Wellevate Aims to Take The Headaches Out of Lab Testing

Lab work. It is an essential part of any medical practice, especially in functional medicine clinics. It can also be a big hassle factor for practitioners and patients alike.

While companies like Quest and Labcorp have done a good job of bundling standard conventional lab tests into single one-stop shops, so to speak, the situation within functional medicine is more complex.

Practitioners routinely deal with multiple lab companies, each with its own offerings, its own timelines, and its own idiosyncratic methods. There’s the challenge of ordering and stocking test kits to give to patients. And that’s on top of the general headaches of scheduling blood draws when needed, chasing and aggregating test results, and booking patient visits to discuss them.

With its new Wellevate Labs platform, Emerson Ecologics—one of the nation’s major practitioner-focused supplement distributors—aims to take the hassles out of functional diagnostic testing with a one-stop digital platform through which practitioners can order tests, store results, schedule visits, and develop care plans.

Simplicity & Continuity

Emerson’s fully HIPAA-compliant Wellevate “Connected Care Platform” launched in November 2020. The lab management component is the latest inclusion in an already robust set of practice management tools that includes a secure telemedicine system (powered by Vsee). Qualified practitioners can access the Wellevate suite free of charge.

“Diagnostic and functional testing labs are so disparate. Practitioners have to maintain all these relationships with different labs, deal with multiple portals, keep supplies of test kits. Our goal is to simplify all of that,” explains Jaclyn Chasse Smeaton, ND, Senior Vice President of Medical Affairs at Emerson Ecologics. 

The lab management project was driven, in part by the new healthcare dynamics brought about by the COVID pandemic.

Emerson saw a major surge in Wellevate users since the pandemic began, as practitioners and their patients sought online substitutes for in-person clinic visits. On the supplement dispensing side, the company saw a big rise in product sales in early 2020 that has stayed consistent throughout 2021.

But the Wellevate team was aware that the pandemic has been extremely challenging for many clinics.

Born From Pandemic Pressures

“When the pandemic hit, we were very worried about the small, solo practitioners,” says Smeaton, who still maintains a small private naturopathic practice of her own.

Independent practices make up a significant proportion of Wellevate’s practitioner base. While many small practices were struggling to stay afloat, Smeaton and her colleagues saw that others were thriving despite the pandemic.

“Some were even doing better than before. So, we phoned them to ask about what they were doing and how they were making it work, so we could share those tips with others.”

Among the gleanings, Wellevate learned that many practitioners wanted ways to simplify lab work. Input from the clinical community shaped Wellevate Labs, as well as other innovations like Wellevate’s “Pivot Your Practice” practitioner education campaign.

The lab venture draws on Emerson Ecologics’ 40 years of experience and expertise in aggregation and distribution.

“We had already developed solutions to help practitioners dispense a wide range of different supplements from diverse companies,” Smeaton explained. Aggregation of lab tests, simplifying the ordering process, and consolidating the results was a similar multi-vendor distribution challenge.

The venture also benefits from a creative partnership with Evexia Diagnostics, a practitioner-founded practice management company that has been a pioneer in lab test aggregation. Evexia provides the software infrastructure for Wellevate Labs.

A One-Stop Portal

As with its online dispensary, Wellevate Labs is a one-stop portal through which practitioners and their patients can access the vast majority of common lab tests—standard conventional panels as well as “specialty” functional medicine ones. 

Wellevate maintains the relationships with the various lab companies, obviating the need for practitioners to do so. On the front end, like their virtual dispensary, the lab platform is fully customizable with a practice’s graphics, color schemes, and patient-facing editorial content.

Wellevate currently offers tests from 16 major specialty labs including Genova Diagnostics, SpectraCell, Doctor’s Data, Precision Analytical, US BioTek, and Diagnostic Solutions. Clinicians can also use Wellevate to order conventional tests via Labcorp, though these appear as a separate order on the portal’s dashboard.

Wellevate Labs already has roughly 650 users, with more logging on every week. Smeaton says onboarding and implementation is quick, especially for practitioners already using the basic Wellevate platform. Most clinics can get the system up and running in a matter of minutes.

Wellevate Labs does require users to enter NPI (National Provider Identifier) numbers, to validate medical credentials. The platform is accessible to all physicians with prescribing rights. In states where they are licensable, naturopaths can access it independently. NDs in unlicensed states, chiropractors, nutrition professionals and others can use Wellevate Labs but only under MD oversight. 

Seamless Orders

On the practitioner side, ordering tests for a patient is as simple as clicking the name of the lab(s), and then clicking the desired tests. The system offers some pre-set combination panels that aggregate diverse tests from different labs. It also allows practitioners to customize their own test combos.

On the patient side, the Wellevate app shows patients what tests their doctors have requested with complete price transparency, since most specialty tests are not insurance reimbursable.  Once the patient affirms the order and pays, the test requests are automatically sent to the labs.

If a particular test requires a kit or special supplies, the labs send them to the patient, or to the clinic if need be.

“It’s really seamless. There’s one order, and one checkout, with no balance billing.”

Patients and practitioners can also use the app to schedule phlebotomy appointments at the clinic, in the patient’s home, or at any Labcorp draw center. They can also use the app to review care plans and supplement recommendations, and to order refills.

Once tests are completed, the labs report the results directly into the Wellevate platform where they become visible to practitioners and patients for review. This facilitates interpretation, discussion, and care planning.

Wellevate handles all patient tech support calls, freeing practitioners from the need to talk patients through logistics, answer common questions, or troubleshoot glitches.

Competitive Pricing

Functional diagnostic testing can get expensive; the Wellevate team is conscious of this fact. Smeaton says the platform offers specialty tests at the lowest allowable prices, and that Labcorp has given them very good rates on conventional tests.

The proximity of this new test aggregator and Emerson’s supplement dispensary inevitably begs the question of conflict of interest: Will practitioners order tests with the unstated goal of driving supplement sales revenue?

Smeaton says it is a reasonable question for someone to ask. But she stressed that the potential for conflicts of interest exists whenever a patient is purchasing anything from a medical practice. “Wellevate does not change that in any way. It still comes down to whether a patient can trust that a practitioner has their best interests in mind.”

