Healthcare disruptors like Amazon get good patient reviews, but questions about quality abound

Erika Grotto: Questions about quality in a time of healthcare disruption, today on HFMA’s Voices in Healthcare Finance podcast. Hello and welcome to the podcast. I’m your host, Erika Grotto. Today, I’m handing the reins over to our news team to discuss the latest news in healthcare disruption. You may remember their episode about this topic a few months back. Now, as Amazon prepares to shut down Amazon Care and acquire One Medical, new questions are emerging about quality. Here to discuss these issues are Senior Editor Nick Hut and Policy Director Shawn Stack.

Nick Hut: Hey, everybody. Erika’s given us license to take over the entire podcast, at least for this episode. We did the same thing a few months back with an episode on healthcare industry disruptors and their current and future impact. This time, we want to put a twist on that topic and talk about  potential issues with the quality of healthcare provided by disruptors. The impetus for this conversation in part was a Washington Post article published in August that described how nurses at Amazon Care were concerned about aspects of that organization’s clinical operations, namely that a byproduct of the emphasis on convenience and access was that optimal care standards weren’t always met. Shawn, what was your general reaction to that piece, just in terms of whether it rang true?

Shawn Stack: Thanks, Nick. Yeah, it did ring true to me, and it’s something that I think we have been talking about for the last year here, is what’s all this disruption in healthcare going to mean for the final product of healthcare. So having multiple folks entering this market and providing services, what’s that do and what’s that look like for the patient who could suffer from very disjoined care, right. The continuity of care could be broken if this is not implemented with a very thoughtful approach and relationships are not built to refer patients to other care organizations as they outgrow potentially some of these services that are being provided that are typically less acute for these disruptors. I think the article really spoke to a lot of our fears of what’s been morphing here before our eyes in the disruption market.

Hut: Yeah, definitely. And we’re going to delve into the whole fragmentation aspect of this issue a little bit later in this episode. As the article mentioned, this kind of dynamic highlights a conflict, almost like an inherent tension, between the tech and medical sides of a healthcare startup. The Post reported that because Amazon, like with so many aspects of its overall business, doesn’t want to be providing a product or service in a physical location that nurses were having to, for example, stabilize patient blood samples using centrifuges while sitting in their cars—not while driving, I can only hope. But that was because they obviously had no medical office to work in. It sounds like Amazon Care tends to get very good reviews, but patient satisfaction with care does not always align with the best quality care. There are certain things all of us as patients may reflexively be more attuned to, like waiting times, does a physician or nurse smile a lot. But obviously those things, although important, don’t always equate to getting the best possible healthcare. One note to mention is that very shortly after that article was published, it was announced that Amazon Care will be disbanded. Now, that announcement surely had nothing to do with that article, but rather it was a strategic move in that Amazon did not think Amazon Care was providing great value to clients, and they’re looking to make the most of their recently announced purchase of the primary care chain One Medical, which was an acquisition that we also talked about on a recent episode. Shawn, let me turn it over to you. We talked before recording this segment and one thing you brought up was regulatory and oversight issues surrounding some of these disruptors.

Stack: What we’re seeing more and more is, a lot of the disruption is focusing on—and rightly so—making healthcare more affordable to that self-pay patient or that managed care patient where you have a coinsurance or deductible. But many of these providers, Amazon included, is really focusing on making healthcare very attainable, not only logistically but also from a price point. So many of these—and I’m not just speaking of course to Amazon here, I’m speaking across the board—many of these disruptors are not working with CMS because they’re not focusing on the Medicare population. They’re focusing on the cash and carry population. So as we know with hospitals, working across all payers and all populations really requires a lot of governance and oversight from the federal market, from CMS, from Medicare and Medicaid, and all the managed care groups that fall under them. So there is some angst here on what is the regulatory body that will be overseeing a lot of these services from the disruption standpoint in all of the states across the U.S. What does that disjointed or combined oversight look like, and I think the feds and regulatory bodies are just finding their footing right now in addressing some of these stresses and some of these needs that the disruption market is making right now.

