Above the Fold

IVF ban shows us the thin edge of the theocratic wedge


In order to save the Republican party, we all need to vote Democratic this year.

Without hyperbole, Project 2025 feels similar to Germany in the early 1930’s. Their website introduction reads:

It is not enough for conservatives to win elections. If we are going to rescue the country from the grip of the radical Left, we need both a governing agenda and the right people in place, ready to carry this agenda out on Day One of the next conservative Administration.”

Alabama’s 73-year old Justice Tom Parker is clearly one of those “right people.” He did not flinch in his February 16, 2024 decision in “LePage v. Center for Reproductive Medicine.” Citing an 1872 Alabama state law that allows for individuals to sue over the “wrongful death of a minor,”  he confidently declared that 8-cell embryos cryopreserved in fertility clinics were people. He then added insult to injury. He tied  the decision to declaring that individuals responsible for the mistaken loss of the cells liable for damages to the state’s (Dobbs decision enabled) 2019 law banning abortion. A messy backlash against and for IVF soon followed.

Not content to be both lawyer and doctor, Parker added theologian to his credentials stating in his decision: “In summary, the theologically based view of the sanctity of life adopted by the People of Alabama encompasses the following: (1) God made every person in His image; (2) each person therefore has a value that far exceeds the ability of human beings to calculate; and (3) human life cannot be wrongfully destroyed without incurring the wrath of a holy God, who views the destruction of His image as an affront to Himself.”

Determined radicalized leaders, fueled with a religious fervor, long ago rejected the Founding Fathers commitment to separation of Church and State.

Consider the words of James Madison, in a speech to the House of Representatives in 1789: The civil rights of none, shall be abridged on account of religious belief or worship, nor shall any national religion be established, nor shall the full and equal rights of conscience be in any manner, or on any pretext infringed.”

As we now turn the corner on our way to a November election, it is important to acknowledge that the threat we face is larger than Trump alone. To not acknowledge the leaders of Project 2025 and beyond at this moment in our history would be equivalent to believing that WWII was only about Hitler, Mussolini, and Hirohito, when in fact the challenge was far greater than that.

Stated simply, the human species in the Axis societies had gone off the rails and channeled themselves into a death spiral. “Breaking the spell” required unprecedented force and ultimately the use of atomic bombs, followed by multi-decade investments through the Marshall Plan to reestablish civilized human societies.

It is for this reason that “limping to the finish line” is no longer an option for our nation. Project 2025, the Supreme Court’s recent Chevron decision, and the multi-pronged assault on women’s reproductive freedom all suggest that an overwhelming defeat of Republicans down ballot will be required to lay the ground for recovery of a healthy two-party Democracy.

Anything less will embolden an already captive Supreme Court and MAGA insurrectionists. A two-party system of Democracy has delivered reliable and peaceful transition of power for over two centuries until 2020. One of those parties has been usurped, placing our treasured Democracy at risk. The quickest way to reset a viable two-party system is to decisively defeat Trump and all MAGA down-ballot allies across the United States in November.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex (Grove/2020).

Vote, for Health Sake


If you had on your political bingo card that our former President Trump would survive an assassination attempt, or that President Biden would drop out of the race a few weeks before being renominated for 2024, then you’re playing a more advanced game than I was (on the other hand, the chances that Trump would get convicted of felonies or that Biden would have a bad debate almost seemed inevitable). If we thought 2020 was the most consequential election of our lifetimes, then fasten your seat belt, because 2024 is already proving to be a bumpier ride, with more shocks undoubtedly to come.

I don’t normally write about politics, but a recent report from the Commonwealth Fund serves as a reminder: it does matter who you vote for. It is literally a matter of life and death.

The report is the 2024 State Scorecard on Women’s Health and Reproductive Care. Long story short: “Women’s health is in a perilous place.” Lead author Sara Collins added: “Women’s health is in a very fragile place. Our health system is failing women of reproductive age, especially women of color and low-income women.”

The report’s findings are chilling:

Using the latest available data, the scorecard findings show significant disparities between states in reproductive care and women’s health, as well as deepening racial and ethnic gaps in health outcomes, with stark inequities in avoidable deaths and access to essential health services. The findings suggest these gaps could widen further, especially for women of color and those with low incomes in states with restricted access to comprehensive reproductive health care.

“We found a threefold difference across states with the highest rates of death concentrated in the southeastern states,” David Radley, Ph.D., MPH, the fund’s senior scientist of tracking health system performance, said in a news conference last week. “We also saw big differences across states in women’s ability to access care.”

