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Sleep: Watch This Space

By MIKE MAGEE

In case you’ve missed it, sleep is all the rage in neurosciences these days. They are fast at work rebranding it “the brain’s rinse cycle.”  The brain, protectively encased in an unyielding bony casing, lacks the delicate lymphatic system that transports used body metabolites to breakdown and extraction sites in all other parts of the body.

But in 2012, neuroscientist Maiken Nedergaard, identified a unique network of delicate channels (“tiny passages alongside blood vessels”) inside the brain that collect and discharge brain metabolites and waste materials including amyloid. This system, or “ultimate brainwasher” as some labeled it, was formally titled the glymphatic system.

That same study also suggested that flow through the glymphatic system is enhanced during portions of the sleep cycle. Now 12 years after the original research, the same team, in a study in mice published in the Proceedings of the National Academy of Sciences USA journal, found that regular contractions or oscillations of tiny blood vessels in the brain, stimulated by adrenaline cousin, norepinephrine, generated the brain scrubbing liquid flow through the channel system. The focal contractions, normally occurring ever 50 seconds, speed up the pump to every 10 seconds, in sync with peaks of norepinephrine release during sleep.

Sleep deprivation appears to not only interrupt this cycle, and allow harmful wastes to accumulate, but also disrupts other mental health functions that scientists are just beginning to understand. For example, researchers in 2021 established that “sleep deprivation impairs people’s ability to suppress unwanted thoughts.” They were able to identify a special location on the brain cortex responsible for storing away memories, and  suppressing and delaying their future retrieval. They further demonstrated enhanced activity at the site during REM sleep. As the lead investigator noted, “That’s interesting because many disorders associated with debilitating intrusive thoughts, such as depression and PTSD, are also associated with disturbances in REM.”

The new work may help explain destructive recycling of historic conflicts among and between Silicon Valley AI uber-competitors. They may not be getting enough sleep, recycling historic grudges and grievances.

As the sleep scientists reported in the December, 2024 publication, “The functional impairments arising from sleep deprivation are linked to a behavioral deficit in the ability to downregulate unwanted memories, and coincide with a deterioration of deliberate patterns of self-generated thought. We conclude that sleep deprivation gives rise to intrusive memories via the disruption of neural circuits governing mnemonic inhibitory control, which may rely on REM sleep.”

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)

Why Financial Incentives Oppose Quality Improvement Projects in Healthcare

By TAYLOR J. CHRISTENSEN

When I attended the Institute for Healthcare Improvement’s 2024 annual forum in Orlando, Florida, one of the best parts of the conference, as always, was talking to the other attendees. Every time I would sit down to eat a meal or sit down in a session, I would talk to the people around me. And I heard about so many different quality improvement (QI) projects!

After several conversations, I started to notice a pattern: Many of the projects were fighting an uphill battle because they were going against financial incentives. Or, at a minimum, they were not supported by financial incentives. All of this got me thinking about a new exhaustive, mutually exclusive categorization . . .

All QI projects can be divided into three categories:

Category 1: Supported by financial incentives

Category 2: Neutral to financial incentives

Category 3: Opposed by financial incentives

Determining which category a potential project will fall into is important for predicting how much support from hospital leadership a QI project will have.

So how do you determine which category a potential project is in?

Remember that seeking profit (or “surplus” if you’re a non-profit organization) is what drives most behavior in all organizations, even in healthcare. And whatever is profitable is what organizations have a financial incentive to do. Here’s a simple formula for profit:

Profit = Revenues – Costs

In most industries, providing a higher-value product or service (Value = Quality / Price) compared to competitors will earn that organization greater market power, which they can use to extract greater profits either by keeping prices the same and winning more market share or increasing prices while maintaining the same market share. Either way, that greater market power turns into greater profit.

In healthcare, however, higher value does not lead to greater market power. The reasons for this have been explained elsewhere, but it really comes down to patients not making value-sensitive decisions when they are choosing where they will receive care.

Thus, quality improvement efforts that result in a healthcare provider delivering higher-value care are not automatically financially incentivized. Instead, the only factor that matters from a financial incentives standpoint is whether the QI project increases revenue or decreases costs.

