment beyond standard co-pays for physician visits and prescription drugs, the costs of acquiring individual patients as customers are likely to be quite high.
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To understand why, it is useful to compare CDM apps with other apps, such as those that enable a user to engage in leisure activities like playing a game or listening to music. For these apps, consumers may naturally be willing to pay for access. Consumers, however, do not see the management of chronic disease as a leisure activity. In fact, CDM apps often dictate a set of behaviors (for example, exercise and dietary restriction) that many individuals would prefer to avoid. Potential users thus see CDM apps that monitor health conditions and give medical advice as something for which the health care system — insurers or providers — ought to pay.
With relatively few patients willing to pay for the digital tools, the most likely source of revenue for app developers becomes health care organizations. The leading candidates are providers (health systems or primary care practices) or payers (self-insured employers or health insurers).
To the extent that CDM apps allow providers to manage a larger number of patients effectively, they would seem to be a productivity-enhancing technology for clinicians, and therefore something that they would be willing to purchase. In fact, many providers praise the technological potential of digital apps to help them manage chronic conditions in a collaborative manner with their patients. Yet they worry that patients will not use these apps as regularly as required to manage their disease effectively. Further, most providers continue to face a fee-for-service reimbursement system that pays substantially more for seeing a patient in person than for managing care electronically and remotely. As a result, it’s not surprising that many providers still prefer to see patients in their offices, where both parties can engage in more-natural discussion and providers can better observe patient behavior and body language, rather than communicating electronically through CDM apps and other digital health technologies.
The prevalence of fee-for-service payments in the United States leaves insurers and self-insured employers as possible customers who could, in theory, pay a small monthly fee per member to make an app available to the populations they cover. As the bearers of financial risk for the health spending of these individuals, both insurers and self-insured employers have an incentive to use CDM apps to reduce health care costs or to improve the convenience and quality of care for their patients with chronic disease. Nevertheless, many payers still lack the ability to get individual providers — whom they contract and don’t employ — to use CDM apps actively.
In addition, the same forces of denial and inertia that discourage patients from paying for digital health apps may also cause them to be less likely to use those apps, even when they are provided free of charge. For a CDM app to be effective, it must be adopted and used by both providers and their patients. Getting a payer organization to pay for it, therefore, is not enough.
We have written about Twine Health, a digital health company with an eponymous CDM app. Once a patient has been diagnosed with a chronic disease, their physician can set up a multifaceted treatment regimen using the Twine app, including appropriate medication, exercise, dietary recommendations, and routine patient monitoring of symptoms (for example, blood pressure for hypertensive patients, or blood sugar levels for diabetics). The physician and the patient, along with a health coach, develop a management plan based on the patient’s individual needs and health goals. The app reminds the patient when they need to take a particular action or enter a specific piece of data. Through the app, the patient regularly connects with the coach, who initiates check-ins and answers minor questions related to the treatment protocol or the patient’s symptoms. When needed, the physician is consulted. When used as intended, the app has demonstrated success in helping patients manage their disease and reducing their need for in-person maintenance visits with physicians.
Despite the success of the Twine app in managing chronic disease, the company’s early experience highlighted the customer challenges described above. The Twine team found that traditional primary care practices — most of which still faced fee-for-service reimbursement — were impressed by the app’s capabilities but often were not enthusiastic about adopting it. Some providers expressed concern that patients would not truthfully enter their data into the app, and thus stressed the need to continue to see patients in their offices at regular intervals to monitor their health. Whether this need for in-person contact was legitimate or the byproduct of the reimbursement structure of fee-for-service health care was not clear. What was clear was that Twine faced challenges in getting fee-for-service providers to use its app with their patients.
A Path Forward
To drive broader adoption and use of their products, developers of CDM apps need to work with organizations that both see the value proposition of paying for an app and are able to entice individual physicians and patients to use it. Today, such organizations include employers who offer on-site health care for their employees and large, integrated health care systems such as Kaiser Permanente and Intermountain Healthcare that both offer health insurance products and employ many, if not all, of the providers who care for their enrolled beneficiaries. App developers should employ a four-step process — what we call the “adopt-diffuse-use-improve” cycle — to work with these integrated organizations.
First, app developers must make a compelling enough argument to get a client organization to adopt a new digital health product — that is, to agree to offer the app to its associated providers and patients. This typically involves showing that appropriate use of the app can improve health outcomes or lower costs significantly enough to justify the cost of the app to the organization.
Next, the developer must work with the client to diffuse the app within the organization — that is, to convince individual providers and patients to give it a try. This typically requires an internal marketing campaign that may include information about how use of the app could significantly improve patient health or financial incentives for individual providers or patients.
Getting providers and patients to try the app, however, is only half the battle; savings and improved outcomes will only come as providers and patients use the app. Achieving sustained use typically requires the app to be integrated with the natural flow of the provider’s and patient’s daily activities. For example, an individual provider might find it inconvenient to have to toggle between multiple apps to manage several chronic conditions for a single patient. Over half of Americans with chronic diseases have two or more, so it is crucial that CDM products support multiple conditions and integrate smoothly with a provider’s workflow and electronic medical record system. For patients, the app may need to be customizable, so the frequency of protocol reminders does not become overwhelming or discouraging.
With expanded use by clients, an app developer has the potential to improve its product. Such improvement is critical: As is the case with any software product, development is an ongoing process. Early versions often inspire users to suggest opportunities to make the current functions of the app more useful or add new features to improve its value. Such improvements have the potential to expand the app’s reach in several ways. First, product improvements may lead existing users (including physicians and patients) to engage with the app more intensively. Second, improvements may entice additional users within existing client organizations to start using the app. Finally, they may cause organizations that have not adopted the app to do so.
Recently, Fitbit, a leading provider of wearable health trackers, announced that it is acquiring Twine. This combination is emblematic of the state of digital health apps in the CDM arena. The two companies noted the benefit of connecting Twine’s software with Fitbit’s hardware, which has significant traction with consumers. But whether individual providers will gravitate to this combined offering remains to be seen.
Though many CDM apps provide the functions needed to manage chronic disease effectively, they still must overcome substantial institutional barriers to their sustained use. By understanding the importance of managing several steps — adoption, diffusion, use, and improvement — developers of CDM apps will improve the chances that their promising technologies will be successful in practice.