Want to lower healthcare costs? Design for those at highest risk.

By Priyanka Agarwal, MD, MBA

Ms. Thomas was hunched over in a hospital bed, gasping for breath when we first met. Her profile: 62-years-old with mild obesity and a history of smoking in her 20s and 30s. Prominent wheezing in her chest and swelling in her legs led me to determine her shortness-of-breath was due to undiagnosed emphysema, related to smoking, and heart failure, likely developed from years of poorly-controlled hypertension. When we sat down to review her next steps, Ms. Thomas was in utter dismay – one day she thought she was in good health, and the next day she was holding a long list of medications and specialists she needed to see. She asked me very frankly if she was going to die.

There was no reason for Ms. Thomas to lose hope prematurely – the steps for her to improve her health were clear: weight loss, exercise, and medications. But she was overwhelmed by her diagnoses, and felt isolated. In reality, Ms. Thomas’ conditions are common1, 2 – so common it should have been easy to find resources to help her manage her health. Yet I struggled to find anything appropriate. On-line handouts from the Cleveland clinic3 and COPD Foundation4 were text heavy and lacked specifics.

The healthcare community must place even more emphasis on the highest-risk individuals, like Ms. Thomas. Without proper guidance and encouragement, Ms. Thomas is poised to become one of the top 5% of individuals who account for 50% of healthcare costs.5 Heart failure and emphysema are associated with frequent admissions (and readmissions)6 to hospitals, and both carry a significant 5-year mortality. A lifestyle management service designed for patients like Ms. Thomas would help improve her health dramatically. Repeated on a population level, we could significantly reduce excess financial burdens to the healthcare system.

Targeting specific populations runs counter to the strategy employed by many mobile-health companies, where education or monitoring services are often designed for the general populous. The spirit of most health apps is to be lauded, especially in regards to the broader movement of wellness, but their utility in effecting meaningful change for high-risk patients with many co-existent conditions is less assured. Patients like Ms. Thomas – with limited ability to exercise the way younger, healthier individuals do – need apps designed around the activities they can engage with to manage their health. Given the lack of knowledge and fear around what activities Ms. Thomas could participate in, recording general activity was significantly less valuable to her than an exercise regimen and tools designed for individuals with lung disease.

Building products for specific health verticals is more challenging than building for the general use-case. Some developers will find it difficult to design products for which they may not be the target audience. However, as a physician, I am much more likely to partner with a developer who builds a product with a targeted and specific use case. I will understand which patients of mine will benefit from the product, and how I can use it to serve their needs. I strongly believe products tailored to individuals with specific health conditions will be significantly more effective at addressing the major pain points of our healthcare system and will ultimately help empower individuals to improve their health.

Dr. Priyanka Agarwal is a resident physician of internal medicine at the University of California at San Francisco. Her areas of interest include patient engagement and education, consumer-driven health, and healthcare delivery reform.