So, if a project will increase revenue and/or decrease costs, it’s in Category 1; if it will not have any net impact on profit because either it doesn’t change revenues or costs or it increases or decreases both of them equally, then it’s in Category 2; and if it increases costs or decreases revenues, it’s in Category 3.

This all probably seems heartless–we’re talking about quality improvements that can save lives and quality of life here, and all I’m focusing on is money?

Continue reading…

Ain’t no shame in the heart of VC

By MATTHEW HOLT

It’s JPM week. That means a ton of startup bros wandering around San Francisco wondering who all the biotech guys and investment banker greyhairs are and why they’re still wearing suits.

Unlikely to be wearing suits are the digital health kids and the VCs they are trying to hunt down. The glory days are long gone. Athenahealth and Venrock are no longer having competing parties (or parties at all) and most of the starving startup kids looking for free booze and food are trying to scrounge invites to law firms who are still charging $1500 an hour for associate time before their clients notice that ChatGPT will do the same for $20 a month.

But venture in digital health continues on, even if much of it is subtexting cramdown M&A, such as last week’s General Catalyst deal funding Transcarent’s takeover of Accolade. But I’m not really here to talk about the digital health VC market per se. 

What I do want to talk about is who is getting VC. This was prompted (to my slow Small Language Model) by a female friend who has been a CEO and was once a star at a fast growing digital health company. She told me that being female was now an active hindrance to raising money. Every time some tech bro on LinkedIn says how they raised $XXm in 12 minutes with no pitch deck, you’ll see lots of female CEOs explode in anger.

You don’t need me to repeat the numbers. Women & minorities find it hard to raise money. First time founders get a massive run around. Even when things were crazy in 2020-2022 the survey of startups I ran showed that it was very hard for early stage companies to raise money. Now it’s the apocalypse.

That’s not to say some female CEOs aren’t raising. Just last week Nema Health run by former Health 2.0 star intern (and now practicing Psychiatrist–which may be more relevant!) Sofia Noori raised $14m Series A to expand its amazing PTSD cure program. Maven’s Kate Ryder raised another $125m late last year to keep expanding their women’s health program, and must be viewing that elusive IPO sooner or later. And at a JPM party I ran into some of Joanna Strober’s team, reminding me that I thought Midi Health had perhaps raised too much money when it pulled down another $60m last year–but apparently it is going gangbusters. There’s also Equip for eating disorders with Kristina Saffran & Erin Parks at the helm (over $95m in so far) and doubtless a few more I’m forgetting. But in general they are the exceptions.

What’s not the exception is the tech bros raising for AI. Obviously the big players here are OpenAI, Anthropic et al pulling down billions to build their AI infrastructure. Anyone with a 401K is probably hoping that all works out given how much of the value of Nvidia, Tesla, Google, Meta, Microsoft & Apple seems to be based on a perhaps mythical AI abundant future. But there’s plenty in health care. Just this week Innovaccer ($275m), Qventus ($105m) & Truveta ($320m) all backed up the truck, all to combine data, AI and hope it will solve some of health care’s troubles.Those CEOs are men. But that’s not what I am complaining about.

You can also be a man and get away with a lot more. Hippocratic AI’s CEO Manjul Shah ran his last company HealthIQ into the ground. He screwed over suppliers, employees and customers to at least the tune of $17m in unpaid bills according to Katie Jennings at Forbes, then took another $170k personally out of the bankrupt company after he’d left. Was he a pariah to the investors who’s lost over $200m? Not in the least. The same investors A16Z and General Catalyst gave him another $50m right away to build an AI nurse chatbot company, and apparently health systems are lining up to buy it according to a podcast he was on with Julie Yoo of A16Z last week. This week Kleiner Perkins (and more) kicked in another $141m.

You might also have noticed that Ali Parsa who went through over $1 billion and crucified all his public market investors too when Babylon Health cratered is also back. His new company – an AI assistant launched with some famous doctors including Shafi Ahmed – is called Quadrivia AI. Funding isn’t clear but Sifted found some filings that indicate a Swedish VC is behind it.There’s also more than a little controversy about whether Babylon’s demise was just a series of bad business decisions or Parsa was lying about the tech. (I had Parsa on a couple of panels and always found him deferential and charming, but you can google Sergei Polevikov’s opinion!)

