Building Around the Individual, Not the Disease – Part 2

This interview with Jonathan Anscombe is part of a larger series of interviews where we discuss the intersection of healthcare and technology with subject matter experts from Adhera Health’s Advisory Board.

Jonathan Anscombe is the newest addition to Adhera Health's advisory board. Jonathan spent an impressive 30-year career at Kearney, the leading global management consultancy firm. As the former head of the Europe and Middle East healthcare practice at Kearney, he guided major healthcare and global pharmaceutical companies on topics related to digital transformation, digital solutions, product launches, and service redesign.

Jonathan's expertise further extends to areas including population health management, healthcare payment and delivery, system reform, and the social determinants of health.

In this second part of the interview, we continue where we left off in Part 1 and explore the importance of digital health personalization and evidence-based solutions. 

True Personalization and Differentiating Between Existing Digital Health Solutions

“One thing that I think virtually all of these [digital health] applications have struggled with is true personalization.” In the past, Jonathan had done research on compliance and whether people miss their medications. “Somebody who forgets to take their Atorvastatin on Saturday morning will also forget to take their cancer medications on Saturday morning. It's not a function of pill, it's a function of person.” Medical non-adherence for patients with chronic conditions is well-documented; studies indicate that a high rate of non-adherence (~40-60%) exists among patients with chronic conditions.

“Adhera has a particular capability around fatigue… which virtually nobody’s talking about, yet it is a function of many of these [chronic] diseases, particularly the more acute ones, cancer and some of the autoimmune diseases, and a major driver of non-adherence.”

As Jonathan says, a comprehensive approach across multiple conditions is necessary for these applications to find success. However, he feels that a lot of the current digital health applications miss the mark. “I think quite a lot of the applications are very focused on the clinician interaction, and that's great, but they miss out on the carer. And those carers can be parents when the patient is a child or young adult, they can be children when patients are older, they can be spouses, they can be colleagues or other health professionals.”

There is great importance in engaging those “nearest and dearest in the care of that individual. It becomes absolutely central that the caregivers and loved ones are engaged in that process. And I will speak about this from a very personal experience with both my parents.” Jonathan has seen firsthand that there are no current technologies that focus on caregivers, “I mean nothing…The only time I've ever felt myself starting to struggle with mental health issues is when both my parents had dementia, and sometimes the pressure on me and my family was unbearable.”

Adhera Health’s focus on supporting caregivers is a piece of the comprehensive approach that is excites Jonathan. The “ability to handle complex comorbidities as well as issues related to the patient’s specific context comes out naturally because with Adhera we are building around the individual, not the disease.” The evidence is there,” explains Jonathan, “there are numerous studies that you could refer to in terms of the importance of these relationship factors, yet there isn't any kind of solution that is able to address them head on.”

Breaking From Traditional Models

“We know that we can reverse diabetes, even those who have progressed to requiring insulin, with behavioral change, with increasing exercises supplemented with a protein-rich diet, with the right mental health support. Type two diabetes is recognized as a disease of inappropriate behavior and addressing that behavior can resolve the disease.” What is less known, explains Jonathan, is “the fact that you can have much better outcomes across a wide range of diseases, cancer for example, if people have the right mindset and mental resources.” Most leading clinicians will accept that certain diseases are behaviorally based, “what is not yet been so clearly understood is the importance of those same factors around other diseases.”

Jonathan references the microbiome research of ZOE, a UK company that analyzes an individual’s gut microbiome, blood fat, and blood sugar responses to generate a dietary plan that is ‘tailored to your biology.’  Regulating microbiomes has a huge impact on a wide range of diseases. “There are these emerging areas of science, but still much of the medical profession is quite traditional, focused on the apparent problem and not taking account of more holistic issues”.

“I'm not sure that every clinician is convinced that engaging people in their own healthcare is really important for a health outcome. You're always going to have skepticism because with limited resources there is a huge pressure to process people as quickly as possible to move on the next patient.”

This is why it’s so important to provide incontrovertible evidence that a solution is both clinically tested and cost-effective. “I did a little work some time ago for the mobile phone industry,” says Jonathan, “it was called mobile health: ‘Who Pays?’, and the basic essence of it was: look, if we can prove that better patient engagement, leads to better health outcomes, leads to lower costs, then what you need to do is talk to the person who pays the bill. That is not usually the clinician.”

“The relationship between the patient and clinician is often quite transactional. The person does not exist before they walk into their consulting room. And [they] no longer exist the moment once the intervention and follow-up is complete. Now, for diabetes, it’s different because they are going to have the patient for the next 15 years.  In contrast, “for an orthopedic surgeon repairing a knee, the treatment process lasts for a few weeks, and that's the entirety of the relationship.”