Joseph R. Betancourt, M.D., Commonwealth Fund President, said: “Where you live matters to your health and healthcare. This is having a disproportionate effect on women of color and women with low incomes.” Dr. Jonas Swartz, assistant professor of obstetrics and gynecology at Duke Health in Durham, North Carolina agreed, telling NBC News: “Your zip code shouldn’t dictate your reproductive health destiny. But that is the reality.”

The study evaluated a variety of health outcomes, including all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence. To measure coverage, access, and affordability, it looked at insurance coverage, usual source of care, cost-related problems getting health care, and system capacity for reproductive health services.

There are, as you can imagine, charts galore.

The lowest performing states – and I doubt these will be a surprise to anyone — were Mississippi, Texas, Nevada, and Oklahoma. The highest rated states were Massachusetts, Vermont, and Rhode Island.

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Medicare Catheter Scam Sparks Calls for Reform


According to a recent report in the Washington Post, a $3 billion scam involving urinary catheters has brought to light serious flaws in Medicare, prompting strong calls for reform. Apparently, several companies have been accused of gaming the system by submitting fraudulent bills for millions of catheters using patient and doctor information. This isn’t the first time Medicare has faced such challenges; fraudsters often target the system, especially in cases involving unnecessary medical equipment. With a budget nearing $1 trillion, the agency has faced significant challenges in tackling fraudulent claims for durable medical equipment. Leaders at CMS have appealed to Congress for more resources to strengthen their efforts against potential scammers.

Healthcare providers and lawmakers are now pushing for tougher measures to crack down on these companies and improve fraud prevention efforts. The National Association of Accountable Care Organizations (ACOs) has praised CMS for taking steps to address suspicious billing practices related to catheters, underscoring the importance of policy changes to protect against future abuses.

“This is unlike anything we have seen before in terms of its size and scope,” said Clif Gaus from the National Association of Accountable Care Organizations, which played a crucial role in uncovering and drawing attention to the alleged fraud.

Several accountable care organizations (groups of hospitals and doctors) said they could each lose more than $1 million if the fraudulent billing issue isn’t fixed.

In a proposed rule released on Friday, CMS stated that an investigation is currently underway, and that initial steps have been taken in response.

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U.S. Executive Branch Leadership Turnover and Misbehavior Is Common


This has been two weeks of mixed messages when it comes to the highest offices of the land. Just two weeks ago on July 1, 2024, a majority of the  Supreme Court decided to expand Presidential immunity for criminal malfeasance while in the office that former President Trump had so severely tarnished on January 6, 2021.

The Supreme Court’s meddling occurred just three days after President Biden was forced to acknowledge that he had badly flubbed the First Presidential debate, which led to a series of recovery moves (the ABC Stephanopoulos interview on July 6; the live Press Conference in D.C. on July 11; and the full-energy “Don’t You Quit” rally in Detroit, Michigan on July 12) to try to prove he wasn’t too old or infirm to do the job.

In the meantime, Vice President Kamala Harris remained loyal and capable in the wings, while Trump went silent, cagily delaying his decision on his own running mate until he had greater clarity on who exactly he was running against.

And one day later, a 20-year old registered Republican, came within inches of successfully assassinating the former President with an automatic sniper rifle of the variety vigorously defended as just fine for civilian circulation by Republicans.

All of this might lead you to believe, when it comes to the top two positions in our Executive Branch of government, that we have entered unusual times. But, as history well illustrates, nothing could be farther from the truth.

In our brief history as a functioning Democracy, eight of our Presidents have died in office and one has resigned. Four sitting Presidents were killed by gunshot (Lincoln, Garfield, McKinley, JFK) and three have survived attempts on their lives (Reagan, Teddy Roosevelt, and now Donald Trump). As for their #2’s, seven VP’s have died in office and two have resigned in office. And that doesn’t even begin to cover the many cases where these top elected officials have managed to maintain their positions by hiding and covering-up a range of debilitating physical and mental illnesses while in office.

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Upgrading public health IT infrastructure: Craig Behm, CSS & Britteny Matero, Innsena

I had the chance earlier this week to talk with Craig Behm, CEO & President of Crisp Shared Services (CSS), and Britteny Matero, Partner & SVP at Innsena. The topic is the upgrading public health IT infrastructure which was exposed by the pandemic as a bit of a mess. CSS, Innsena and partners are one of four new centers set up with a $255m CDC grant to help public health departments upgrade their technology and get on the same page about reporting for all the good reasons we heard about in the pandemic. There are hundreds of public health departments running thousands of programs and they’ve been the ugly stepchild of health data. Craig and Britteny got in depth we me about what that looks like and how they’re going to change it! — Matthew Holt

Google Hopes Nobody Beats This Wiz


When I saw the Wall Street Journal article about Alphabet being in “advanced talks” to buy cybersecurity firm Wiz for an eye-popping $23b, I must confess that – never having previously heard of the company – my thoughts flashed back to the Seinfeld episode (“The Junk Mail”) where Elaine dates a man whose job turns out to be an outlandish mascot for electronics store The Wiz, whose motto he gleefully repeats: “Nobody beats The Wiz!”  That firm is long gone but this Wiz is alive and well, enough so that the acquisition would be Alphabet’s largest ever.

