Can we improve health equity with a double bottom line approach?

As an industry, we are good at admiring the problems of health disparities but have been unsuccessful at addressing them. The horror of the disproportionate burden of COVID-19 on underrepresented communities coupled with the power of the Black Lives Matter movement gave many of us hope that we may finally have the momentum for substantial and lasting change.

As it turns out, hope is not a strategy.

Last year we saw another epidemic sweep across the US with disparate impact, a decades-long wait for action to address racial disparities in pulse oximeter performance. Combine this with the unsurprising finding that value-based payments in healthcare do not improve health equity and we can see that little has changed. Again.

It’s time to stop simply admiring the problem of health disparities. We must deliver a strategy that goes beyond 'hope.'

The digitisation of healthcare presents a fleeting opportunity to move away from a system designed to treat the sick and towards one that is defined by each individual’s health. Successfully harnessing this opportunity requires that we don’t simply improve the way we care for people with great insurance, the ability to self-pay or using the best apps at guzzling data on their expensive smartphones.

Healthcare is in crisis and transformation is needed.

When used appropriately, digital tools can move care beyond the walls of the clinic, making it easier to access care regardless of place and removing many of the barriers, such as the cost of time off work, childcare and transportation. Digital tools can help overcome the mal-distribution of specialist practitioners and the patients who need them the most. With more and better health data, people, patients and communities can take greater control over their health and live healthier lives.

Digital tools also give us the ability to measure health in unprecedented ways. They offer the possibility of detecting illness before it becomes complex and expensive, for example. But to fulfil this promise, digital tools must be built with intention and work for everyone.

Historically, innovation in healthcare has done little to advance health equity. However, pockets of success at the intersection of technology innovation and health equity offer a strategy ripe for success in healthcare where funds abound, but margins are slim.

Innovators and investors have used a double bottom-line approach, measuring profits alongside social impact to quantify the value to power the success of enterprise technology. It’s time we take this approach in healthcare, combining the financial incentives of this $10 trillion global industry with the ethical obligations of our field to care for all people. We must deliver a strategy to translate the unchecked virtue signalling around inclusion in healthcare into tangible incentives for progress.

Innovation in healthcare is hard. Margins are slim. For digital products, the investment required to successfully bring solutions to market for patients outstrips traditional technology funding rounds and timelines. This makes it critical for digital products to capture the greatest market value, both in the domestic US market and globally.

The Digital Health Measurement Collaborative Community (DATAcc) – an FDA strategic priority hosted by the Digital Medicine Society (DiMe) – developed an open-access Market Opportunity Calculator to help users quantify inclusivity in digital health product design.

Let’s consider heart disease, the leading cause of death for people of most racial and ethnic groups but more common among African American people than other racial groups. If a company was developing a digital tool for monitoring heart health with a unit price of $150 ( the actual price of Karida Mobile’s EKG monitor) and doubled the target users among the African American community in its product development and commercial strategy, the potential market size increases by $1 billion, from $1.4 billion to $2.4 billion.

The Market Opportunity Calculator is based on data on the benefits of inclusive product design drawn from over 100 sources and was developed with input from colleagues at Harvard Business School. It allows users to contemplate the financial benefits associated with the intentional inclusion of all potential users of new digital products in other conditions, including hypertension, diabetes, arthritis, stroke and generally poor health. Inclusion vectors that a user can explore include race and ethnicity, age, education, household income and disability status.

Across the board, this tool demonstrates the potential for an inclusive approach to digital health innovation to drive financial gain. This gain may now be amplified further in light of the FDA Draft Guidance, which is proposing updates to the Breakthrough Devices Program Guidance with the goal of reducing disparities in health and healthcare. Digital products that address health disparities have a new potential pathway to gain market access sooner.

This is the double bottom line in action and this is what’s required for the digitisation of healthcare to address health disparities in the US and other countries in the global north, where every other strategy has failed.

Bill Gates recently highlighted the opportunity for the digitisation of healthcare and, in particular, the use of artificial intelligence to transform global health. By addressing the mal-distribution of healthcare workers and the patients who need them and by identifying early symptoms of disease before they become catastrophic – both clinically and financially – digital health offers huge potential to improve lives, even beyond the high-resourced settings that have accounted for the majority of digital health investment.

This opportunity was identified last year by the Digital Health Action Alliance, a rapidly growing network of 50+ organizations from health and healthcare, technology, finance, employers, academia, civil society and governments that I’m proud to be a part of. Together, we have been working to harness the power of digital health to combat rising rates of non-communicable diseases across the world and, in particular, cardiometabolic diseases, which remain the leading causes of death globally, with a burden that is increasingly shifting towards low- and middle-income countries as risk factors such as air pollution, inactivity and unhealthy diets become more prevalent.

Digital health offers the possibility of stopping this shifting burden in its tracks. The risk factors, behavioural changes and treatment regimes for cardiometabolic diseases are well-understood, yet much of the world lacks access to the solutions necessary to reduce premature death. By pursuing this global market, digital innovators open the door to substantial new revenue streams. They simultaneously help reduce global health inequity alongside associated secondary inequities, such as caregiver burden and earning potential. Truly the double bottom line in action.

Much has been made of the digitisation of healthcare, with proponents touting the healthcare utopia of improved outcomes, coupled with dramatically reduced costs.

The reality is that there is no silver bullet solution to the challenges facing today’s healthcare system and our nation’s health crisis. But the data-driven, connected and accessible system that the digitisation of healthcare can deliver promises a different type of care experience. One that uses data to intervene before people’s health deteriorates too far; one that meets patients where they are to provide the care they need when they need it; one that allows clinicians to spend their days caring for people, not acting as glorified data entry clerks.

Hope is not a strategy, but the pursuit of the double bottom line is.

Innovators, investors and consumers of digital solutions have a shared responsibility to insist upon an inclusive approach to digital health innovation. And they should expect this approach to drive improved financial performance, as well as improved health for all of the patients our industry is intended to serve.