Keith Loria is a contributing writer to Medical Economics.

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Climbing the Career Ladder: Sixth of 10 profiles of healthcare executives and their careers.

Rahul Sharma, M.S., CEO of HSBlox, learned early in his career to take risks, build a team that works well together and focus on solving the harder problems that bring value to the industry and the shareholders.

“I also learned to be the bridge between business teams and technical teams to help provide solutions that bring the vision to life and bring value to everyone in the ecosystem,” he says.

Born and raised in northern India, Sharma spent the first 23 years of his life in India and the past 25 in the United States. As a youngster he played cricket and soccer, both competitive team sports, which helped instill in him discipline.

Sharma earned his bachelor’s degree in engineering from the Indian Institute of Technology Roorkee in 1995 and then his master’s degree, also in engineering, from the University of Alabama in 1998.

He worked in India for the Tata Group before coming to the U.S. His first jobs in this country were with Peachtree Software, an accounting software firm that pioneered online accounting, and Manhattan Associates, a supply chain software company. At Manhattan Associates, he led the systems and database services group in the research and development department. The clients included Walmart, Mary Kay, Dell, Home Depot and the Mayo Clinic. After a seven-year stint, Sharma “took the entrepreneurial route,” a path that has included spearheading five startups. 

Sharma’s introduction into healthcare came when he built a SaaS-based solution called VIMS (Vaccine Inventory Management System) at his first company, Decipher Information Systems. But then he shifted gears and partnered with Davidi Gilo, an Israeli entrepreneur, to build INVeShare, a fintech company.Sharma’s other startups included Bloxshare, which offered a blockchain platform for the fintech industry; PatientBlox, which built a prospective bundled payments platform that enabled payer and provider collaboration; and now HSBlox, a healthcare technology company whose CureAlign platform connects community care networks to address social determinants of health issues.

Sharma says he has a passion for building out great teams and tackling difficult problems. “This creates opportunities for our team members and value for our shareholders and the industry,” he says. “We have shown with our sister company PatientBlox, which we sold to Signify Health last year, that difficult problems like prospective bundled payments can be addressed with proper thought leadership and a technical solution that addresses those points.”

The current model of American healthcare is focused on “sick care” and crisis management, says Sharma. Perhaps it is his training as engineer; Sharma thinks that can be fixed with the right application of technology and data.

“One of the key reasons for this (the focus on sick care) is the data challenge that exists in the industry, not only pertaining to interoperability, but also to digitization of the wealth of data that is available in unstructured and semistructured data sets,” Sharma says. “In order to move towards value-based care programs, we have to start addressing the social determinants of health more adequately.”

Sharma says some challenges of traveling upstream to the social determinants of health can be overcome with digitization of the data, forming a longitudinal healthcare record — an LHR to go along with the electronic health record (EHR). The LHR could be used for better predictive and risk-score analysis.

“Technology exists today that can help us achieve these objectives and help us to be more proactive in providing care, and, hence, intervene before issues become a crisis,” he says.

Articles

Rahul Sharma, M.S., CEO of HSBlox, say that early in his career he learned “to be the bridge between business teams and technical teams."

Rahul Sharma, M.S., HSBlox: See Challenges? Head in That Direction

pecialists are key partners for delivering value-based care, particularly for patients with chronic diseases. This involves the appropriate diagnosis of conditions, including rare diseases, stewardship of diagnostics and value-based prescribing for specialty medications.

Lawrence Kosinski, M.D., MBA, founder and chief medical officer of SonarMD, a tech-enabled care coordination solution for digestive health, notes the great majority of high per-capita cost of care comes from specialists’ orders.

“Right now, most specialty value-based care programs focus on procedure episodes like hip or knee surgery,” he says. “But specialists also care for patients with complex, chronic medical conditions, and this care accounts for $220 billion in healthcare spending annually — not including the fast-growing specialty pharma expense.”