Hut: Yeah, that’s a point that may be overlooked when people think about the strategic impact of some of these new entrants to the industry, but it’s absolutely going to have to be sorted out as we go forward. Another thing you noted that I think it’s really important to mention is clinician safety, which certainly, anecdotally speaking is all the more significant of a concern in the pandemic era. Obviously, when care is provided virtually, the clinician doesn’t have to worry about being harmed physically, but in many instances, these startup companies will be providing in-person clinical care. So what’s the risk in your mind?

Stack: I mean, it’s very concerning. During the pandemic, studies have found that 44% of RNs have reported physical violence and 68% I think reported verbal abuse during the pandemic. So numbers have risen, and that is in hospital settings, so whenever you’re out providing healthcare services, whether it’s at home or at a clinic that has less staff in it, that risk just increases for the medical staff and for the patient, for patients who are coming into that atmosphere if it’s a very small clinical office where staffing may be bare bones minimum. So it is a concern. It’s a concern with the virtual mental health services that are rolling out. What are the backups? What are the backups if that virtual care escalates and that has to be referred to someone in that community to check on that patient or go out and see that patient? That’s one of the pieces I think that was divulged in the Washington Post article, was that in the startup, it sounds like Amazon made bridges to correct the issue, but in the startup, nurses were really struggling when they had patients suffering from mental health issues, getting them transferred to the appropriate provider timely, doing a warm transfer rather than just dropping that patient into a queue to see a mental health provider at Amazon Prime. So I think there’s a lot of growing pains with any new healthcare services started up, but it’s a little bit easier, and I feel a little bit more safeguarded, when you have a legacy hospital organization that has trained their staff and their staff has grown with them and they understand delivering that healthcare service and the importances of continuity of care, of those warm transfers, of getting that patient to the right clinician in a hand-holding method. What you said earlier, Nick, the focus on a lot of this disruption has been meet the patient where they are, patient satisfaction. But it’s kind of like parenting, right. You want to be accommodating and loving and caring toward your patient population and their needs, but you also need to be able to draw the line and say, “We can’t offer you that care in that type of setting. You do need to be in a more appropriate setting for that type of care.” And I think that’s where some of the stresses are coming in here, finding that balance in that disruption market, right.

Hut: No doubt. No doubt at all. And yeah, I think continuity of care and fragmentation are key issues to get sorted out as the market evolves the way it seems to be doing in recent years. There are obviously things disruptors can do to fortify their clinical operations. Amazon, like we just said, bought One Medical, although by the way, it sounds like that deal is going to be scrutinized pretty closely by the FTC.

Stack: Right, I agree.

Hut: But assuming it goes through, One Medical has physical locations, actual clinics, and while it does provide a lot of care remotely, it has more of an actual healthcare infrastructure to fall back on, at least in terms of just looking at primary care than Amazon Care did when starting out.

Stack: Yeah, it seems like they’re evolving in a way that they know they should be evolving, and that next week, Nick, as you probably remember, they formed a relationship with Ginger, which is a mental health organization disruption. So they’re building their portfolio in what their patients need I think now, so I think they’re beginning to learn from their mistakes. Right?

Hut: Right. Definitely seems that way. And another example, CVS Health was planning to buy Signify Health for $8 million, which is twice what Amazon paid for One Medical. And I thought that was a blockbuster deal, but this is twice that. So that’s going to allow CVS Health to theoretically care for patients starting with home health assessments, which is one of Signify Health’s core capabilities, and then guide them to other settings as needed, whether retail as far as the minute clinics or to specialists that are in some of Signify Health’s ACOs, which can take patients all the way through the post-acute care setting. So they’re developing kind of a full healthcare ecosystem under the CVS Health banner. In a lot of cases—and we both made this point in the previous episode we did on disruption—it’s still going to be important for a lot of these newer entrants to establish formal partnerships with hospitals and health systems. What, Shawn, is the opportunity for partnerships to be developed, do you think?