“So, there's a real different mindset here, you know, and if you're going to have a successful business, it's well worthwhile not predicating that on changing the medical mindset because it's kind of going to take quite a long time.” Jonathan says, laughing. “But, what you can do is you can think about ‘what evidence do I have that this is effective, and over what timescale?’ Who ultimately has the financial interest in this being effective? So the question is: am I selling to an insurance company or to a hospital? And I'm probably selling to the insurance because they're the people with the long-term interest.”

“However, probably the most important actor in the long term is the patient. If the patients like a solution so much that they prepared to take that into account in their choice of health plan or health provider”.

“So, anybody providing solutions to address these longer-term health outcomes needs to work at multiple levels. They need to persuade the treating health professional that the solution delivers better health outcomes without unduly increasing their workload. The solution needs to make commercial sense to the person who's got a financial interest in keeping this person healthy for a long period of time, which is generally the insurer; though I said, the problem with an insurance system when you move around is they often don't have a long-term view. And finally, you need to have a solution that is valuable to the patient who will then say, look, this has been helpful to me, and I'm not particularly interested in working with somebody who doesn't continue to provide that to me.”

Building Around the Individual, Not the Disease – Part 1

This interview with Jonathan Anscombe is part of a larger series of interviews where we discuss the intersection of healthcare and technology with subject matter experts from Adhera Health’s Advisory Board.

Jonathan Anscombe is the newest addition to Adhera Health's advisory board. Jonathan spent an impressive 30-year career at Kearney, the leading global management consultancy firm. As the former head of the Europe and Middle East healthcare practice at Kearney, he guided major healthcare and global pharmaceutical companies on topics related to digital transformation, digital solutions, product launches, and service redesign.

Jonathan's expertise further extends to areas including population health management, healthcare payment and delivery, system reform, and the social determinants of health.

In Part 1 of this interview, we explore global healthcare system challenges, the management of chronic diseases, and the role of digital health solutions as a bridge between patients, payers, and providers.

What do you think are some of the most pressing global health challenges that you see happening today?

“Global health challenges vary somewhat depending on the wealth of the country. The majority of the world's population doesn't even have access to what we in the developed world would regard as any kind of basic healthcare. Infectious diseases is still a huge problem and a quarter of the world’s population still does not have access to clean drinking water. Tuberculosis is endemic in much of the developing world.”

“In the developed world…. the biggest burden is chronic disease, particularly associated with obesity.”

In the U.S., the CDC has found that chronic disease accounts for seven out of ten deaths each year; chronic care treatment represents a massive expenditure of health care costs. Looking to the future, Jonathan believes Alzheimer’s and Dementia pose a great burden to global healthcare systems. “I don't think I have seen any country really come up with a view about how it's going to deal with that.”

“Things like cancer and heart disease maintain a big share of mindset and a huge amount of expenditure, particularly in the U.S. And rather surprisingly, there seems to be more progress being made on cancer, particularly with RNA vaccines, potentially than dementia, though some of the latest drugs are promising.”

What technologies have you seen over the years that truly address the health challenges you mentioned?

“The technologies in the developing world, I think, are probably in many ways more interesting than in the developed world.” Because of a shortage of healthcare professionals in the developing world, “simple applications, for example, basic health information around preventing infant mortality, the leading cause of mortality in poor countries, can have a dramatic impact on the lives of people.”

“In terms of the developed world, I think most of the big technology-driven breakthroughs have been in diagnostics. Scanning technologies and genomic profiling of cancers for example. Diagnostic AI is starting to have an impact. Obviously, we've got really interesting stuff about gene editing coming through, but it's still massively expensive and a long way from mass deployment.”

“What we haven't really seen yet is the widespread use of technologies for remote monitoring and patient support, despite solutions being available for a long time. There are all sorts of reasons for that; difficulty in proving effectiveness, reimbursement and payment systems, patient attitudes, and vested interests. So although there are a lot of technologies around that [remote monitoring], their uptake is probably not as high as you would've thought given the technology base we have.”

What are some of the common mistakes health insurance organizations made when they were trying to transition to digital health technologies?

“There are similar challenges in virtually every healthcare system. One of the most significant barriers has been the nature of proof. Do technologies actually work? And I did quite a lot of work for a variety of different parties looking at that.”