She stressed that the new labs platform is fully HIPAA-compliant, and that Wellevate takes cybersecurity very seriously. The platform does not store any patient credit card information, and Emerson’s information security team works with independent third-party consultants that monitor the system for vulnerabilities.

Smeaton and her colleagues expect that the Wellevate Labs platform will continue to expand and improve as more practitioners use it, and more lab companies offer their tests.

“This is only the beginning.”

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Pandemic Boosts Telemedicine Use

Telemedicine has been the big winner in the COVID economy, and growth of this sector has shown no sign of slowing.

In 2020, as the COVID-19 crisis forced practitioners, patients, and legislators to recognize the need for expansion of telehealth, the global market for digital healthcare services reached an estimated $152.5 billion. Researchers project that the industry — which comprises digital health systems, healthcare analytics, and telemedicine — will grow to $456.9 billion by 2026.

The use of telemedicine services in particular skyrocketed in early 2020. A CDC report shows that in the first quarter of that year, the number of virtual healthcare visits increased by 50%, compared with the same period in 2019. In the last week of March 2020 alone, telemedicine visits jumped 154% over the number of visits that same week in 2019.

That acceleration continued in 2021. By one account, ten times more telehealth visits occurred in March 2021 than in March 2020.

Big Tech is paying attention to these trends. About a year ago, Google announced a major $100 million investment in Amwell, one of the largest telehealth service providers.

Amwell’s revenue jumped from $69 million to $122 million — a 77% increase — in the first six months of 2020, according to its IPO filing. Alongside other recent developments the company noted the significant reduction of regulatory and reimbursement barriers for telehealth, surging demand for on-demand remote COVID-19 services, and a desire to protect healthcare workers and patients from people infected with coronavirus.

Stay-at-home orders and business closures also boosted the popularity of fitness apps and “smart” exercise equipment.

Millions of smartphone users downloaded meditation and sleep apps like Calm and Headspace, programs that promise better rest, lower stress, and less anxiety.

A host of digital health platforms now offer quick, discreet, on-demand access to medical services. They can also eliminate long wait or travel times to receive medical attention. The trade-off for convenience means that health tech users accept the risk of their sensitive personal data being hacked or used in ways that aren’t initially intended or clearly disclosed.

Threats to data privacy have worsened since the pandemic began. Cyberattacks on healthcare institutions spiked last year, as Forbes and others reported earlier this Summer. For the fifth straight year in a row, hacking incidents rose again in 2020, up a striking 42% from 2019.

The increase in healthcare hacking events raised enough red flags that in October 2020, the Cybersecurity and Infrastructure Security Agency, Department of Health and Human Services, and FBI issued a joint cybersecurity advisory warning of “an increased and imminent cybercrime threat to U.S. hospitals and healthcare providers.” They cautioned healthcare institutions to “ensure that they take timely and reasonable precautions to protect their networks from these threats.”

Leaked healthcare data — the presence of pre-existing conditions or potentially “embarrassing” diagnoses — can unknowingly affect the ability to obtain life insurance, the amount paid for coverage, or the interest rates they’re charged on loans. In the wrong hands, health data shared without a patient’s knowledge can also result in workplace discrimination.

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In Healthcare, High Tech Gets a Taste of Its Own Disruption

Over the last five years, nearly all of the major information technology companies have launched some sort of healthcare initiative. The COVID pandemic, with its surging demand for telemedicine and rapid exchange of medical data, only intensifed that trend.

But some tech giants have learned the hard way that healthcare is very different from other business sectors.

High-profile failures like the demise of Haven — a nonprofit healthcare organization formed by Amazon in partnership with JP Morgan Chase and Berkshire Hathaway — are cautionary tales, showing that the creative disruptions that proved so successful in retail, transportation, and financial services can crash and burn in the medical sphere.

Successful or not, Big Tech’s healthcare ventures raise profound ethical questions about the uses of personal medical data and the limits of privacy in the digital age.

Haven & Hell

Haven was founded on the lofty goals of improving healthcare services and lowering medical costs for employees of the three founding companies, an aggregate workforce of roughly one million people.

The venture started out strong in 2018, but proved to be short-lived. By early 2021, barely three years after its launch, Haven posted a vague statement on its now defunct website announcing plans to disband.

Many healthcare analysts have opined on why Haven hit the rocks. CNBC reported that despite the outward appearance of collaboration, “each of the three founding companies executed their own projects separately with their own employees, obviating the need for the joint venture to begin with.”

Other speculations cite sluggish progress, high executive turnover, lack of “bold ideas,” absence of “strategic clarity,” and the company’s status as a not-for-profit rather than a profit-driven venture.

But it might also be that Haven’s leaders simply overestimated their own strengths and underestimated the depth of healthcare’s quicksand. The hiring of a few medical superstars like surgeon/author Atul Gawande, MD, and former ZocDoc chief technology officer, Serkan Kutan, was not enough to transform an online retailer, an investment bank, and a corporate holding company into a healthcare business.

“A real possibility is that the entrenched complexity of the American healthcare business model proved too daunting to change. As large as these parent organizations are, they still don’t possess the economies of scale to tip the balance when it comes to healthcare,” said Lyndean Brick, president of healthcare consulting firm Advis, in an article published by Fierce Healthcare.

Many healthcare analysts have opined on why Haven hit the rocks. Speculations cite sluggish progress, high executive turnover, lack of “bold ideas,” absence of “strategic clarity,” and the company’s status as a not-for-profit. But it might also be that Haven’s leaders simply overestimated their own strengths and underestimated the depth of healthcare’s quicksand.

Moving forward, Amazon, Berkshire Hathaway, and JPMorgan Chase have stated—in perfect corporate-speak–that they will “leverage the insights” gained from Haven, and will “collaborate informally to design programs tailored to address the specific needs of their own employee populations.”

Healthcare on Demand

Amazon seems undaunted by the Haven debacle; the company has forged on with several independent healthcare ventures.

Earlier this year, it confirmed plans to broaden Amazon Care–a virtual healthcare service previously available only to Amazon employees—to other big employers.

Amazon Care was piloted in 2019 as a benefit for Amazon workers and their families in the company’s home state of Washington. This Summer, it extended the virtual service to all its US employees.

Through a smartphone app, Amazon Care offers employees “immediate access to high-quality medical care and advice,” including on-demand connections to primary and urgent care services, 24 hours a day, 365 days a year.