Stack: I agree, Nick, and I do think that there is definitely a place for disruption and for these new healthcare products and services to enter the U.S. market. I mean, we’ve had healthcare deserts in the U.S., especially in behavioral health and mental health and primary care for years. So there’s definitely space for these folks to function and excel within our legacy system, within the continuum of care that used to be legacy only. But I do think the successful key is going to be having those legacy providers, those healthcare providers that have been in the market for years providing services really take a look at collaboration and referral patterns and build those relationships with the new folks coming into the market, because I do think it’s needed and I think it is the future. I really do believe that.

Hut: Yeah, definitely, and that’s something One Medical did to establish its foothold in the healthcare industry, was to partner with hospitals and health systems in core markets. There was some criticism that maybe they could have chosen more cost-effective hospitals and health systems than they did, but nonetheless, those partnerships, those alliances, allowed them to establish themselves as a viable healthcare entity that was able to provide care at the primary care level to large populations. In the last six months, we’ve done an hour-long webinar and two full podcast episodes on various aspects of disruption. It’s just a fascinating topic with major implications for the industry, so I’m sure we’ll have much more to come. So many thanks, Shawn, and thanks to all of you.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is the director of content strategy. Our president and CEO is Joe Fifer. Our Healthcare 2030 series is back for a second year, and the first report is on a really hot topic: Trust in healthcare. You can check that out by visiting hfma.org. And if you want to talk with us about the podcast, reach out to our team. You can email us at [email protected].

A recent Washington Post article described nurses’ concerns about the clinical operations at Amazon Care as the company’s emphasis on convenience pushed quality aside. On a recent episode of HFMA’s “Voices in Healthcare Finance” podcast, HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack discussed the article and larger questions about quality when disruptors from outside the industry are entering the market.

Amazon’s movements in the industry

Although Amazon announced plans to disband Amazon Care shortly after the article was published, its plan to purchase primary care chain One Medical keeps questions about quality at Amazon in the forefront, Hut said. One Medical’s current focus could help Amazon as it works to find its footing in healthcare. One of the concerns about Amazon Care cited in the Post was that without physical locations, nurses were performing tasks such as stabilizing patient blood samples in centrifuges while sitting in their cars. By contrast, One Medical more closely resembles a legacy system.

“One Medical has physical locations, actual clinics, and while it does provide a lot of care remotely, it has more of an actual healthcare infrastructure to fall back on, at least in terms of looking at primary care, than Amazon Care did when starting out,” Hut said.

“It seems like they’re evolving in a way that they know they should be evolving,” Stack added.

Continuity of care

Stack said the entrance of disruptors could raise issues with continuity of care. As patients outgrow the services one organization can provide, that organization will need to have partnerships in place to refer patients where they need to go next. He cited an example from Amazon but said these issues could occur with any disruptor.

“In the startup, nurses were really struggling when they had patients suffering from mental health issues, getting them transferred to the appropriate provider, doing a warm transfer rather than just dropping that patient into a queue to see a mental health provider,” he said.

Hut cited the example of CVS Health’s plan to acquire Signify Health as an opportunity to capitalize on high quality continuity of care.

“[That deal] is going to allow CVS Health to theoretically care for patients starting with home health assessments, which is one of Signify Health’s core capabilities, and then guide them to other settings as needed,” he said. “They’re developing a full healthcare ecosystem under the CVS Health banner.”

The need for partnerships

Legacy providers would be wise to find ways to collaborate with disruptors, Stack said. Hut noted that One Medical’s ability to partner with hospitals and health systems was part of what made them successful in primary care.

“There is definitely a place for disruption and for these new healthcare products and services to enter the market,” Stack said. “We’ve had healthcare deserts, especially in behavioral health and mental health and primary care for years. There’s definitely space for these folks to function and excel within our legacy system, within the continuum of care that used to be legacy only.”