Look, unlike Lisa Bari at The Health Tech Talk Show, I love the idea of getting AI to answer patients’ questions, call them with information and generally use bots to add “abundance” to the health care workforce. I mean it’s just an extension of what Alex Drane and Eliza (and Silverlink & others) were doing 15 years ago. And there is huge possibility in using AI to actually diagnose and treat. I’m sure Parsa’s new AI bot also has the potential to improve physician care. 

But should it be that easy for guys like Shah and Parsa to immediately get back in the game given the chaos they left in their wake? Shouldn’t VCs have some qualms about anointing as saviours the very people who just screwed over their previous customers, partners, employees and investors?

But I guess we have our answer already. Adrian Aoun took a big swing with Forward and closed it after losing $650m and leaving patients in the lurch with no notice and 200 people unemployed. He was back on a podcast days later saying his investors wanted to give him more to start again. And the biggest loser, chaos agent and conman of recent years, Adam Nuemann of WeWork infamy, was back very soon after with another $350m for yet another real estate startup.

Neumann’s benefactor in the latest round was A16Z’s Mark Andreesen. Andreesen also famously helped fund Trump’s election in 2024. That’s the biggest comeback of someone with no morals, ethics or competence ever.

So I guess at least some VCs have decided, there’s no shame. 

(If you’re wondering about this piece’s title, I am riffing off this blues classic)

Some real medical innovation!

This may be the best comeback performance of all time. Not only did Lindsey Vonn come out of retirement to race a World Cup downhill at age 40 but she placed 6th and did it on an artificial knee! Here’s the details on the surgery but first watch her performance and just look how happy she is at the end!

Past Presidents Posthumous Advice To Trump #47

By MIKE MAGEE

For those many, many millions of viewers who tuned in to the live coverage of former President Jimmy Carter’s funeral this week, they were rewarded with two hours of intriguing video images, and moving words and song, including a recounting of the beginnings of environmental advocacy as Los Angeles burns, and John Lennon’s “Imagine” performed by Garth Brooks and Trisha Yearwood.

Five former Presidents and four Vice-Presidents were in attendance. And there were notable firsts, like the first greeting and handshake between incoming President Trump and former VP Pence since January 6, 2021.

But perhaps the most striking events of this carefully staged national funeral were the  two especially haunting posthumous eulogies delivered by the sons of a former president and vice-president. Presented by Steven Ford, son of former President, Gerald Ford, and Ted Mondale, son of former Vice-President Walter “Fritz” Mondale, they appeared to be directed to America itself, and its’ soon-to-be 47th president.

As the speakers explained, Jimmy Carter, some years back, asked both Ford and Mondale if they would be willing to present eulogies at his funeral. Both agreed, and put pen to paper in anticipation. But as it became evident that Carter might very well outlive them, they each asked their sons, in that event, to read their remarks at his funeral. And today they did.

Both President Ford and Vice-President Mondale’s words (voiced by their sons) deserve a full viewing when time allows. But in the meantime, let me share the closing remarks of each, prescient and timely now, at American democracy’s hour of need.

Steven Ford, son of former President Gerald Ford (7/14/13 – 12/26/06), reciting the president’s written words posthumously:

“…Now is time to say goodbye, our grief comforted with the joy and the thanksgiving of knowing this man, this beloved man, this very special man. He was given the gift of years, and the American people and the people of the world will be forever blessed by his decades of good works. Jimmy Carter’s legacy of peace and compassion will remain unique as it is timeless…As for myself, Jimmy, I’m looking forward to our reunion. We have much to catch up on. Thank you, Mr. President. Welcome home, old friend.”

Ted Mondale, son of former Vice-President Walter “Fritz” Mondale (1/5/28 – 4/19/21) reciting the vice-president’s written words posthumously.

Ted prefaced his reading with this sentence – “My father wrote this in 2019, and clearly he edited it a number of times since then, but here we go.”