Successful or not, Big Tech’s healthcare ventures raise profound ethical questions about the uses of personal medical data and the limits of privacy in the digital age.

Aspects of Amazon Care resemble other well-established telehealth services. To begin using the app, patients answer questions about their physical and mental health. Users can then schedule medical visits and chat with nurses or doctors via video or messaging features. Amazon claims employees are typically able to connect with medical professionals in less than 60 seconds.

Along with virtual care, the system also provides options for in-person services. Patients can request home or office visits for COVID-19 and flu testing, vaccinations, illness and injury treatment, preventive care, routine blood draws, sexual health services, prescription requests, refills, deliveries, and more.

Amazon ambitiously aims to bring its virtual and in-home healthcare platforms to at least 20 major US cities in 2021 and 2022. The company also plans to expand Amazon Care beyond its own employee base by “supplying” it as a workplace benefit to other companies.

The paradox is that as Amazon strives to be a healthcare leader, it simultaneously faces accusations of unsafe working conditions and employee abuse.

During the “heat dome” weather event last summer, indoor temperatures at an Amazon warehouse in Washington state allegedly reached 90 degrees. Despite the extreme heat and lack of adequate climate control, workers were asked to move as quickly as possible to “boost productivity,” the Seattle Times reported. This follows many prior charges from Amazon employees who’ve described unhealthy working conditions while being treated “like robots.”

Beyond Amazon Care

Amazon Care is not the tech titan’s only foray into healthcare. Its most recent is a direct-to-consumer at-home COVID-19 test kit.

Last Spring, the Food and Drug Administration issued an Emergency Use Authorization for Amazon’s real-time RT-PCR test for SARS-CoV-2. Customers can now order these Amazon COVID-19 test kits through the company’s diagnostics site, AmazonDx.com, by providing the same login credentials used to access its online shopping site. Amazon hinted at further moves into diagnostics, including tests for respiratory infections and sexually transmitted diseases, Business Insider recently reported.

Last June, Amazon Web Services (AWS) unveiled the AWS Healthcare Accelerator, a four-week “technical, business, and mentorship accelerator opportunity” for fledgling digital health companies.

The paradox is that as Amazon strives to be a healthcare leader, it simultaneously faces accusations of unsafe working conditions and employee abuse.

According to a blog post from Sandy Carter, AWS’ vice president of worldwide public sector partners and programs, the Accelerator is specifically focused on startups seeking to “accelerate growth in the cloud.” The program is now accepting applications from up-and-comers looking to leverage Amazon’s technical and commercial expertise “to help solve the biggest challenges in the healthcare industry.”

The Accelerator will focus on “solutions” — a favorite tech industry term — such as remote patient monitoring, data analytics, patient engagement, voice recognition, and virtual care. By using AWS, Amazon says “organizations can increase the pace of innovation, unlock the potential of data, and personalize the healthcare journey.”

Data Fuels Deep Learning

But what exactly is the “potential” of data? And who does it really benefit?

Among the more revolutionary developments in IT are data-driven “smart” machines, which use artificial intelligence to “think” and act like humans.

One branch of AI, called deep learning, relies on algorithms that mimic the neural networks of the human brain. Like the brain, AI-based machines continually receive and process large amounts of data, and teach themselves new tasks based on what they glean.

People across the globe generate huge amounts of data every day, all of which — when captured — fuels the deep learning process. The more information the algorithms take in, the better they become at predicting outcomes — including things like human behaviors, disease progression, and treatment responses.

Most of our digital gadgets now rely on machine learning to some extent. Virtual assistants like Amazon’s Alexa or Apple’s Siri use AI to decipher users’ unique speech and language patterns. Driverless AI-guided vehicles learn not only the mechanics of driving, but how to respond spontaneously to unexpected obstacles or occurrences.

Whether or not users realize it, social media platforms like Facebook, Twitter, and Instagram continuously collect and analyze personal behavioral data. Our data is, essentially, a form of payment to access these “free” online services. AI-based programs glean information about our favored activities, habits, aesthetic preferences, socioeconomic status, political inclinations, and our health.

Presently, the US does not have comprehensive consumer data privacy regulations governing what can and cannot be done with data that users enter into online apps. Instead, we have a patchwork of inconsistent state-level regulations.

Amazon, with its diverse healthcare operations, are no doubt amassing astonishing amounts of medical information. So are most of the high-tech healthcare companies.

Big Promises, Big Problems

Proponents of AI present it as a powerful problem-solver that helps us overcome the limits of our own brains. Because machines can process much larger quantities of information than can the human brain, AI expands our ability to think creatively and develop novel solutions to serious problems.

Tech companies say they use AI to enhance the “user experience.” In healthcare, the rationale is usually “to improve clinical outcomes,” to “reduce complexity,” to “streamline the patient experience” or some similar pastel-toned platitude.

And there’s no question that AI does hold great promise for improved patient care. One of the most exciting medical applications is in the detection of cancer.

An article published last year in Nature describes an AI technology “capable of surpassing human experts in breast cancer prediction” (McKinney, S et al. Nature. 2020; 577: 89–94). The AI system’s ability to interpret mammograms outperformed humans in detecting both false-positive and false-negative results.

Researchers have also used artificial neural networks to predict the likelihood of recurrence within 10 years following breast cancer surgery. One group posits that accurate predictions by machine learning algorithms “may improve precision in managing patients” post-surgery and increase the understanding of risk factors for breast cancer recurrence (Lou, S et al. Cancers (Basel). 2020; 12(12): 3817).

But the price for AI-enhanced healthcare is loss of privacy.

Flow of Information

Take, for instance, AI-driven menstrual trackers. The popular menstrual app, Flo, which is used by an estimated 100 million women, offers what claims to be “the most precise AI-based period and ovulation predictions by tracking 70+ body signals like cramps, discharge, headaches and more.”

Flo users enter a host of health details related to their menstrual cycles and sexual activity, and the app tracks period symptoms and fertility patterns. The company says it helps users determine whether their cycles are “normal” or “irregular.”

Similarly, Apple iPhones contain a built-in app whose features include menstrual cycle tracking. Apple says the tracker will “improve predictions for your period and fertility window.”