A large proportion of that cost is variable. For example, among gastrointestinal (GI) diseases, inflammatory bowel disease (IBD) drives more than half the total variable cost. That’s an indicator that there’s an opportunity to better manage those patients with IBD through value-based care arrangements.

“If clinical and financial incentives are aligned, specialists would be further incentivized to keep patients out of acute-care settings, lowering the overall cost of care and improving quality of life for patients with chronic disease,” Kosinski says.

A major challenge is that many chronic conditions do not have current published clinical pathways. “The care is provided in a reactive fashion, as it is dependent upon a patient recognizing symptom deterioration,” observes Kosinski. “Unfortunately, they often don’t detect this deterioration until a hospital visit is necessary.”

Additionally, specialists typically do not have a financial incentive to proactively manage complex care or specialty formulary costs. Many specialists have thrived in a healthcare system geared toward fee for service, which rewards doing procedures and sometimes writing a prescription. The stakes are higher now with specialty drugs making up an increasing proportion of total drug expenditures. Kosinski ticks off some ways to infuse more value into healthcare: aligning payer and provider incentives with the best outcomes for the lowest possible costs, deploying technology to make efficient use of whatever resources are at hand and getting patients vested in their healthcare.

Keith Boell, D.O., chief quality officer for population initiatives at Geisinger, a healthcare system and health plan headquartered in Danville, Pennsylvania, says the industry has been slow to get specialists involved in value-based care.

“Specialists can help influence the care of patients across a large geographic footprint, including patients they may not see in their clinics,” he says. “When the majority of reimbursement is fee for service, specialists are incentivized to focus on patients in their clinics and may not become as engaged in the broader population health discussion.”

Distance can be a major barrier for some patients. Many specialists practice in large, multispecialty practices, frequently at academic medical centers, requiring patients to travel from their local communities. Many people in and out of healthcare see telehealth solving that problem.

Good patient outcomes have served as the most convincing argument for physicians to accept value-based care strategies. In addition, creating a transparent and representative physician leadership that the medical staff has confidence in is of critical importance. It is essential to have a forum to allow rapid dissemination of information and to exchange feedback. Technology can play a critical role in encouraging this coordination.

Daniel Hommes, M.D., a gastroenterologist who has worked and published extensively in value-based care, notes specialists offer a higher chance of achieving better clinical outcomes and patient experiences at lower cost. An example would be if their clinical network is delivering on Healthcare Effectiveness Data and Information Set quality measures tied to financial incentives and bonus structures. “The biggest challenge is getting a technology infrastructure in place that can facilitate providers (with offering) value-based care since traditional EMR systems do not offer this,” he says.

SonarMD’s IBD solution can leverage technology to facilitate patient engagement and care coordination while driving financial and clinical alignment with payers. “This was especially helpful during the pandemic to ensure patients were proactively engaged and the care team could catch flare-ups before hospitalization was required,” Kosinski says. “Our work with these practices is contracted through Horizon Blue Cross Blue Shield of New Jersey, so physicians are paid to proactively manage IBD, and Horizon Blue Cross can share in savings from the program.”

At Geisinger, specialists are involved in several value-based care initiatives. One is a program called “Lower GI Flag,” a collaboration between Geisinger and Medial EarlySign that uses machine learning to identify patients at the highest risk for colorectal cancer who are overdue for screenings.

“We can do targeted outreach to get those patients scheduled for a colonoscopy,” Boell says. “Additionally, advanced endoscopy services can help patients avoid higher cost settings, including the operating room.”

Because gastroenterologists spend the majority of their time doing colonoscopies for screening and surveillance of colon polyps, which have little variation in cost, these procedures should be bundled into 14-day episodes, which would bring gastroenterologists into the value chain, Kosinski says.

“But gastroenterologists must also think beyond colonoscopies and endoscopies to consider more integrated care management for patients with chronic conditions,” he continues. “This is an opportunity to broaden their financial model and keep patients in their practices instead of in acute care settings.”