The Wiz was only founded in 2020, by four ex-Israeli military officers (they reportedly all originally worked together at Israel’s equivalent of the NSA). They had previously founded cloud cybersecurity firm Adallom in 2012, which they sold to Microsoft in 2015 for its Azure cloud computing firm. Wiz also specializes in cloud cybersecurity, and, according to WSJ, its clients include 40% of the Fortune 500 companies as customers, including Barclay’s, Mars, Morgan Stanley, and Slack. Other notable customers include BMW, DocuSign, EA, and Salesforce.

Pretty impressive for a four-year-old start-up.

Alphabet’s cloud business – Google Cloud Platform (GCP) — badly trails leaders AWS (Amazon) and Azure (Microsoft), although last year GCP’s revenue’s rose 26% and it recorded its first operating profit. It’s Q1 2024 revenue was up 28%. By the way, Wiz lists both AWS and Azure as partners, along with GCP, Oracle Cloud Infrastructure, VMware, and Alibaba Cloud. 

Alphabet had bought security company Mandiant two years ago for $5.4b, as well as Siemplify, another Israeli cloud cybersecurity company, that same year, and evidently sees these acquisition as a way to bolster its cloud business.

For some perspective, just this past May Wiz raised $1b in a funding round that gave it a $12b valuation. Its annual recurring revenues are estimated at $500 million, so Alphabet’s offer is a 46 multiplier. By contrast, WSJ notes that competitor CrowdStrike has a market capitalization that is 25 times annual recurring revenues. “This could be one of the largest and fastest returns ever for a private security company in tech history,” Alex Clayton, a general partner at Meritech Capital, told WSJ.

“There are two advantages of Google acquiring Wiz,” Ray Wang, principal analyst and founder of Constellation Research, told CSO. “One, cloud security is hot and allows Google to cut into AWS and Azure clients, and two, having Wiz would give them some consistently large workloads to monetize.”

If you’re wondering why cloud security is hot, I need only mention AT&T, which recently disclosed that the records of “nearly all” of its cellular customers had been breached. Well, those records came from its cloud provider Snowflake — and that was not the first time Snowflake has been attacked and possibly breached. Azure has also suffered some serious breaches, and has been accused of “repeated pattern of negligent cybersecurity practices.” AWS has had its share of data breaches as well.

So, yeah, a cloud service better have good cybersecurity.

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Digital Health: There is No Exit


All of a sudden we are back in 2021.

You digital health fans remember that halcyon time. In 2019 a few digital health companies went public, and then somehow got conflated in the pandemic meme stock boom, with the harbinger event being the August 2020 sale of Livongo to Teladoc that valued it at $19bn and early in 2021 rather more, as Teladoc itself got to a market cap of $44bn in February 2021

Venture money poured into digital health as a fin de siecle for the ZIRP, that had been going for a decade, combined with the idea that Covid meant we would never leave our houses. The vaccine that became generally available at the start of the Biden Administration in 2021 put paid to the idea that telehealth was the majority of the future of care delivery.

Nonetheless between mid 2021 and early 2022 Jess DaMassa and I were reporting on VC funding in a show called Health in 2 Point 00 (later Health Tech Deals) and every week there were several deals for $100m and up going into new health tech companies.

Things don’t look so pretty now. Even while venture money was flooding into digital health, those public companies, as exemplified by Teladoc, started to see their stock price fall. While it was actually a good year for the stock market overall, in 2021 the digital health sector fell by around 60%. It kept going down. 2022 was worse and although one or two individual companies have recovered (Hi Oscar!), nearly two years later the market cap of the entire sector remains in the toilet.

Of the list that I’ve been following for years there’s only 11 broadly defined digital health companies with a market cap of more than $1 billion–that is only 11 public unicorns

What’s worse is that only one company on that list is decently profitable, and that’s Doximity. It made over $170m profit on revenue of less than $500m last year and trades at 10 x revenue. But Doximity always was profitable, going way back to 2014 (long before its IPO), and although it’s doing cool stuff with AI and telehealth, it’s basically an advertising platform for pharma.