“…Two decades ago, President Carter said he believed income inequality was the biggest global issue. More recently, in a 2018 Commencement Address at Liberty University, I think now the largest global issue is the discrimination against women and girls in this world. He concluded that, ‘Until stubborn attitudes that foster discrimination against women change, the world cannot advance, and poverty and poverty and income equality cannot be solved.’ Towards the end of our time in the White House, the President and I were talking about how we might describe what we tried to accomplish in office. We came up with a sentence which remains an important summary of our work. ‘We told the truth. We obeyed the law. And we kept the peace.’ That we did, Mr. President. I will always be proud and grateful to have had the chance to work with you towards noble ends. It was then, and will always be, the most rewarding experience of my public career. Thank you.”

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)

Robert Krayn & Georgia Gaveras, Talkiatry

Robert Krayn is the CEO and & Dr. Georgia Gaveras the CMO of Talkiatry. Robert and Georgia are quite the dynamic duo (she says, “He’s the money I’m the medicine!”). As a relative latecomer in the online mental health world, Talkiatry is trying to differentiate itself from the other big players like Lyra, Headspace, Brightside et al. It’s focusing on using psychiatrists as opposed to psychologists, counselors or coaches. This is both as an advertisement to patients but also they’ve set up a system that is much easier for psychiatrist themselves to join as employees and they showed me the way that patients get onboarded in their system, and how they get to that first appointment–in an average of 5 days!

You, Me, and Our Microbiome

By KIM BELLARD

You may have heard about the microbiome, that collection of microorganisms that fill the world around, and in, us. You may have had some digestive tract issues after a round of antibiotics wreaked havoc with your gut microbiome. You may have read about the rafts of research that are making it clearer that our health is directly impacted by what is going on with our microbiome. You may even take probiotics to try to encourage the health of your microbiome.

But you probably don’t realize how interconnected our microbiomes are.

Research published in Nature by Beghini, et. al., mapped microbiomes of almost 2,000 individuals in 18 scattered Honduras villages. “We found substantial evidence of microbiome sharing happening among people who are not family and who don’t live together, even after accounting for other factors like diet, water sources, and medications,” said co-lead author Francesco Beghini, a postdoctoral associate at the Yale Human Nature Lab. “In fact, microbiome sharing was the strongest predictor of people’s social relationships in the villages we studied, beyond characteristics like wealth, religion, or education.”

“Think of how different social niches form at a place like Yale,” said co-lead author Jackson Pullman. “You have friend groups centered on things like theater, or crew, or being physics majors. Our study indicates that the people composing these groups may be connected in ways we never previously thought, even through their microbiomes.”

“What’s so fascinating is that we’re so interconnected,” said Mr. Pullman. “Those connections go beyond the social level to the microbial level.”

Study senior author Nicholas Christakis, who directs the Human Nature Lab, explained that the research “reflects the ongoing pursuit of an idea we articulated in 2007, namely, that phenomena like obesity might spread not only by social contagion, but also by biological contagion, perhaps via the ordinary bacteria that inhabit human guts.” Other conditions, such as hypertension or depression, may also be spread by social transmission of the microbiome.

Professor Christakis thinks the findings are of broad importance, telling Science Alert: “We believe our findings are of generic relevance, not bound to the specific location we did this work, shedding light on how human social interactions shape the nature and impact of the microbes in our bodies.” But, he added: “The sharing of microbes per se is neither good nor bad, but the sharing of particular microbes in particular circumstances can indeed be good or bad.”

This research reminded me of 2015 research by Meadow, et. al., that suggested our microbiome doesn’t just exist in our gut, inside other parts our body, and on our skin, but that, in fact, we’re surrounded by a “personal microbial cloud.” Remember the Peanuts character Pigpen, who walked around in his personal dirt cloud? Well, that’s each of us, only instead of dirt we’re surrounded by our microbial cloud–and those clouds are easily discernable from each other.

Dr. Meadow told BBC at the time: “We expected that we would be able to detect the human microbiome in the air around a person, but we were surprised to find that we could identify most of the occupants just by sampling their microbial cloud.”