Tonny M. Lee, M.D., medical director of the GI laboratory and chair of the Gastroenterology Division at Providence Little Company of Mary Medical Center in Torrance, California, says as healthcare delivery continues to evolve on both regional and national levels, health systems must also strive to meet new and expected standards.

With that in mind, great efforts have been implemented to achieve the goals of value-based care, including enhancing patient experiences, elevating providers’ clinical experience and serving unique needs of various communities. To meet these demands, the hospital has created clinical institutes across eight specialties. “The clinical institute model differentiates Providence from other health systems by pulling on the expertise across our 11-hospital region to share latest findings, treatment options and any advances through research,” says Lee. 

For example, physician leaders have met on a routine basis to share clinical concerns and establish consensus guidelines for acute GI hemorrhage management, colorectal cancer prevention and approaches to treating patients with irritable bowel syndrome and IBD, he says. “The clinical institute model has facilitated a free exchange of ideas among surgeons, radiologists, oncologists and gastroenterologists, fostering a stronger bond and camaraderie on a personal level," observes Lee. Patients are less likely to seek care academic medical centers as a result. Ultimately, the efforts lead to better access and outcomes and improved patient satisfaction.

Physician engagement continues to be an issue, though, as the system’s goals and those of independent specialists often do not completely align, Lee continues. Educating clinicians to recognize the value of quality over quantity remains a top priority. The disruption of healthcare caused by the COVID-19 pandemic and a renewed interest in preventive care may help push them along.

Many health systems are banking on value-based care, now and in the future, Lee says. It’s an opportune time for specialists to get involved and join the trend, he says: “By adopting value-based care, specialists not only can achieve the Holy Grail of improved patient care but also can potentially enhance financial rewards by shared savings and other revenue enhancements.”

Keith Loria is a freelance writer in the Washington, D.C., area.

After having thrived in a fee-for-service healthcare system, can chronic disease specialists be enticed to switch?

Specialists are Testing the Value-based Care Waters 

Climbing the Career Ladder: Second of 10 profiles of healthcare executives and their careers.

Koleen Cavanaugh grew up in Maryland but went to college at Villanova University, outside of Philadelphia. She fell for the city.

“I knew I wanted to stay here after I graduated, but the job market was not great at the time,” she says. Armed with a bachelor’s degree in communications with a minor in English, in 1991 she took a position in customer services at Independence Blue Cross (IBX), a Blues plan with an 80-year history in Philadelphia.

“I wouldn’t say I had a dream of necessarily being in healthcare. But what I really wanted to do is help people through communications and work with people to help them better understand products, services, etc.,” Cavanaugh explains. “Starting in customer service was the best thing for my career as it allowed me to completely understand the ins and outs of all of the products that we offer.”

That firsthand experience was instrumental as Cavanaugh rose through the ranks of the company. Thirty years later, she is vice president of marketing at IBX.

“When I started in marketing, I really understood what people understand and didn’t understand about the products and where we needed to be clearer in the way that we communicated certain benefits and services,” Cavanaugh says. “Others may have had a marketing background or had more experience from a marketing perspective, but they didn’t understand how the products really worked like I did.”

She learned negotiation skills, how to work closely with a sales team and how to deal with external vendors. “Understanding how to manage a vendor relationship was extremely pivotal as my career grew and important for me to ultimately negotiate contracts,” Cavanaugh says. “That groundwork helped when I was promoted to manage the department.”

In her current role, Cavanaugh leads different marketing teams, including a client broker team focused on the life cycle of customers who purchase coverage for their employees. There are also teams that focus on the member side of things and corporate marketing. “We also have a very robust engine driving digital engagement with our members, and two-thirds of our subscribers have opted in to receiving digital messaging from us,” Cavanaugh says.

Cavanaugh says one of things she’s proudest of her in her career is the approach that IBX took to the ACA. “We as an organization decided we were going to fully embrace the ACA and saw it as a huge opportunity for us to really live up to our social mission,” she says.