While menstrual tracking apps might offer benefits like helping couples to either achieve or avoid pregnancy, they also raise significant safety and privacy concerns. In exchange for period-tracking services, patients provide the tech companies — and potentially others — with a wealth of very personal information.

The price for AI-enhanced healthcare is loss of privacy

Researchers have questioned both the reliability of fertility apps and the unregulated nature of the market (Ali, R et al. Repro BioMed Online. 2021; 42(1) 273-281). One study from 2020 looked at 140 different menstrual apps and concluded that while some are accurate and useful, “many more are of low quality, and users should be wary of relying on their predictions to avoid pregnancy or to maximize chances of conception.”

Some menstrual trackers, including Flo, have significant data privacy flaws and they have been called out for sharing user data despite promises to keep that information private. In 2019, a Wall Street Journal investigation revealed that the app shared users’ intimate reproductive and sexual health data with Facebook, Google, and other third parties that provided marketing and analytics services for Flo.

According to Consumer Reports, analysis of privacy and data security practices of Flo and four other period trackers showed that users receive no guarantee that their data would not be shared with third parties for marketing or other purposes.

Following a 2020 complaint, the Federal Trade Commission announced last January that it had reached a settlement with Flo. Among other requirements, it mandates that the company must obtain users’ consent before sharing their health information.

Lack of Oversight

Presently, the US does not have comprehensive consumer data privacy regulations governing what can and cannot be done with data that users enter into online apps. Instead, we have a patchwork of inconsistent state-level regulations.

There are data privacy laws governing specific sectors, including healthcare. The best known is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Other laws also regulate electronic health records systems and telehealth technologies.

But in the post-COVID world, many of HIPAA’s protections have been curtailed.

Early in the pandemic, the Department of Health and Human Services (HHS) — the entity charged with enforcing HIPAA — announced a temporary relaxing of regulations with which healthcare practitioners formerly had to comply. HHS saw the massive need for accessible telehealth services, and rightly recognized that in this public health emergency, HIPAA compliance was an obstacle to the speedy expansion of telemedicine.

The agency acknowledged that “some of these technologies, and the manner in which they are used by HIPAA-covered healthcare providers, may not fully comply with the requirements of the HIPAA Rules.” Therefore, HHS chose to “exercise its enforcement discretion” by refraining from “impos[ing] penalties for noncompliance with the regulatory requirements under the HIPAA Rules…in connection with the good faith provision of telehealth during the COVID-19…emergency.”

Many telehealth platforms, remote monitoring tools, and health apps are not really HIPAA-compliant. And nearly two years on, the “temporary” HIPAA suspensions are starting to feel permanent.

Hackers Target Health Data

There’s no question that sensitive medical data gathered by health apps, telemedicine platforms, and EMR systems is vulnerable to both marketing misuse and cyberattacks.

High-profile hacks targeting government agencies and private companies alike regularly make news headlines. Healthcare organizations, from hospitals to health plans to practitioners themselves can be targets of cybercrime — a threat that’s escalated significantly in the past year.

HHS indicates a 25% increase in healthcare data breaches in 2020 over 2019, itself a record-breaking year. In 2020, the department recorded the highest total of large health data breaches –1.76 incidents per day on average–in any year since it began tracking the problem in 2009. Officials have warned medical groups of a rise in hacking attempts during COVID, in part stemming from cybercriminals’ efforts to steal vaccine-related research and other medical data.

Aware of these threats, some politicians are advocating for tighter federal data privacy and security laws. US Representative Suzan DelBene (D-WA) introduced legislation last March that, if passed, would create the country’s first-ever national data privacy standards.

The Information Transparency and Personal Data Control Act seeks to protect individuals’ personal identifying information, including data relating to financial, health, genetic, biometric, geolocation, sexual orientation, citizenship and immigration status, Social Security Numbers, and religious beliefs. It also protects all information pertaining to children under age 13. Further, it would strengthen the Federal Trade Commission’s capacity to enforce privacy rights and punish bad actors.

That’s good as far as it goes. But, notably, the bill does not mention either AI or facial recognition technologies, or the ways in which they capture consumer data.

Meanwhile, the use of these technologies—and in some cases, their exploitation–is only accelerating within and beyond the healthcare realm.

AI-driven systems do indeed hold tremendous potential to transform medical care for the better. But these advances do have downsides—both predictable and unexpected. It is naïve to think otherwise.

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Functional Med Practices Show Resilience Through the COVID Storm

Data from a survey of over 3,500 functional, integrative, and metabolic medicine practitioners suggests that most are navigating the stormy post-COVID waters with considerable resilience.

Compared with other physician surveys posted over the course of the last 9 months, the functional and holistic clinicians in this cohort report fewer practice closures and less income loss.

Membership (aka “concierge”) and bundled practice models appear to be protective against the economic forces that have hobbled many conventional insurance-based practices in the wake of COVID. This is especially true for small, independent practices.

This new 33-question survey was fielded from late August through early September by OvationLab, a strategic consulting agency for the health, wellness, and nutrition space. OvationLab’s principals—Laurie Hofmann, Andie Crosby, and Tom Blue—have all served in leadership roles at the Institute for Functional Medicine for many years.

“This is a triumph for value-based medicine over conventional fee-for-service insurance models. There’s never been a better rationale for conventional practitioners—especially those in independent practices– to expand their capabilities, and to learn to apply root-cause medicine.”

—Tom Blue, OvationLab

They obtained 3,505 responses, representing clinics from all across the nation. MDs and DOs make up 28% of the total, with naturopaths, nurses, and integrative chiropractors representing 12% each. Eighteen percent are “straight” chiropractors, the remainder represents a mix of nutrition professionals, acupuncturists, and others.

Roughly two thirds are female, and the average age was 54.

The respondents work in a wide range of practice models including conventional insurance-based practices (29%), direct fee-for-service (46%), membership (aka “concierge”) practices (5%), Bundled or fixed-price programs (4%), and hybrid models (9%) that combine conventional insurance with low-level engagement in direct pay, bundled programs, group visits, or other revenue models.

An additional 7% have practices in which supplement sales are a major revenue source.

