HIStalk Interviews Sumit Nagpal, CEO, Alere Accountable Care Solutions

Sumit Nagpal is president and CEO of Alere Accountable Care Solutions.

Tell me about yourself and the company.

I started a company called Wellogic in 1993. I’ve been at this for now over 20 years. I took Wellogic through three generations of product development with always a common vision, which was unifying clinical information for doctors at the point of care. Making that easily available to them.

In December of 2011, as we started hitting our stride and started seeing actual growth in the marketplace, some real growth opportunities, we realized that obviously we needed to bring in capital for that growth. We sought ought various types of capitalization strategies. The one that made the most sense for us was what we arrived at with Alere. I met with Alere’s founder-CEO Ron Zwanziger some time in October of 2011 and hit it off immediately. We had a common vision for how to make a real impact on clinical practice and improvement of both outcomes on the one hand and reduction management of cost on the other.

We had a very common vision. He came at it from the diagnostics perspective. I came at it from what happens in workflows, in physician offices, and how to tie everything together into a unified story. The rest is history. We became a part of Alere in December of 2011 and have been on an incredible journey ever since. That’s where we are today.

What’s the vision for a company that was primarily medical devices and diagnostics to cover HIE platforms, analytics,  wellness, biometric device connectivity, and EHRs?

It’s pretty simple when you step back and see what Alere started out to do. We started out as a diagnostic company, both point of care and diagnostics in patient’s homes. Our goal was to help patients with chronic conditions stay as healthy as they could wherever they were, primarily as they received physician instructions and worked to comply with them in their homes. What we deployed as diagnostic device into patients’ homes, our hope was that we would be able to improve outcomes simply by giving patients the information that they needed to stay compliant. 

There were challenges there. While were seeing improvements and outcomes, we weren’t seeing the dramatic changes that we had hoped for, primarily because patients weren’t getting the help they needed to make sense of the numbers. And of course there were compliance issues as well. We expanded our company’s offerings to include care management, where nurses would build relationships with patients and help them remain compliant, help them understand what their numbers were, help them with their dosing changes, and so on, so that outcomes were improved. On the one hand, costs and unnecessary hospitalizations and other types of adverse events were reduced.

What we found in that expansion was that our nurses and care managers were operating with two key handicaps. They typically operated without the help of the rest of the care team in understanding the physician’s care plan for the patient. They weren’t tightly integrated into the continuity of care for the patient. Telehealth or home monitoring, depending on what market you’re in, were separated, isolated types of services that didn’t really interweave themselves into routine clinical care.

Secondly, our care managers were operating with just about the information that the patients were able to report, either through the results that they shared from tests or what came across on the home monitoring channels. Some of that was augmented by payer data, but that was also always after the fact. We realized that we really need to close those gaps. That’s where the information technology portion of our vision came together.

Six years ago, Alere began its journey to start filling in those gaps, firstly by enhancing what we could get from our traditional sources of information from the payers, and then tying in the clinical feed, the information that came in from routine day-to-day clinical practice, from office-based and hospital-based settings, and then extending that into long-term care on the one hand, and then some of our markets now also extending that into social care. When you think of it that way, these are really not isolated thoughts. It’s really one very coherent vision that puts the patient at the center regardless of where they’re receiving care, we pull that information together. We activate that information through evidence-based guidelines. We deliver gaps and care reports to doctors, PCPs and such. so that they are better able to manage the healthcare and financial outcomes for those patients. We’re able to also then follow those patients into their homes as they get identified with chronic conditions and are able to help intervene early so that they avoid hospitalizations on the one hand and also continue to receive guidance from their providers and remain a part of a medical home with their providers in the long term.

The vision is very cohesive from that perspective. Diagnostics and information technology are really both essential for making it all work.

Do you think there’s any potential that we’ll ever have a single care plan for a patient that crosses all disciplines?