“The way health systems look at proof is rooted in pharmaceuticals. I have a chemical agent and I have a disease and I show that this particular agent has this impact on the disease within a controlled environment.” When you’re talking about remote management for chronic disease, “it’s not as straightforward… you have multiple variables, and the environment is uncontrolled. The performance of that technology is very highly varied between individuals and contexts and companies really struggle to get proof that it works consistently.”

 “If you can't get proof that it works, you can't get reimbursement; if you can't get proof that it works, doctors won't prescribe it.” Jonathan continues.

Another big area of concern is incentives.  “I think one really, really critical question with these technologies is: who do they financially benefit?”

One of the problems with an insurance-based system where patients can change between providers, Jonathan says, is that “virtually all of the kinds of really interesting technologies around chronic disease only manifest their outcome over many, many years.”

“In a traditional insurance-based system the focus is on controlling cost: I've got a sick person, so I have to try and find the cheapest way of treating them. Now, in European-style social healthcare, or if you are an integrated system like Kaiser who also has the provision as well as their healthcare plan, and [who] tends to have people for a long time, the economics can work a bit better.”

What is the interaction between Adhera Health and pharmaceutical companies?

“I was doing a lot of work around digital patient solutions… the most active players in this are actually the pharmaceutical companies because virtually all of the treatments they have require some kind of behavioral change on behalf of the patient, even if it's just to try to get them to take their medications on time.” says Jonathan. “The biggest mistake for pharma is very clear, it is that they tend to create solutions around the drugs they're selling at that moment in time. That is pretty useless from the perspective of a healthcare system.”

“If I'm a healthcare system, I'll say ‘I'm not interested’, because I've got thousands of patients and they're on hundreds of different therapeutic combinations. Why would I be interested in taking an application which only works with one particular drug?”

 Jonathan believes these solutions struggle to be successful because they don’t “apply to all the patients in the cohort.” Not only that, “they don't really have any way of getting that information into the patient record where it's going to be stored and be useful over a long period of time.”

“I was helping to develop products for pharma companies and healthcare systems would not take them for free. They're just more trouble than they're worth.” He continues, “the idea that a healthcare provider would have 20 different apps from different pharma companies: what a complete nightmare! There is a real fundamental issue here for pharma companies as they create ‘beyond the pill’ solutions.” 

“If they are dominant leaders and they've got a small, controlled population like a specific cancer, it's fine. But as soon as you get into COPD, heart disease, and diabetes, most of the people are co-morbid, and can shift between therapies, these kind of very therapy focused apps just don't really work.”

Jonathan says that essentially all supportive digital applications, in the context of pharmaceutical interventions, are associated with behavior change. “If you have tried to recover from a cancer operation, or you've got diabetes, or you've got COPD or indeed most other serious conditions, you actually have pretty much the same types of interventions that you need to do with the individual… they need to eat well, they need to exercise, they need to be informed about the disease. They need to be mentally engaged. They need to not be depressed. And, all of those things apply, but all of those are not features of the disease, they're features the person.”

“ The reason why Adhera Health is such an interesting platform and the reason why I agreed to come on the advisory board is that there is no reason to produce multiple different apps to support multiple different diseases… what you really need to do is have a single platform that is patient-focused, where you can tailor the kind of interventions you’re doing to the particular disease or set of diseases.”

— Jonathan Anscombe

 “I think that's where the interest in someone like Adhera Health comes; you can use the same platform regardless of the disease or set of diseases that the individual is suffering and regardless of the specific pharmaceutical intervention you are using at that time. The patient can become familiar with the system, and you only have to do one integration with the healthcare record.” This simplification and unification of data creates transparency between payers and providers; “the neutrality of the platform, the transparency of the platform over a long period of time, that potential makes Adhera so interesting.”

 “One consistent set of notations – the ability to review  patient data over a long period of time and take some sensible decisions on that basis… if you can move between insurance companies as well, you're seeing something that is much more like the integrated care record that you might some find, for example, in the U.K, which is neutral to provider, to individual, to therapy, and everything else.”

“By partnering with healthcare providers, Jonathan says Adhera Health provides “a neutral source of useful, consistent interrogatable and analyzable data on the individual that can be used by that individual, by their carers to try and generate some good long-term health outcomes.”

Ultimately, the data “has to reside with either the healthcare provider or the healthcare insurer or the health plan, or preferably in some format that's accessible by all of the above plus carers.” By partnering with healthcare providers, Jonathan says Adhera Health provides “a neutral source of useful, consistent interrogatable and analyzable data on the individual that can be used by that individual, by their carers to try and generate some good long-term health outcomes.”

Click here for Part 2 of this interview.