IBX set up mobile education and enrollment centers. “We were out in festivals and fairs and block parties, so we created awareness anywhere we could,” Cavanaugh says. The insurer also used a variety of direct mail and social media strategies. It paid off. During the first enrollment period, 90% of consumers who purchased a product on the ACA exchange for southeastern Pennsylvania bought an IBX product.

There’s still a lot that Cavanaugh hopes to accomplish with the company. A big part of her focus this year has been on equity in healthcare and in the delivery of healthcare. She also is examining how IBX can leverage what it does as a health insurer to ensure that it’s bringing health equity to all its members and the communities it serves.

“We’re really focusing on the whole-person health, not just the medical side, but also the mental health and behavioral health side of things,” she says. “We’re looking at how we can continue to improve access for members and on education.”

Having been at IBX for her entire career, Cavanaugh obviously knows what it takes to be successful. “My advice for people coming up in this business is just to always stay positive,” Cavanaugh says. “No matter what level of an organization that you reach, I think it’s always important to stay inquisitive to understand how things work and the impact that you’re having on your customers.”

Koleen Cavanaugh, vice president of marketing at Independence Blue Cross in Philadelphia, says starting in customer service was the best thing for her career.

Koleen Cavanaugh, Independence Blue Cross: Understanding Gained at the Entry Level Pays Off

Because of concerns over community spread of COVID-19, the pandemic has greatly accelerated patient interest in home hemodialysis treatments. There’s also a need to find solutions that will improve the quality of life of people living with kidney failure.

For these reasons, Fresenius Medical Care North America, based in Waltham, Massachusetts, encourages many to consider home dialysis for greater scheduling flexibility, fewer food restrictions and improved clinical outcomes.

“These aspirations are shared by CMS, which has launched payment initiatives to support a greater uptake of home dialysis in the U.S.,” says Joe Turk, president, home and critical care therapies, Fresenius Medical Care North America. “While our company was aligned toward home dialysis well before this federal effort, the entire industry is now clearly focused on advancing technology, education and support for home dialysis.”

Theresa Mottes, M.S.N., RN, president of the Nephrology Nursing Certification Commission, has more than 25 years of pediatric renal replacement therapy experience in the critical care and outpatient dialysis settings and spent 15 years with the pediatric dialysis program at C.S. Mott Children’s Hospital in Ann Arbor, Michigan. She says she has witnessed a big shift from predominantly in-center to home dialysis, either hemodialysis or peritoneal dialysis.

“Technological advancements will be necessary for the success of home dialysis,” she says. “For a paradigm shift to home dialysis, the industry will need technology to develop a machine that is fully integrated and improves the ease of use.”

Although some are out there already, in development are several smaller, potentially wearable devices that reduce the burden of chronic kidney disease treatments, Mottes says.

Home dialysis also makes it much easier for physicians to prescribe individualized therapy without the constraints of an in-
center schedule, which is typically three days per week for all patients.

“We’ve seen significant improvement in cardiovascular-related hospitalizations for patients dialyzing at home five or six days a week, and many patients report having more energy with a more frequent schedule,” Turk says. “We also have studies showing that the use of connected health can also help reduce hospitalizations, allowing for more timely interventions.”

Transitional care units (TCUs) continue to be important to in-home dialysis. Industry experts reveal half of patients experiencing kidney failure who start dialysis do so without any ability to prepare for this life change. This means they do not have the chance to be fully educated on all treatment options and make informed decisions aligning with their life needs and values.

According to Turk, TCUs give patients a better chance to stabilize, offering the ability to start dialysis in a simpler, more focused fashion. “It also tends to lead to more patients pursuing home dialysis because patients are better prepared and empowered to make this choice,” he says. “In fact, FMCNA (Fresenius) has seen over 40% of patients who go through a TCU ultimately choose a home modality: hemodialysis or peritoneal dialysis.”