Few Closures

COVID-related practice closures were far lower among functional/holistic medical practitioners compared with physicians as a whole. The closure prevalence in this cohort ranged from 2-13%, depending on practitioner type. It was lowest among the MDs, DOs, and NDs (2%), and highest among the acupuncturists (13%), the “straight” chiropractors (5%), and nutrition professionals (5%). 

There were no closures among doctors who run membership or bundled service practices. Among insurance-based practices, the closure prevalence was 3%; it was 5% in the cash fee-for-service segment. 

This compares favorably against data from a Physicians Foundation (PF) survey published in August showing that 14.5% of 3,513 respondents had closed their practices, and an additional 4% expected to close over the course of the year. Most of the closures (76%) were among independent private practices.

There were no closures among doctors who run membership or bundled service practices. Among insurance-based practices, the closure prevalence was 3%; it was 5% in the cash fee-for-service segment.

A regional survey in April by New York University’s School of Global Public health showed 15% of metro-NYC area practices were temporarily or permanently closed due to lack of PPE, insufficient staff, or drastic declines in patient volume and revenue.

Impact on Income

Though closure rates were low, OvationLab’s data show that many functional medicine practices have borne revenue shortfalls. Upward of 75% of respondents were economically impacted in some way. Between 20% and 25% are operating at 25-49% of their pre-COVID revenue levels, and between 1% and 11% are getting by on less than 25% of pre-pandemic income.

On the positive side, roughly one-fifth of the respondents say that their income has remained at pre-pandemic levels, and 7% to 14% say it has actually increased over the last 9 months.

In contrast, the PF estimates that 16% of the total US physician workforce—that’s roughly 134,000 doctors—have changed their practice patterns in some way that temporarily or permanently disrupted continuity of care. In that survey, 72% of physicians had experienced income reductions and 55% expected income drops by the year’s end. 

The hardest hits have been on solo and small-group independent practices.

OvationLab’s Tom Blue points out that the vast majority of holistic and functional physicians fall into that independent solo or small-group bracket, and it seems they are faring considerably better than their peers in conventional practice.   

Membership Has Benefits

Though only 5% of OvationLab’s cohort run membership practice models, these proved extremely resilient to the post-COVID economic assault.

None of the membership practices had closed, 36% reported they were operating at “business as usual” revenue levels (100% of Pre-COVID), and 23% say revenue is up. 

Among those clinics deriving a major portion of their income from bundled clinical services—things like cardiovascular risk reduction programs, weight management groups, and hormone replacement protocols—22% have maintained pre-pandemic income, and 13% have seen revenue increases.

In contrast, only 17% of the insurance-based practices maintained their pre-COVID revenue, and just 8% saw increases.

Some clinics offering bundled services did see revenue drop; 28% reported a 50% or greater revenue hit due to COVID. In contrast, only 10% of the membership practices saw such big revenue declines.

Practices that completely ignored COVID, and offered nothing specific to support patients concerned about the virus are worse off because of this. On average, these practices have generated 13% less revenue than those offering at least one COVID-related services.

Overall, the findings do suggest that membership and, to a lesser extent, bundled practice models provide independent practices with some protection against the economic and social forces that drove many insurance-based indie practitioners to shut their doors during the pandemic’s first wave.

“When you look at the active patient census of membership practices collectively across the country, you can’t even tell that COVID happened. According to data from Hint Health, the largest membership payment processor for the concierge and DPC industry, membership practices collectively grew 4% between March and July,” Blue says. Hint processes patient payments for roughly 1,000 practices around the US.

“They ran the numbers, and nationwide, there was no net attrition (in patient membership payments) over the 60 days in total shutdown. In fact, it grew 1%,” Blue told Holistic Primary Care. “A pandemic is not a smart time to fire your doctor.”

Challenges Ahead

The economic tenacity of the membership model may be more a reflection of the affluence of its patient base than of its intrinsic strengths.  People who can afford to pay a monthly out-of-pocket fee to join a clinic—typically in addition to, not as a substitute for what they pay for standard health insurance—are generally well-off and much less likely to be forced to choose between healthcare and food or shelter.

Whether the situation remains so sanguine for private-pay remains to be seen.

Many well-paid white-collar jobs have been dashed during the pandemic, and more could be lost in the coming months. While COVID has caused many more people to focus on their health—and to recognize the limits of conventional medicine–it has also put many in precarious fiscal straits. 

“If this carries on long enough it could become a big challenge for people to pay for private-pay healthcare services,” Blue said in an interview with Holistic Primary Care.

“It would be prudent to take a hard look at practice efficiency and optimizing for value, which is basically outcomes over cost. We talk a lot about this, but in terms of doing the work to optimize, that’s a big opportunity.”

“If this carries on long enough it could become a big challenge for people to pay for private-pay healthcare services.”

–Tom Blue, OvationLab

According to an IFM survey, the throughput of a typical functional medicine practice is seven patients per day, give or take. “If you bring this up to 12 per day– which is still far less than in conventional care–it makes a huge difference financially,” Blue says.

Group Visits: No Panacea

The business model that appears to be gaining the greatest traction is the use of bundled programs. In OvationLab’s survey, 19% of the respondents indicate that they are generating some revenue from this approach. But by and large, this model is the exception, not the rule.

That said, 54% of respondents agreed that they would implement bundled programs if these were set up in a turn-key manner by trustworthy and experienced third parties.

While a growing number of practices are beginning to work with groups of patients, either through group visits or group coaching and education programs, these were not a meaningful source of practice income within the cohort.

“Some of the most exciting implementations of group visits have taken place in health systems like Cleveland Clinic Center for Functional Medicine. But the great majority of our respondents are in independent practices,” Blue points out.

Telemed: Finding the Right Mix

Telemedicine is playing an important role in functional medicine practice survival during COVID, but not exactly in the ways that one might assume.

“The practitioners that were doing 30% to 40% of their visits as virtual visits did the best,” in terms of overall practice resilience, said Blue. “The doctors who pivoted 100% to virtual visits fared worse and now have a significantly lower percentage of their pre-COVID revenue.”

“The healthiest practices have evolved to accommodate a continuum of patient preferences with respect to virtual care. The big take-away seems to be to focus on maximizing access and availability to patients in the ways that they want to use the practice. That means offering virtual visits while maintaining a brick-and-mortar presence.”

