By 2014, half of low-income adults in the U.S. owned a smartphone and about 84% of adults in low-income households had mobile phones. Photo credit: Highways England/Creative Commons

There’s enormous potential for digital health technology to improve the care and health of safety-net patient populations, and not just affluent early adopters, according to the findings of a new report.

The key is understanding the needs of this audience, said Jane Sarasohn-Kahn, a health economist and author of the California Health Care Foundation report.

“What’s surprising is the arrogance of developers—this overlooking of cultural relevance and individual market segmentation,” said Sarasohn-Kahn. “Health insurers are getting better at it but digital developers, not so much. It’s really thinking about what is required.”

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Wearable technology, for example, is an area that is relegated to the affluent, she noted. Developers looking to develop the next Fitbit often overlook the needs of the underserved such as the homeless, those who don’t speak English as a first language, the elderly, those who earn less than $30,000 per year and rely on Medicaid, as well as those who earn a little too much money to enroll in Medicaid but are still struggling financially.

Healthcare costs are currently under scrutiny in the U.S., driven by a range of factors including the increasing number of Americans with health insurance as well as higher rates of cost-sharing, new federal incentives for healthcare providers to keep people out of the ER and the hospital, and a higher number of patients dealing with multiple chronic diseases. At the same time, the cost of new technology is rapidly decreasing, which has created opportunities for developers.


According to the report, non-elderly Medicaid patients use emergency departments at higher rates than non-elderly privately insured patients. Photo credit: Can Pac Swire/Creative Commons

Some 90 million Americans have multiple chronic conditions and a large portion of that population have incomes below $30,000, according to the report’s findings.

“Each additional chronic disease increases a person’s risk of adverse drug events, higher out-of-pocket expenses, impaired functional status, hospitalization, and mortality,” Sarasohn-Kahn wrote in the report. “Two-thirds of health spending is associated with patients managing [multiple chronic conditions].”

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Those patients with low incomes are less likely to have a regular physician and often rely heavily on emergency departments. In addition, they are often socially isolated and harder to reach, lack stable housing, transportation, work schedule flexibility, consistent Wi-Fi access, and language ability.


Despite these issues, the use of digital technologies such as mobile phones is increasingly prevalent among low-income consumers as the technology has become more accessible and affordable. By 2014, half of low-income adults in the U.S. owned a smartphone and about 84% of adults in low-income households had mobile phones.

The report points to a 2014 global survey of healthcare leaders in the public and private sectors that revealed that reaching safety-net populations was the most promising role for mobile phone technology. Similarly, a 2015 Commonwealth Fund survey of 200 urban and rural health center leaders found that providers want to “more effectively engage patients for a range of purposes,” including chronic disease management, preventive care like screenings and immunizations, and wellness activities such as nutrition and physical activity.

“The bad news is that too many people don’t have a data plan to support the use of a phone,” said Sarasohn-Kahn. “But they can text and call.”


Polyglot Systems’ Meducation translates medication and discharge instructions into 18 languages.

The report identified a range of digital health products that are currently serving safety-net populations and categorized them according to their most effective features: uses texting; customizes language and communication style; delivers health information via portals and kiosks; delivers health information via video, telephone, or cable (telehealth); combines medical and social services; leverages a trusted human being; and collects data passively.

“Texting is universal and inexpensive,” said Sarasohn-Kahn.

Montefiore Medical Center, a hospital in New York City, uses customized text messaging developed by digital health communications company Sense Health. The customized text messages increased appointment adherence by 40% and medication adherence by 12%. Another healthcare messaging platform, HealthCrowd, found texting the most cost-effective way to connect with Medicaid members. The company saw a 30-times ROI for text messaging, which costs less than $1, versus direct postal mail, which costs at least $34.59.

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“It’s extremely cost effective, it’s not sexy,” said Sarasohn-Kahn. “But if we scale it, it’s really sexy because we can impact medical adherence and health outcomes.”

Other solutions include KP HealthConnect, telemedicine company Direct Dermatology, community resource platform Healthify, asthma tracking company Propeller Health, and Polyglot Systems’ Meducation, which translates medication and discharge instructions into 18 languages and provides visual instructions through pictograms and graphics.

Susan Perry, CEO of enhanced VOICE application maker Taylannas, told Sarasohn-Kahn a cautionary tale about a Spanish-speaking elderly patient in Florida.

“The word ‘once’ was written on her prescription,” said Sarasohn-Kahn. “Does it mean one time or eleven times a day? [Ed note: ‘Once’ means eleven in Spanish.] That is the light bulb moment when we realize in this field that we want to gain traction in digital health. We have to put ourselves in the shoes of the user.”

However, one of the drawbacks is that current payment models for the most part do not cover the costs of digital tools like these. The report argues that the sooner Medicaid and other health plans engage in value-based care, the sooner these patients can have access to these kinds of new technologies.


UberHealth provides transportation for registered nurses who deliver free flu shots to people in 35 U.S. cities who purchase a $10 “wellness pack.”

Taxi companies such as Lyft and Uber are also joining in. In January 2016, Lyft partnered with the National Medtrans Network and started offering patients 65 years old or older rides for non-emergency and medical appointments in New York City.

Uber works with MedStar Health, a health system, to allow patients to schedule rides to one of ten MedStar hospitals or hundreds of outpatient locations in the Baltimore and Washington D.C. region. The company launched UberHealth in 2015 to provide transportation for registered nurses who deliver free flu shots to people in 35 U.S. cities who purchase a $10 “wellness pack.”

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Pharma companies can be the real heroes if they can help reduce costs and keep people out of the expensive emergency department, said Sarasohn-Kahn. Drugmakers “ can think about the self-care aspects of the person at home and work, so people can stay well and out of the healthcare system,” she said. “That’s the real value.”