There is no such thing as a profitable public digital health company in the mainstream of care delivery or even insurance–unless of course you count Optum. Which means there’s almost certainly no profitable VC-backed private company either.

Which leads me to this month. You remember those huge rounds that Jess & I used to report on and make fun of? They’re back.

I get it. The stock market is hot and all those pension funds are trying to put their winnings from Nvidia somewhere. VC looks a reasonable bet and there have been a few tech IPOs. If you squint really hard, as STAT’s Mario Aguilar did, you can pretend that Waystar & Tempus are health tech IPOs, although a payments/RCM company and a diagnostics company which are both losing a ton of money wouldn’t give me confidence as an investor.

But the amounts being thrown around must give anyone pause. Let’s take a few examples from the last month. Now these aren’t a knock on these companies, which I’m sure are doing great work, but let’s look at the math.

Digital front door chatbot K-Health raised at a $900m valuation. This round was a $50m top-up but it has raised nearly $400m. It says it’ll be profitable in 2025, and has Elevance as its biggest client. Harmonycares is a housecall medical group, presumably pursuing the strategy that Signify and others followed. It raised $200m, so presumably has a $500m+ valuation–Centene bought an earlier version of the company for $200m a decade ago and sold it to some investors two years back. Headway is a mental health provider network that uses tools to get providers on their system and markets them to insurers. It raised $200m at a reported $2.3bn valuation.

You can look at that list of public companies, including ones taken private like Sharecare, and see that there are lots of telehealth chatbots, medical groups and mental health companies on the list. Any of which probably have similar technology buried inside them. I’m sure if you shook Sharecare hard enough all those technologies would fall out given the number of companies it acquired over its decade plus of expansion.

But let’s take mental health.

Amwell acquired a mental health company called Silvercloud, and a chatbot called Conversa. Its market cap is bouncing around between $250m & $350m and it has more than that in cash–which means the company itself is worth nothing! The VCs who put money into K-Health and Headway could literally could have bought Amwell for about what they invested for a fraction of those companies. Is Headway is doing more than the $250m a year in revenue Amwell is putting up? Headway’s value is nearly 6 x the value of Talkspace which is bringing in about $150m a year in revenue. And if you consider BetterHelp to be 50% of Teladoc — which it roughly is — Headway is 3 x the value of BetterHelp which is doing $1bn a year in revenue. Is there any chance that Headway is doing close to those numbers? Maybe somone who saw the latest pitch deck can let me know, but I highly doubt it.

Now of course these new investments could be creating new technology or new business models which the previous generation of digital health companies couldn’t figure out. They might also have figured out how to grow profitably–although as far as I know Doximity stands alone as a profitable company that took VC funding it never needed and never used.

But isn’t it more likely that they are in the market competing with the public companies and those private companies that got funding in 2020-22, have similar pitches, similar tech and are similarly losing money?

I am a long time proponent of digital health and really hope that technology can change the sclerotic health care sector. I want all these companies to do well and change the world. Maybe those VCs investing in those mega rounds are more sensible than they were in 2022. But given the state of the digital health sector on the current stock market–which is otherwise at all time highs–I just don’t know what the exit can be, and it pains me to say it.

Pamela Stahl, Avalon Healthcare Solutions

Pamela Stahl is the President of Avalon Healthcare Solutions. You’ve heard of pharmacy benefits managers (PBMs) but Avalon is a labs benefits management company. Working on behalf of health insurers Avalon ensures that patients are getting the right labs at the right price, . Why are they needed? There are 14 billion lab tests and they drive a lot of health care decisions (70%+!). As you might guess there’s a ton of variation in test price, lots of test are ordered in error, many are repeated, and many are unnecessary. Avalon’s job is to figure that all out!–Matthew Holt 

Health Care Needs a 21st Century Infrastructure


Matthew Holt is going to tell me I’ve been thinking about infrastructure too much lately (e.g., cybersecurity of them, backup plans for them), but if you don’t have infrastructure right, you don’t have anything right.

And healthcare most definitely does not have its infrastructure right.

We’re spending between 15-30% of our healthcare dollar on administration, and no one views our healthcare system as efficient or even particularly effective. We have numerous intermediaries like PBMs, billing services, revenue cycle management vendors, and all sorts of digital health solutions. There are layers upon layers upon layers, each adding its costs and complications.