Contrary to what many might assume, the main determinant of practice viability during COVID was not the presence or absence of telehealth services, but the overall strength or fragility of the practice’s core revenue and patient engagement models.

One quarter of the MDs/DOs, one-third of the NDs, and nearly half of the nutrition professionals in OvationLab’s cohort are doing more than 60% of their total patient visits remotely.

Not surprisingly, engagement with telemedicine was much lower among chiropractors and acupuncturists: Fully 85% of the straight chiropractors, 53% of the integrative chiropractors, and 55% of the acupuncturists and doctors of oriental medicine are not doing any virtual visits. The services they offer simply cannot be done online.

While the respondents showed a generally high comfort level with things like teleconsults, remote patient monitoring tools, and other big tech, Blue says the processes of adaptation and technology implementation for the COVID era are still very much underway for a lot of practitioners. Many expressed the need for help in further integrating patient-friendly tech solutions in their practices.

Contrary to what many might assume, the main determinant of practice viability during COVID was not the presence or absence of telehealth services, but the overall strength or fragility of the practice’s core revenue and patient engagement models. On that front, practices based on fee-for-service—whether direct pay or insurance-based–appear to be the most vulnerable.

COVID Care

Many of the OvationLab respondents, particularly MDs, DOs, and nurse practitioners, have treated patients with active COVID, though these cases represent a relatively small segment of total patient consultations. 

Just over 60% of the MDs/DOs and roughly 55% of the NDs are offering some sort of COVID-related services, such as COVID testing, antibody testing, monitoring or ongoing support of infected patients, COVID prevention programs, or “back-to-work” support programs contracted with employers. 

Blue says the practices that completely ignored COVID, and offered nothing specific to support patients concerned about the virus are worse off because of this. On average, these practices have generated 13% less revenue than those offering at least one COVID-related services.

But the COVID crisis creates a unique and thorny paradox for practitioners: on the one hand there’s the imperative to educate patients and provide the care they seek; on the other, patient-focused COVID communication can easily cross the line into “marketing” or “false treatment claims” in the eyes of the Federal Trade Commission and/or Food & Drug Administration. (Visit www.HolisticPrimaryCare.net and watch our webinar Your COVID Communications Could Be Illegal)

Both agencies have been aggressive in scrutinizing practitioners’ online messaging about the pandemic.  Since it began, they’ve issued hundreds of warning letters to medical professionals requiring them to delete COVID-related posts if they suggest specific treatments to prevent or cure the syndrome.

Bottom line is, it is easy to unwittingly step over the regulatory line. While it is vital to meet patients’ needs for guidance, you need to be careful about how you do that.

Better COVID Outcomes?

There’s some evidence from OvationLab’s survey that bundled services and membership practices might deliver better overall outcomes for COVID patients.

Insurance-based MDs and DOs who treated COVID patients reported hospitalizing 19% of their infected patients, and had a 3.1% mortality rate.

The MDs and DOs in membership practices reported a 7.2% hospitalization rate for their COVID patients and only a 0.9% mortality rate.

The analysis also showed that physicians who order a lot of advanced cardiovascular lab work (Cleveland Heart Lab, Boston Heart Lab, PULS), tended to have lower COVID hospitalization rates (7.7%), and fewer COVID-related patient deaths (1.8%) than the MD/DO cohort as a whole.

These findings are intriguing but difficult to interpret: Are the lower hospitalization and death rates truly due to the functional medicine approach? Or do they reflect the fact that these clinics tend to serve affluent patients with better overall health status and fewer risk factors?

With respect to these particular observations, OvationLab cautioned that the total number of respondents with heavy COVID caseloads is small, and all the numbers are self-reported.

Value Triumphs

Few healthcare professionals are experiencing smooth sailing these days, and functional medicine practitioners are no exception.

But to OvationLab, the message from their survey is very clear: the principles of root cause medicine combined with value-based practice models have been profoundly protective of independent practices during the COVID crisis, at least so far.

“This is a triumph for value-based medicine over conventional fee-for-service insurance models. There’s never been a better rationale for conventional practitioners—especially those in independent practices– to expand their capabilities, and to learn to apply root-cause medicine,” Blue told Holistic Primary Care.

According to Patrick Hanaway, MD, head of the IFM’s COVID-19 task force, many physicians are doing just that. “At our Annual International Conference (held online this year), we had 50% new people. That’s just amazing to have that many people engaging with the functional medicine conference for the first time. Usually, it’s around 25-30%.”

The surge is partly due to the fact that this year’s online conference was simply more accessible, and did not carry the costs and time-burdens of travel.

But Hanaway also sees it as an indicator that COVID has made more physicians aware of the limits of drug-based care models.

“There’s an openness to other tools. They’re looking to see what can I do to protect myself, what can I do to help my patients? What can I tell patients about how to enhance their immune systems, reduce symptoms, reduce transmission? All those things are very important, and we’ve got tools.”

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The Practitioner Channel Forum 2020: The Future of Holistic Medicine in the COVID Era

The COVID-19 pandemic has had profound impact on all aspects of healthcare. Holistic, functional, and naturopathic medicine are no exceptions. Some of these changes are positive, opening new opportunities for natural medicine to demonstrate its value. Others pose serious challenges.

Positive or negative, the impact of COVID will be felt long after the virus is contained.

Learn how practitioners—and organizations that represent them—are adapting to the “new normal,” how the regulatory and medicolegal landscape is changing, and what the post-COVID future might look like.

This free half-day program features presentations from leaders of the Institute for Functional Medicine, and the Academy of Integrative Health & Medicine, as well as regulatory experts, patient survey data, and perspectives from Holistic Primary Care.

With New Platform, Fullscript Streamlines Practice-Based Dispensing

Virtual practice has become a necessity in the COVID era, and telemedicine will likely continue to expand even after the pandemic wanes.

For practitioners of holistic and functional medicine, the dispensing of supplements and other products is a vital component of both in-person and virtual practice. But managing dispensaries whether online or in-clinic, can be tedious and time-consuming.

Fullscript, one of the world’s leaders in online dispensing and product distribution, is working to simplify the process.

With the launch in October of its new comprehensive platform, Fullscript is making it possible for clinicians to manage their direct-to-patient online dispensaries and their in-clinic product procurement “all from the same account, in the same browser tab,” says Bruce Smith, Fullscript’s senior manager of public relations.