Those researchers predicted:

While indoors, we are constantly interacting with microbes other people have left behind on the chairs in which we sit, in dust we perturb, and on every surface we touch. These human-microbial interactions are in addition to the microbes our pets leave in our houses, those that blow off of tree leaves and soils, those in the food we eat and the water we drink. It is becoming increasingly clear that we have evolved with these complex microbial interactions, and that we may depend on them for our well-being (Rook, 2013). It is now apparent, given the results presented here, that the microbes we encounter include those actively emitted by other humans, including our families, coworkers, and perfect strangers.

Dr. Beghini and colleagues would agree, and further suggest that it’s not only indoors where we’re sharing microbes.

I would be remiss if I didn’t point out new research which found that our brains, far from being sterile, are host to a diverse microbiome and that impacts to it may lead to Alzheimer’s and other forms of dementia.

Could we catch Alzheimer’s from someone else’s personal microbiome cloud? It’s possible. Could we prevent or even cure it by careful curation of the brain (or gut) microbiome? Again, possible.

The truth is that, despite decades of understanding that we have a microbiome, we still have a very limited understanding of what a healthy microbiome is, what causes it to not be healthy, what problems arise for us when it isn’t healthy, or what we can do to bring it (and us) to more optimal health. We’re still struggling to understand where besides our gut it plays a crucial role.

We now know that we can “share” parts of our microbiome with those around us, but not quite what the mechanisms for that are–e.g., touch, sharing objects, or having our personal clouds intersect.

We feel like we are where scientists were two hundred years ago in the early stages of the germ theory of disease. They knew germs impacted health, they even could connect some specific germs with specific diseases, they even had rudimentary interventions based on it, but much remained to be discovered. That led to vaccines, antibiotics, and other pharmaceuticals, all of which gave us “modern medicine,” but failed to anticipate the importance of the microbiome on our health.

Similarly, we’re justifiably proud of the progress we’ve made in terms of understanding our genetic structure and its impacts on our health, but fall far short of recognizing the vastly larger genetic footprint of the microbiome with which we co-exist.

A few years ago I called for “quantum theory of health”–not literally, but incorporating and surpassing “modern medicine” in the way that quantum physics upended classical physics. That kind of revolution would recognize that there is no health for us without our microbiome, and that “our microbiome” includes some portion of the microbiomes of those around us.  We talk about “personalized medicine,” but a quantum breakthrough for health would be treating each person as the symbiosis with our unique microbiome.

We won’t get to 22nd century medicine until we can assess the microbiome in which we exist and offer interventions to optimize it. I just hope we don’t have to wait until the 22nd century to achieve that.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

“Hospital Mergers Kill”: An Economists’ Exercise in Reality Distortion

By JEFF GOLDSMITH

In late June, 2024, two economists, Zarek Brot-Goldberg and Zack Cooper, from the University of Chicago and Yale respectively, released an economic analysis arguing that hospital mergers damage local economies and result in an increase in deaths by suicide and drug overdoses in the markets where mergers occur. Funded by Arnold Ventures  their study characterizes these mergers as “rent seeking activities” by hospitals seeking to use their economic power to extort financial gains from their communities without providing any value. 

The Brot-Goldberg-Cooper analysis was a spin-off of a larger study decrying the lack of federal anti-trust enforcement regarding hospital mergers. These two studies used the same economic model. The data were derived from the Healthcare Cost Institute, a repository of commercial insurance claims information from three of the four largest commercial health insurers, United Healthcare, Humana and Aetna (a subsidiary of struggling pharmacy giant CVS) plus Blue Cross/Blue Shield. HCCI’s contributors account for 28% of the commercial health insurance market.

The authors use a complex econometric model to manipulate a huge, multifactorial data base comprising hospital merger activity, employer health benefits data, county level employment data and morbidity and mortality statistics. This data model enabled a raft of regression analyses attempting to ferret out “associations” between the various domains of these data.

Using HCCI’s data, the authors construct what they termed a  “causal chain” leading from hospital mergers to community damage during their study period–2010 to 2015.  It looked like this: hospital mergers raise prices for private insurers-these prices are passed on to employers–who respond by laying off workers–some of whom end up killing themselves. So, according to the logic, hospital mergers kill people. Using the same methodology, the authors argued that between 2007 and 2014, hospital price increases of all sorts killed ten thousand people. 