Connectivity is another important development. Dialysis machines traditionally have been very analog, but today’s systems can instantly, securely transmit data to the cloud for providers to access remotely. This makes kidney disease treatment more convenient for patients and providers. In the home setting, utilizing smart sensors and wireless data transfer frees patients from manual data entry and ensures that providers get the information they need.

Leslie Trigg, CEO of Outset Medical in San Jose, California, notes that the company has always believed dialyzing at home was vital to restoring identity, autonomy and a sense of self-worth for those managing kidney disease. “Due to reported patient satisfaction, compounded with the government’s initiative to shift towards home dialysis, we’re expecting to see this segment expand significantly over the next few years,” she says.

To deliver on its promise, Outset embarked on a clinical trial in 2016 to generate data showing the safety and efficacy of dialyzing at home with Tablo. The clinical and regulatory journey took four years and culminated in FDA clearance of the device in 2020 for the home setting.

Tablo combines the technology of multiple machines into one compact, 36-inch-tall unit that is approved for use from the hospital to the home.

“Our vision is to create a seamless and supported transition to the home, and the Tablo Hemodialysis System offers a new level of operational simplicity aimed at improving patient adoption, experience and retention,” Trigg says.

Recently, Outset Medical heard from clinicians that the pandemic introduced a critical need to reduce patient proximity during dialysis treatments to reduce COVID-19 transmission rates. In response to this, it incorporated their feedback to update the design of Tablo’s data analytics platform, TabloHub.

“TabloHub uses data transmitted securely and wirelessly from Tablo systems to the cloud to enable physicians to remotely support and monitor this vulnerable patient population with live and historical data,” Trigg says. “Clinicians have the ability to view real-time patient data without needing to be in the same room as their patients.”

Fresenius’ The NxStage home hemodialysis machine is the first and only portable hemodialysis system cleared for home use in the U.S., according to the company, and the only machine small enough to take on the road or even on a plane.

“While the machine itself has been transformative, the 37% growth in home hemodialysis treatments among our patients in 2020 is also attributed to the depth of patient and staff training and real-time support that surrounds the device,” says Turk of Fresenius. “We also recently expanded our long-standing collaboration with DaVita (another dialysis company) to help bring NxStage home hemodialysis to more patients than ever before.”

Fresenius’ connected health solutions also include TheHub that comprises three integrated applications allowing patients, care teams and physicians to better collaborate and monitor patient treatments. Fresenius is also using artificial intelligence to develop and apply predictive models that can help pinpoint the reasons for hospitalizations. “Importantly, we incorporate these algorithms and data into our clinical care models across our 2,600 dialysis clinics to ensure these insights are converted into actionable intelligence,” Turk says.

Many people involved in kidney disease care expect the use of home hemodialysis to continue to increase over the next five years.

“This past year has shown health professionals and patients that remote dialysis treatment works due to the benefits home dialysis provides — independence and convenience for patients and the reduction of resources and staffing needs for providers,” Trigg says. “Dialysis clinics are already reporting higher home dialysis growth rates as a result of the COVID-19 pandemic and telehealth utilization.”

CMS’ new kidney care payment model, which began this year in January, increases the incentive for the home dialysis care with increased payments. This federal push for more at-home kidney disease treatment is expected to seed more innovation in kidney care.

Value-based care in collaboration with private insurers and the federal government will continue to play an important role as the industry advocates for more timely referrals to a nephrologist and early, upstream efforts to slow the progression of kidney disease. As a result, clinicians will have more time to educate patients about the advantage of home therapies.

“We believe every patient should be considered for home dialysis” comments Turk. “The best way to help grow adoption of home dialysis is to have more patients prepared to make this choice earlier in the process.”

The latest technology is changing treatments for patients.

Keith Loria

Articles

Rahul Sharma, M.S., HSBlox: See Challenges? Head in That Direction

Specialists are Testing the Value-based Care Waters

Koleen Cavanaugh, Independence Blue Cross: Understanding Gained at the Entry Level Pays Off

At-home Dialysis on The Rise