Full Integration

The new platform represents a complete integration of the original Fullscript system with Natural Partners’ distribution and dispensing capabilities. The two companies merged in 2018, but have maintained separate dispensing platforms and distinct branding.

The new platform is part of a broader effort to streamline, simplify, and optimize the systems, so they best support practitioners and their patients.

“We have a lot of practitioners who like virtual dispensing. It is simple for patients, there’s no inventory to manage, nothing goes out of stock or out of date,” says Smith. At the same time, many clinicians continue to maintain in-clinic dispensaries, even in the wake of COVID. 

The new platform provides an easy way to administer both.

“There are lots of technologies and apps out there (to support virtual practice),” Smith told Holistic Primary Care. But managing them can be problematic. Our aim was to design something where you can do everything via one account.” The platform is built around the Fullscript – Natural Partners catalog of over 300 practitioner-facing supplement brands.

He added that, “This is the most significant upgrade we’ve done on the Fullscript side.” The company launched the new platform after several months of beta-testing with hundreds of practitioners and their patients.

Comprehensive Practice Support

The new platform is designed to be much more than simply an online dispensary; it is a comprehensive practice support system that facilitates ongoing communication between practitioners and patients, Smith explained. This can increase patient adherence to treatment suggestions, potentially improving clinical outcomes.

It can be integrated with electronic health record systems, and offers a number of “one-to-many” care tools. Practitioners can also use it to disseminate automated wellness-oriented self-care content to patients.

System users get access to the Fullscript Knowledge Center , which compiles scientific content and commentary from leading holistic, functional, and integrative medicine practitioners.  There’s also a feature called Shareable Wellness Protocols, that enables practitioners to share specific treatment protocols, product instructions, and support messages to their entire patient database.

Fullscript has a fully-dedicated in-house support team to help practitioners implement and trouble-shoot the new system, which was developed with input from the company’s medical advisory board: Tieraona Low Dog, MD; Jeffrey Bland, PhD; Joseph Pizzorno, ND; Robin Berzin, MD; Cheng Ruan, MD; and Jeffrey Gladd, MD.

Founded in 2012, in Ottawa, Fullscript has was already experiencing rapid growth when the company merged with Natural Partners in 2018. The alliance brought together Fullscript’s technological strengths with NP’s distribution capacity and its long legacy as one of the mainstay distribution channels in the holistic and naturopathic world.

Since the COVID pandemic hit the US, Fullscript Natural Partners has experienced 20% to 30% growth in the number of new practitioners signing up each month, says Alex Keller, ND, Fullscript’s medical director, in a webinar hosted by the Council for Responsible Nutrition last July. The strongest growth has been among medical doctors and chiropractors.

Poised for Rapid Growth

That surge is strongly linked to the sudden embrace of telemedicine that has happened in the wake of COVID. “Prior to COVID only about 5% of our practitioners worked completely virtually,” Keller said reflecting on data from a survey of 500 Fullscript practitioners. “Now, 60% are exclusively working virtually.”

Fullscript currently has 75,000 registered practitioner accounts, and now serves close to 1.75 million patient accounts.

For the time being, the merged companies will maintain both the Fullscript and the Natural Partners brand identities, though they will both operate via the unified platform.

Eventually, though, the company will sunset the Natural Partners brand. “There’s no firm timeline yet on when that will be,” says Smith. “When the time does come we’ll give Natural Partners customers all the personalized support they need to use the improved experience on Fullscript.”

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Remote Patient Monitoring: From Luxury to Necessity

Patient self-assessment tools, along with remote consultation technologies, have evolved rapidly over the last decade. Until recently, they’ve been considered luxuries for highly motivated patients and future-forward clinicians.

In the post-COVID world, where many physicians have closed their clinics and patients are deferring all but the most essential in-person visits, telemedicine and remote monitoring are no longer luxuries, they’re necessities. And they will shape the future of clinical practice—especially in preventive medicine.

Here are a few home monitoring and self-assessment strategies that allow patients to take more active roles in their care, while providing practitioners with pertinent information to guide them along the way.  

Befriend Technology

The current situation is obliging all of us in medicine to befriend new technologies. I have found a few basic tracking devices particularly helpful. These gadgets are user-friendly and built for ease-of-use at home. They can accurately track various health measurements and are compatible with many different wireless and internet platforms. They make it easy for patients and their practitioners to view and manage health data together as a team.

Blood Pressure Monitor: Maintaining a healthy blood pressure is essential. I suggest using a device like the Omron wrist blood pressure monitor. It is lightweight and portable, allowing patients to track their blood pressure on the go. It stores the readings, and the app interfaces with the patients’ computers, so they can keep and share comprehensive records of their recordings. I personally find the wrist version less cumbersome than the arm version.

Digital Stethoscope: Digital stethoscopes such as Eko stethoscopes use Bluetooth to pair with smartphones and tablets through the Eko App. Clinicians can listen to, visualize, and share auscultations of the same quality as if they were listening directly to their patients’ hearts in person, through ordinary stethoscope earpieces. This foregoes the need for close doctor-patient contact. Wireless stethoscope technology makes telemedicine exams much easier.

Assessing Cardiovascular Function

Heart Rate Monitors: The Resting Heart Rate is the number of times the heart beats per minute when someone is at rest. A good time to check this is in the morning after a good night’s sleep. For most of us, the RHR is between 60 and 100 BPM. But this can be affected by factors like stress, anxiety, hormones, medication, and level of physically activity. Athletes and highly active people may have RHRs as low as 40 BPM. When it comes to RHR, lower is definitely better, because it means that the heart muscle is in better condition and doesn’t have to work as hard to maintain a steady beat. Studies show that a higher RHR is linked with lower overall fitness, higher blood pressure, and overweight.

The Peak Heart Rate is 85 to 100 percent of someone’s maximum heart rate. I like to strive for a resting pulse rate of 50 BPM or less while asleep, and not more than 100 BPM when active. 

Most of the current generation of smart phones come with the capacity to monitor both resting and peak heart rates. There are dozens of heart rate monitoring apps that make use of this built-in capacity to provide quick and easy analyses, no math required. I recommend looking for one that suits your patients’ needs. They are very useful.