A classic problem with correlational studies of this kind is their failure to clarify the direction of causality of data elements.  The model lacked a control group–comparable communities that did not experience hospital mergers during this period–because the authors argued that mergers were so pervasive they could not locate comparable communities that did not experience them.    

The model focused on a subset of 304 hospital mergers from 2010 to 2015, culled from a universe of 484 mergers nationally during the same period. The authors excluded mergers of hospitals that were further than fifty miles apart, as well as hospitals with low census. The effect of these assumptions was to exclude most rural hospitals and concentrate the mergers studied in metropolitan areas and cities. The densest cluster was in the I-95 corridor between Washington DC and Boston. See the map below:

According to the model, these mergers resulted in an average increase of 1.2% in hospital prices to commercial insurers, 91% of which were passed to their employer customers in those markets. This minuscule rate increase had a curiously focused and outsized effect–a $10,584 increase in the median employer’s health spending in the merged hospitals’ market.

According to the model, local employers “responded” to this cost increase by reducing their payrolls by a median amount of $17,900, all through layoffs–70% more than the alleged merger cost increase. This large overage was not explained by the authors. Moreover, the layoffs took place almost immediately, in the same year as the merger-induced increases, even though many health insurance contracts are multi-year affairs, and lock hospitals in to rates for that period.

At the end of the “causal chain,” 1 in 140 laid off people in those communities for whatever reason killed themselves through suicide or drug overdoses. By extrapolation, the authors accuse the perpetrators of overall hospital rate increases of killing ten thousand people in the affected communities during seven years overlapping the study period.   

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Public Health Policy: At the Intersection of Law and Medicine.

By MIKE MAGEE

As 2025 kicks off, it’s wise to pause, and gather our thoughts as a nation. Few would argue that we’ve been through a lot over the past decade. And quite naturally, we humans are prone to blame individuals rather than circumstances (most of which have been beyond our control) for creating an environment that feels as if it is unraveling before our eyes.

How should we describe our condition – dynamic, tense, complex? Is peace, contentment, and security achievable in this still young nation? Have accelerationist technocrats, armed with bitcoins and Martian fantasy, short-circuited our moment in time that had been preserved for recovery from a deadly pandemic that eliminated a million of our fellow citizens seemingly overnight?

Who do we turn to for answers, now that we’ve largely lost faith and trust in our politicians, our religious leaders, and our journalists? And how exactly do you create a healthy nation? Certainly not by taking doctors and nurses offline for miscarriages, and placing local bureaucrats in exam rooms. Are they prepared to deal with life and death decisions? Are they trained to process human fear and worry? Do they know how to instill hopefulness in parents who are literally “scared to death” because their child has just been diagnosed with cancer? It certainly must require more than a baseball cap with MAHA on it to heal this nation.

Historians suggest this will take time. As Stanford Professor of Law, Lawrence M. Friedman, wrote in A History of American Law, “One hundred and sixty-nine years went by between Jamestown and the Declaration of Independence. The same length of time separates 1776 and the end of World War II.”

During those very early years that preceded the formal declaration and formation of the United States as a nation, our various, then British colonies, fluidly and independent of each other, did their best first to survive, and then to organize into shared communities with codified laws and regulations. It was “a study of social development unfolding over time” impacted by emotions, politics and real-time economics. At the core of the struggle (as we saw with the pandemic, and now the vaccine controversy) was a clash between the rights of the individual and those of the collective community.

This clash of values has been playing out in full view over the past five years of the Covid pandemic. In 2023, Washington Post columnist, Dr. Leana Wen, asked, “Whose rights are paramount? The individual who must give up freedoms, or those around them who want to lower infection risk?”

Continue reading…

My Totally Wrong, Expert Predictions for Health Care 2025

By MICHAEL MILLENSON

January

In a blistering commentary, the American Medical Association’s flagship journal, JAMA, condemns the corrosive effect on patient care of the profit-seeking practices of health insurers. Separately, the organization announces that it’s selling the 13 journals in its JAMA Network to a private equity firm for $375 million “in order to enhance our mission of promoting the betterment of public health.”