All disciplines? Well, there might be a holy grail for that. But our eyes are more on the immediate and mid-term horizon where for specific chronic conditions, a care plan that extends across the community, across the continuity of care from the home into the PCP’s office, into their specialist’s office, where all physicians are collaborating on a common set of goals for the patient. We’re going to see that emerge with our work in New Jersey at Virtua, for example. You’re going to see a common care plan that extends across that entire continuum, emerge out of the work we’re doing there. Very much out of the work we’re doing in the UK with the NHS Leeds. We are working on exactly that type of capability.

Is there convincing evidence that home medical monitoring devices will improve outcomes or cost on a large scale?

We’ve had these outcomes numbers for a long time. We can demonstrate across all the major chronic conditions–diabetes, asthma, COPD, heart failure–we can demonstrate improvements in both outcomes and reductions in cost. We have real and critical data that proves that. Ten, 12, 18 percent reductions in costs across those diseases and measurable improvements in patient outcomes are already on the record. When you look at our anticoagulation program, for example, you’ll see that, compared with all other types of anticoagulation management techniques, our home monitoring, when a patient gets discharged post heart failure on warfarin therapy and we measure the patient’s coagulation time within limits factors at home, around their blood coagulation. Our efficacy of our intervention with the home monitoring exceeds that of every other measure that we have compared that against, by a meaningful margin. 

Home monitoring really does work. The question is, does everyone who needs home monitoring get prescribed it, at discharge or the right moment? How does that home monitoring fit in with routine clinical care? Both of those things have to happen for home monitoring to work on a grand scale. The work we’re doing in large connected communities like Southern New Jersey and the entire city of Leeds in the UK, that work is actually aimed at showing how we can scale this on a large scale. But our studies already performed on very substantial numbers of patients already proved that home monitoring standalone can have that impact.

What advice would you have for a health system that’s trying to figure out what it needs in terms of HIE platforms, analytics, and business intelligence and who to consider buying them from?

There is a lot of hype out there. There is a huge amount of me-too behavior being exhibited by customers. I was asked during a presentation to a pretty large HIE customer when we were making the sale to them, one of the leaders from the buying party essentially asked, "Well, Sumit, we know you, we trust you, but all the other vendors come in and tell us that they’ve got the same stuff. Why should we believe you when you say that they may or may not have it versus what they’re saying?"

That’s a real important problem. It’s a problem that has plagued software forever. The largest companies in the software industry created the notion of vaporware. They set the stage, they created the model where organizations sold a vision first, and when they had the contracts, they went and built the fulfillment of the vision. It’s very hard to distill reality from vapor, even after involving customers, because every customer has a vested interest in having their vendor succeed. Even customers help vendors in presenting themselves in the best light.Those are just the realities of software, unfortunately. 

What’s a buyer to do? The challenge there is ultimately answered by who’s actually going deep into proving the benefits and to proving the outcomes? Who is actually investing tangibly in the full picture rather than lipstick on the pig on the one hand, or, you know, the same-old, same-old, just repackage, just new marketing. Lipstick on the pig on the one hand, or incremental, small-scale investment hoping that they’ll hit the jackpot and then they’ll take off. Those are the things that customers really have to watch out for. Alere is dead serious about R&D. We spend, over $150 million a year on R&D. That is the basis for our differentiation, the fact that we’re serious about making all the stuff work, pre-integrated out of the box, is a key differentiator for us. You’re absolutely right; the market does have to be concerned about this problem.

We don’t really seem to have any alignment here public health and the encounter-based care our system was built around. Are we as a country prepared to move from an encounter-based care model to population health management?

As an economy, we’re certainly set up to be more local. We’re much more autonomous than most other economies in the world. The kinds of public health or population-based measurements that you’re describing that, say, in many European countries, in Southeast Asia, in Africa, might be taken on as national level initiatives. In the US, their implementation ultimately becomes a federated, local matter.