Detecting Atrial Fibrillation (AFib): The irregular heartbeat patterns associated with AFib can lead to blood collecting in the heart, which can form stroke-causing clots. Tracking Afib at home is pure common sense. Just over two years ago, the FDA approved the AliveCor Heart Monitor— a smartphone app plus a special phone case with a set of sensors. Together they convert the phone into an EKG machine that patients can carry around in their pockets or purses. It allows you and your patient to see a simple version of the heart’s electrical activity in real time on the phone screen.

The system is very easy to use. A patient activates the app, places the index and middle fingers of each hand on the sensor pads, and records an EKG tracing.  In the latest version, called Kardia, the sensors just need to be near–not necessarily on– the phone.

Heart Rate Variability & Autonomic Nervous System Assessment: The effect of heart activity on brain function—and vice versa–has been researched extensively over the past 40 years. Early research mainly examined the effects of heart activity occurring on a very short time scale – over several consecutive heartbeats at maximum. Scientists at the HeartMath Institute have extended this research by looking at larger-scale patterns of interaction between the heart, the brain, and the nervous system.

Heart rate variability (HRV) is a measure of the beat-to-beat changes in heart rate. The normal variability in heart rate is due to the synergistic action of the two branches of the autonomic nervous system (ANS). The sympathetic nerves accelerate heart rate, while the parasympathetic (vagus) nerves slow it down. The sympathetic and parasympathetic branches of the ANS are continually interacting to maintain cardiovascular activity in its optimal range and to permit appropriate reactions to changing external and internal conditions.

With that in mind, analysis of HRV over the course of someone’s day therefore serves as a dynamic window into the balance of the autonomic nervous system. While this seems complicated, it can be tracked fairly easily via a set of user-friendly smartphone-based tools. I recommend looking at Heart Math’s devices & apps that patients can use to monitor their HRV and self-entrain healthier, more coherent, and balanced physiological states.

Remote Lung Assessment

Spirometry & Lung Function Assessment: For patients with asthma, and others in need of frequent and regular spirometric testing, the Aluna Spirometer is the perfect solution. It enables patients to measure their lung function at home, which is a great asset for those who’ve had COVID or who are at high-risk, as it can potentially eliminate clinic visits. 

The Aluna system consists of a special breath test device that links wirelessly to a smartphone, and an app for collecting the spirometry data. It calculates FEV1 instantly, and records, stores, and shares the readings. The app also has a medication utilization tracker, and a video game component—particularly well-suited to children and young patients—that explains what the readings mean and allows users to set lung function goals. 

Aluna gives doctors an online dashboard on which to monitor their patients’ spirometry data as it is being collected. Alternatively, patients can choose to share the results over the internet. Aluna can help doctors and patients work together to build a more precise, customized treatment plan that keeps patients engaged in their own self-care.

In addition to these helpful devices and smartphone systems, there are 5 low-tech self-assessments that I recommend that we all use routinely. You can find complete protocols for these simple self-assessments at https://www.perqueintegrativehealth.com/lifestyle/self-tests/.

Low-Tech Options

First Morning Urine pH: The first morning urine pH is a good indicator of the body’s mineral reserve and its acid/alkaline state. The body routinely uses overnight rest time to excrete excess acids. One’s capacity to do so varies based on toxin load, individual ability to inactivate toxins, and to excrete them. Using a pH test strip, this is a simple, inexpensive at-home test.  Maintaining a pH within 6.5- 7.5 is ideal, indicating that overall cellular pH is appropriately alkaline.  Cells in all tissues of the body function best in an alkaline state. 

Digestive Transit Time: The state of one’s digestive system affects all aspects of health. Measuring digestive transit time gives an idea of how long it takes for food to be digested and for waste to be eliminated. The ideal transit time is between 12-18 hours. Most people who eat the standard American diet have transit times of 36-96 hours, which is detrimental to overall health.

With the help of a few charcoal capsules, patients can easily and painlessly find out how well their digestive organs are doing their jobs. This can help guide decisions about the amount of fiber, probiotics, and other digestive support they need.

C Cleanse: This test uses buffered vitamin C (ascorbate)–the body’s universal antioxidant—to identify a person’s risk of oxidative stress and extent of antioxidant protection.

The process involves taking buffered ascorbate powder in increments of 15 minutes till there is a complete evacuation of the GI tract, or a flush/cleanse is achieved (watery stools). In people who are generally healthy and getting enough vitamin C, this “C cleanse” protocol will give a result of ≤4g. But it is not uncommon to see results of 50, 75 or even 100g, indicating that someone is very deficient in ascorbate. I recommend doing the C cleanse every week.

Wrist Skin Pinch Test: Drinking enough water each day is crucial for many reasons: to regulate electrolyte balance, support kidney function, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well-hydrated also improves sleep quality, cognition, and mood.

A simple self-test for hydration status that I like to recommend is called the wrist skin test:

– Gently pull up about ½ inch on the skin on the back of the wrist with the hand extended out (not flexed either up or down).

– On releasing the pinch, if the skin immediately flattens, it is a sign of well-hydrated tissues. However, if the skin maintains a little ‘tent’ i.e., stays pinched and then slowly goes back to normal over 5-10 seconds, it is usually a sign of significant dehydration

Urine Specific Gravity (SG): Urine specific gravity is another important measure of hydration and kidney health that can be used to assess the kidney’s ability to concentrate or dilute urine.  Ideally, urine SG measurements will fall between 1.002 and 1.030 if the kidneys are functioning normally. Numbers above 1.010 can indicate mild dehydration. The higher the number, the more dehydrated someone will likely be.

I like to use a refractometer for this test which projects light into the sample and helps determine the density of the urine.

There’s no question that the COVID pandemic has moved telemedicine and remote monitoring from the margins of healthcare into the mainstream. In many ways, this shift provides new opportunities for patient empowerment and practitioner emancipation.

Office visits will always have a prominent place in medical practice, but they need not be the default setting for everything.

Telemedicine is not the be-all, end-all solution to the problem of healthcare access—many people do not own smartphones or computers—but this technology can help many people improve their health and wellbeing in ways that are convenient and affordable. It opens exciting new possibilities for how we practice and experience healthcare—possibilities we are just beginning to explore.

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