In some ways, healthcare’s infrastructure has changed remarkably in the last two to three decades. Most transactions – e.g., claims or eligibility – are sent, and often processed, electronically. Most physicians, hospitals, and other health care clinicians/organizations have electronic health records. You can find out the expected cost for prescription drugs at point-of-sale. You can do a virtual visit with your doctor. There are vast amounts of health information available online. AI is coming to health care, and, in some cases, is already here.

But: we’re still sending faxes. We’re still filling out paper forms, repeatedly. We still make innumerable phone calls, usually spending long waits in queue. Everyone hates provider directories, which are never up-to-date and often inaccurate. Talk of interoperability notwithstanding, there are far too many data silos, leading to at best us lugging around disks with our downloaded records to at worst physicians acting with incomplete information for us. Healthcare has had far too many data breaches, and cyberattacks have held patient data hostage (e.g., Ascension) or put a halt to those electronic transaction (e.g., Change Healthcare). And we’re not at all sure how to govern AI.

The amount of medical literature has been growing exponentially for decades, and the volume of health care data is growing much, much faster. Physicians once guarded health information like the guild they are, but the Internet has democratized health information – while doing the same for misinformation. If anything, we have too much information; we just can’t use it as effectively as we should (e.g., it can take 17 years for evidence to change physician practice).

This is not an infrastructure that is not coping well with the 21st century.

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Don’t Limp. Crush the “Trump Reich.”


I have always felt a kinship with EJ Dionne. We are both Boomers, though I am 4 years his senior. We share similar politics, religious origins, early Catholic school educations, fathers in health care and mothers who were teachers, deep New England roots, addiction to the written word, blessings with long marriages and children (they 3, we 4), and deep revulsion with Trump and his enablers and everything they represent.

Viewing him as measured and wise, I took special care in reading his Washington Post column yesterday, “The words about Joe Biden I never wanted to write.”

For twelve days since that first debate, I have worked to remain officially neutral on “what next to do,” and stayed focused on how to ensure a decisive (message-sending) defeat not only of Trump but Republicans up and down the ticket, so that there is no confusion that the whole cabal – Project 2025, Leonard Leo et al, the  Supreme Court’s “Doomed Crusade”, Bannon-led MAGA insurrectionists – is sufficiently devastated that it cannot remerge from the cinders.

There is no doubt that Biden’s physical and mental decline was on full view for over 50 million Americans two weeks ago. And you don’t have to be a medical historian or a prize winning journalist to recognize that the degenerative processes that are responsible for his decline are progressive (albeit possibly slowly progressive). That is to say, his decline will continue, as predictably as did Ronald Reagan’s.

But as E.J. makes clear in his opinion piece this week, “Biden’s capacity to do a ‘good job’ is not ‘what this is about.’ Donald Trump’s threat to democracy is the overriding question before the country…”

While Dionne is right that this is not “about Biden,” he understates the problem when he suggests instead that it is about Trump alone. That is no more true than to suggest that WWII was only about Hitler, Mussolini, and Hirohito, when in fact the challenge was far greater than that.

Stated simply, the human species in the Axis societies had gone off the rails, and channeled themselves into a death spiral. “Breaking the spell” required unprecedented force and ultimately the use of atomic bombs, followed by multi-decade investments through the Marshall Plan to reestablish civilized human societies.

President Biden limping to the finish line and repeating slight margin victories in seven swing states will not solve America’s current problem. We are too far along. As with Hitler’s Germany in the 30’s, the enemy’s course trajectory is by now visible for all to see, and it will achieve its’ Project 2025 goals and objectives if allowed. These determined radicalized leaders are more than halfway there, fueled with a religious fervor that cannot be modified by honest debate or calm logic.

Success breeds success as well for evil as for good. So far, with Biden still in power, political arsonists have achieved an immune Executive branch; a biased Judiciary with no Code of Ethics; a House of Representatives directed from Mar-a-Lago; and 14 state houses with absolute control over their citizens reproductive rights.

Clearly the problem is bigger than Trump. Project 2025’s declaration leaves little room for confusion. It states: “It is not enough for conservatives to win elections. If we are going to rescue the country from the grip of the radical Left, we need both a governing agenda and the right people in place, ready to carry this agenda out on Day One of the next conservative Administration.”

There will be no Pearl Harbor to wake us from our sleep, or galvanize our clear majorities that know in their hearts that something has gone very, very wrong. That Presidential debate was our final warning.  Time’s up. As Sen. Chris Murphy (D-Conn.) said this weekend “This is a really critical week. I do think the clock is ticking.”

What then is the formula for an overwhelming defeat of the Trump Reich? Three pillars: Energy, Enthusiasm, Women-Led.

Mike Magee MD is a Medical Historian and regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex (Grove/2020)