How to Narrow the Digital Divide in U.S. Health Care
All too often advances in digital health tools don’t benefit disadvantaged populations. One reason is new ventures and their backers make assumptions about this market that aren’t true. By partnering with academic institutions that are focused on helping indigent patients, digital health companies can develop products that profitably serve all market segments and help make health care more equitable. This article offers six lessons gleaned from an incubator at the University of California, San Francisco.
Private-sector innovations in digital health are critical to delivering high-quality health care. However, many promising health information technology (HIT) solutions are not adopted and used by Medicaid patients and other vulnerable populations or implemented in the care settings where a high proportion of these patients receive care. Without action, this “digital divide” will only widen.
Stark disparities in health care access were revealed anew during the Covid-19 pandemic. These issues are essential to address given the disproportionate burden of illness faced by patients from lower socioeconomic backgrounds and the gaps in digital strategies to provide them with better prevention and treatment.
One solution is academic-industry partnerships. As researchers, we bring deep experience implementing and evaluating technology in underresourced health care settings. Private-sector companies excel at building, testing, and scaling tech innovations. To synergize these proficiencies, we founded UCSF S.O.L.V.E. Health Tech, an HIT incubator embedded in the University of California, San Francisco (UCSF).
Since launching in 2019, S.O.L.V.E has reviewed 33 applications from early to mid-stage digital health companies seeking to expand in the Medicaid space. Our inaugural partners were AppliedVR, which focuses on virtual reality therapeutics, and InquisitHealth, a platform for mentoring patients to make healthy lifestyle choices. During their incubation cycle, each garnered additional venture capital funding and piloted the feasibility and acceptability of their products among socioeconomically diverse patients and settings. With suites of products in use across all 50 states, they have demonstrated improved clinical outcomes for patients from lower socioeconomic groups who are trying to manage conditions such as diabetes, acute pain, and chronic pain.
Here, we share lessons learned to create productive collaborations between for-profit companies and academic organizations focused on public health.
1. Find the Right Partner
We blended the academic practice of peer review with the private-sector model of a pitch competition to identify company partners: stakeholders representing industry, venture capital, academic, health system, payer, and patient perspectives weighed in during the vetting process.
For example, our industry and venture capital advisors helped us assess the business potential of applicants’ proposals. We asked advisors from various payer organizations (e.g., San Francisco’s public insurance plan and Covered California) to describe Medicaid requirements for reimbursing digital therapies. We relied on our research and clinical experience working with diverse patients and discussing their technology preferences to determine if proposed products had the potential to reach culturally and linguistically varied populations.
2. Match Complementary Expertise
The companies appreciated our rigorously tested methods for digital health design, implementation, and evaluation in their target markets. Our skills complemented their well-developed processes of rapid-cycle design iteration, permitting fast translation of insights into their platforms.
Our experience in this iterative process was an extension of our 2015 pilot of an academic-corporate partnership with Omada Health. The company wished to adapt its educational app and web-based diabetes-prevention platform for underserved populations. We helped Omada engage low-income English- and Spanish-speaking patients to provide feedback on the platform, which we synthesized into specific recommendations (e.g., modify language to match patients’ reading levels, create technical assistance tools throughout all phases of the program).
This process identified unrecognized usability challenges, sparking the company to make changes to the platform and onboarding process to improve user satisfaction. Our team published these outcomes in a peer-reviewed journal. This benefited Omada given that Medicaid and other health systems and payers require evidence (often in the form of academic papers) that products will work for their diverse patient populations prior to investing in them.
3. Contextualize Innovations in Real-World Settings
Even when digital health companies understand care delivery systems broadly, they may lack familiarity with the medical safety net. One reason is venture capital firms often discourage their portfolio companies from focusing on provider organizations (e.g., public hospitals, community health centers, clinics, and practices that serve indigent populations regardless of their ability to pay). Another is these companies often operate with different financial models than commercial health systems, struggle with limited resources for technology innovation, and face significant organizational and staffing constraints.
We provide companies with a nuanced understanding of what it will take to implement digital health tools in these settings. For example, we help them understand what frontline staff and purchasing agents think about electronic-health-record integration, privacy, and security so that companies can tailor their offerings to meet the needs of this market segment.
4. Go Beyond the Clinical Trial
Experts have long called for a more robust evidence base for digital health, but HIT companies are often disinclined to invest in the traditional gold standard randomized trials, which are expensive and slow. This is especially true when regulatory approval for their products (e.g., by the U.S. Food and Drug Administration) is not required.
Nonetheless, scientifically rigorous, non-randomized approaches can provide valuable evidence to health care providers and payers and attract investors. S.O.L.V.E. Health Tech has expertise in non-randomized methods, known as implementation science, which can be used to rigorously analyze whether the technology works as intended in real-world settings and if patient outcomes are durably improved.
5. Align Timelines and Expectations
In academia, administrative processes for obtaining ethical approval for studies involving humans and intellectual property contracting can be restrictive and protracted. To successfully partner with businesses, academic partners need to streamline both the administrative and academic aspects of their work. In addition, researchers must check their egos at the door and understand that industry partners bring a pragmatic viewpoint to academic recommendations that will result in their selectively acting on them.
Business partners contending with hectic schedules typical of startups also must adapt when working with academics. This means acknowledging that they frequently “don’t know what they don’t know” about the Medicaid space and remaining open to suggestions for modifying products for this unique market.
6. Debunk Myths about Innovation in Medicaid
Many companies are encouraged by funders such as venture capital firms to sell their product to commercial insurers before pivoting to public insurers such as Medicaid because the latter’s reimbursement rates are lower. In reality, if companies prioritize building a product that works for Medicaid’s diverse patient populations and care settings, they will produce better technology and viable solutions that can more easily be disseminated in commercial settings, rather than vice versa.
For example, a review of 53 studies published between 2013 and 2019 shows that when companies design patient-facing components of electronic health records (“patient portals”) for racially, ethnically, and socioeconomically diverse patients, the portals demonstrate better and more accessible usability for everyone. Similarly, two other of our industry partners, Health Tech 4 Medicaid and Town Hall Ventures, have demonstrated that it is possible to include diverse patients in technology design from the inception.
Separately, many entrepreneurs and investors incorrectly assume that Medicaid patients are disinterested in using digital tools to manage their own health. We conducted a survey of nearly 800 English- and Spanish-speaking patients with chronic health conditions recruited from four public hospitals across the country and demonstrated that most low-income patients are highly interested in using technology to manage their health. This represents a massive business opportunity given that more than 70 million patients are on Medicaid.
Reimagining academic-industry collaboration is critical to digital health innovation. Close alignment is the surest way to achieve the shared goal of developing digital health products and services that will improve health outcomes for all.