Earlier this month, Forbes contributor David Shaywitz asked a necessary question: Are Medical Product Companies Finally Serious About Business Model Evolution? This was in response to medical-device giant Medtronic MDT -0.39%s (NYSE:MDT) friendly acquisition of Cardiocom, a patient-monitoring firm. CEO Omar Ishraks comments at last Thursdays annual meeting suggest that the answer to Mr. Shaywitz question is yes. In his remarks, Mr. Ishrak noted that the U.S. is wisely moving to a fee-per-value approach which incentivizes value over volume and outcomes over inputs.
The $200 million acquisition (small change for a company with $2.46 billion cash on hand) brings Medtronic downstream into a rapidly strengthening link in the value chain: Wireless patient monitoring. Earlier this month, the Food and Drug Administration (FDA) released guidance on the the employment of radio frequency wireless technology in medical devices, giving investors and developers some confidence that the regulator will welcome their inventions.
Were all familiar with the Ive fallen and I cant get up medical-alert systems that are constantly being pushed to the elderly. While these systems have their advantages, most of the buzz around new health information technology seems to concentrate within two areas where the health benefits to society are obscure.
First, wellness apps, such as those manufactured by Fitbit, are certainly exciting and valued by those who use them. However, those users are generally healthy (if not super-athletic) rather than sick. So, we are unlikely to see such apps contribute to bending the curve of health spending. Second, there has been a rapid uptake of electronic health records by providers. However, it is not clear that these EHRs provide any benefit, and may be increasing costs. This may not be the fault of the EHRs themselves. Current adoption of EHR is driven by perverse incentives: The federal government pays doctors to install them, and will begin penalizing those who do not in 2015.
Passive, remote monitoring is far less ambiguous. It requires neither the patient nor the medical provider to do anything. The implanted device sends signals into the cloud that will be used by providers to intervene if necessary, and be compiled in databases that will be used for research. An example would be an artificial knee that measures its range of motion when the patient walks, sending a stream of motion-capture data for analysis. If the range of motion is too narrow or inconsistent, the patient can be called in to have the implant inspected.
Theres a gee whiz element to this thats inescapable. But theres a business case for it, too. As Mr. Ishrak noted, U.S. health care is moving away from paying providers fee-for-service and towards paying them for episodes of care. Medicare will hold hospitals financially accountable for discharged patients for a period after they leave the hospital. Already, hospitals are penalized for re-admissions, and the financial incentives are becoming more complex. So, device makers have to show hospitals that their implants will not result in more costly care after discharge. (Whether Medicare is competent to carry out these changes is another question entirely. Its simply a fact that they are occurring.)
Another threat to device makers traditional sales model is the Sunshine Act, which will will require disclosure of device makers payments to physicians. This is a blow to device makers time-worn strategy of cultivating loyalty by engaging surgeons to train their colleagues so that they develop a preference for one manufacturers implant over competitors. Most of these payments will be publicized, making this strategy more challenging.
Finally, hospitals have been rapidly acquiring physicians practices. It looks like this is increasing costs. However, the increased margins are surely being captured by the hospitals, not their suppliers. As surgeons lose their ability to demand that hospitals stock their preferred devices, hospitals will win greater leverage over device makers.
So, Medtronics acquisition of Cardiocom allows the device maker to become a solutions provider instead of a cost center to hospitals. However, other participants might not see it that way.
Even if it is clear that wireless technology allows good post-surgical patient management, it is far from clear that medical-device makers should own wireless-device makers. This is not how other industries are structured. For example, automobile manufacturers do not own the remote monitoring devices that auto insurers encourage drivers to install in their vehicles. These monitors allow the insurers to observe how drivers are driving, so the insurers pay independent manufacturers for them. Similarly, manufacturers of home-security systems are not owned by home-builders.
If vertical integration is the best way to ensure appropriate uptake of this emerging technology, it might make better sense for remote patient-monitoring firms to be consolidated by larger wireless companies. In this worldview, Qualcomm QCOM +0.17% (QCOM:NASDAQ), not Medtronic, would be a better buyer of a firm like Cardiocom. Alternatively, providers further downstream than medical device makers might also be better buyers. For example, Allscripts (NASDAQ:MDRX), a pharmacy-benefit manager, has made great strides developing its EHR, employing open architecture so that third-party developers can build on its platform. Its not hard to imagine remote monitoring of medical devices being bundled together with remote monitoring of patients adherence to their pills.
And thats before we anticipate the reactions of other interested parties. Who owns the data? If I were an health insurer or hospital, I would not want a patient-monitoring service owned by a device-maker. Instead, I would want a neutral patient-monitoring service that aggregated data from all my patients. The Mayo Clinic, for example, has collaborated with an independent technology vendor to develop a wireless cardiac monitor. Medtronics big competitors include Abbott (NYSE:ABT), Boston Scientific (NYSE:BSX), and Johnson and Johnson (NYSE:JNJ), and there are man smaller implant manufacturers. Are we to expect insurers and hospitals to juggle proprietary datastreams from each device makers captive wireless service?
As the deal proceeds, Medtronic may claim that it will not interfere with Cardiocom, and that the subsidiary will be open to all datastreams from all devices. But this would devalue the acquisitions proprietary value to Medtronic. Nor would the market likely trust such claims. Recall Mercks (NYSE:MRK) ownership of Medo, a pharmacy benefits manager. Many doubted that Medco could be neutral between drugmakers as long as it was owned by one, so was spun off and eventually acquired by Express Scripts (NASDAQ:ESRX).
It will take a while before we see how remote, wireless monitoring of implanted devices will be integrated into the value chain. Meanwhile, it is good to see at least one device maker recognize that the old system of focusing almost exclusively on the surgeon as customer is giving way, and that the firm is preparing for a future where suppliers will be held accountable for reducing total cost of care.
|John R. Graham is a Senior Fellow at the Independent Institute.|