That’s very much all about who we are as a culture and as an economy. We compete, we like to have autonomy, and we like to make decisions about what matters in our own communities. Having said that, there’s lots to be gained, and we’re seeing this already, by individual health systems that actually pay attention to population health as a competitive differentiator for them. I think we will see a real uptake on population health measurement as a commonplace technique for health improvement in this economy. There are obviously incentives that CMS provides for achieving various goals and measures, and so that’s the national level agenda. But there’s lots and lots of local differentiation.

That’s not a bad thing because it creates a kind of innovation and the kind of differentiation and the competition that actually allows us to try many experiments to see what works, rather than everyone barrel down a path that might not pan out. And really provide choice for the various participants who then, given their varying degrees of ability or interest, choose to engage with very local decision making. It’s just our way, and I guess that’s what we will do.

Everybody likes to ask you questions about what it was like to work with Steve Jobs. Do you see any companies or people in healthcare IT that are in any way like Steve Jobs or Apple?

The kind of innovation, the kind of energy, the kind of "we’re going to change the world" spirit that I saw at NeXT, because that’s where I was when I worked with Steve. That kind of spirit is sorely lacking in healthcare. We are rather jaundiced or disillusioned as an entire sector in so many ways, and that’s unfortunate. There is huge amounts of innovation happening in pockets, in small companies that are working on the edges, but by and large, the bulk of the industry is innovating at a pace that is glacial compared with what it should be for the kinds of challenges that we’re all working to solve. We’re hoping to show that we are a different kind of company from those perspectives.

Should expectations be limited given that even Apple probably would have struggled if it had to work in an environment that was so heavily government controlled? Do you think that we’ll ever have real innovation in healthcare IT?

I think you’ve really put a finger on one of the things that gets in the way. We talk about this very often, that Apple succeeded in so many ways because they figured out what the consumer buying their stuff really cared about. They made that thing really enchanting for the buyer.

In healthcare, the buyer happens to be very different almost all the time from the actual user or the consumer. That creates a very big problem for spenders, for companies like us, who are actually working to create things that will gain adoption, that people will be enchanted by, that users will actually love to use, and make a part of their daily routine, blend into their woodwork just the way the iPhone and the iPad and so many other technologies out of companies like Apple have blended into our lives. We all, especially at Alere, we’re focused on bringing that kind of innovation to the market. But we also recognize that the buyer doesn’t necessarily turn out to be the same person who is the user. And in some cases, that does pose a challenge.

Government regulation and the fact that there’s so much of healthcare being paid for under, for example, CMS-based reimbursement. In so many ways that it’s actually created much of the momentum that we’re seeing for the kinds of technologies that are now starting to be talked about and even starting to be adopted. Interestingly enough, the changes that have happened over the past few years have actually boosted, created innovation. They’ve started a pocket. They’ve created benchmarks for healthcare providers to meet, which in turn have created benchmarks for vendors like us to meet. All of that, I think, is goodness.

Will we ever see the kind of innovation that is seen in other industries? As care becomes more and more consumer driven, I see a vehicle for driving more and more transparency, more and more openness with data sharing, more and more ability to make use of the data to engage and benefit the consumer. That will happen, it’s only a matter of time. And the question is, how long will it take. So, you know, I’m bullish on this industry for that reason. Because I think the forces that have been unleashed over the past six years really have started moving us down that path.

Any concluding thoughts?

This is a really exciting time to be in this industry. We are burdened with a legacy. We are burdened with infrastructure and limitations that are in so many ways of our own making. But at the same time, we’re also seeing the same kind of cracks in the fabric, or the infrastructure, that have caused industries ranging from travel to stock brokerages and financial organizations to break down those barriers, reduce the friction, and become consumer focused and consumer driven. We’re seeing those same patterns emerge in healthcare as well. We expect to be right at the forefront of enabling those kinds of changes to happen, and it’s just a very exciting time for that reason.