February

Quickly following up on a campaign pledge to slash the federal budget, the Trump administration announces a radical consolidation of various entities at the Department of Health and Human Services. The new organization will be known as the Agency and Bureau for Children, Drugs, Explosives, Firearms, Families and Food (ABCDEFFF). Reflecting the new president’s strong personal preferences, “alcohol” will no longer be permitted in any agency name.

March

Bipartisan legislation demanding transparency from Pharmacy Benefit Managers dies in committee after industry executives explain that secret rebates to PBMs are like secret political action committee contributions to politicians: they allow you to loudly proclaim you’re an “advocate” for those supposedly paying you while actually serving the interests of those who are really paying you.

April

Pfizer announces that its once-a-day pill version of the wildly successful GLP-1 agonist weight loss drugs will shortly be submitted for government approval, and also that the company is moving its headquarters from New York to Louisiana, a state with a 40 percent obesity rate. Coincidentally, Louisiana is also the home state of Republican senators Cassidy and Kennedy, senior members of the Senate committees overseeing health care and all federal appropriations.

May

The new private equity owners of the JAMA Network say that all staff except one editor at each journal will be replaced by ChatGPT. A source at the private equity firm tells the Wall Street Journal that OpenAI won out over Gemini “because our CEO is a Leo” and over Claude “because nobody likes the French.”

June

Controversial right-wing firebrand Rep. Marjorie Taylor Greene, long the subject of rumors that she’s had cosmetic surgery, is diagnosed with a serious infection after an unspecified procedure. The House quickly schedules its first hearing on medical error in over two decades, but then cancels when the American Hospital Association points out the official term for what the Georgia Republican contracted was a “healthcare-associated infection,” so it’s entirely possible she accidentally brought the infection with her to the pristine hospital. Meanwhile, with House leadership telling Members they were free to vote their conscience, a resolution to send Greene a “Get Well” card passes unanimously after deletion of the word, “Soon.”

July

Following through on years of promises to reveal a “really great” replacement for the Affordable Care Act, President Trump on July 4 announces the “100-100-100” Make America Healthy Again plan. In keeping with the GOP’s advocacy for “skinny” plans with low premiums that encourage “consumers” to “comparison shop,” the plan will cover 100 percent of any medical bill for up to $100 a day for a premium of just $100 a month. Separately, Elon Musk tells a meeting of health insurance executives the plan can also replace both Medicare and Medicaid, enabling the federal government to cut spending by almost as much as the market capitalization of Tesla.

August

Before Congress recesses, a coalition of progressive organizations issues a press release declaring that all basic health services, whether provided by government agencies or the private sector, should be “available to the entire population according to its needs.” Shortly afterwards, the coalition is forced to make an embarrassing retraction after ChatGPT alerts the lone editor of JAMA that the coalition accidentally re-released a section of the report of the Committee on the Costs of Medical Care, formed in 1927.

September

The Business Roundtable says its members are committed to improving the quality of health care for all employees because “quality health care is good business.” An 85-year-old freelancer for The New York Times notes that this was the exact title of a September, 1997 policy paper by a Roundtable task force in which an executive for Sears, which at the time operated over 3,500 stores, declares, “We believe that quality health care is lower-cost health care.” Sears currently has about a dozen stores.

October

Medicare Advantage plans step up their advertising expenditures after public opinion polls show that nobody anymore believes the portrayal of happy and healthy seniors playing pickleball instead of writing tear-soaked letters pleading for approval of hip surgery. The trade associations for hospitals, drug and device companies and PBMs call on Congress to provide greater oversight of greedy insurers. The editor of JAMA resigns after ChatGPT writes an editorial extolling the merits of MA plans run by for-profit companies.

November

The National Rural Health Association says that in the spirit of the Thanksgiving holiday, its members will accept live turkeys in partial payment of the medical debts that now affect 99.99 percent of all Americans after passage of the administration’s “100-100-100” Make America Healthy Again plan. A KFF survey explains that the number is not 100 percent because Congress retained conventional health insurance for itself and top federal officials and because America’s billionaires had opted for self-pay.

December

A Washington Post editorial declares, “The bottom line is that if we want to contain spending, we will have to make critical choices about how care is delivered, to whom, and under what conditions.” Different chatbots differ on where that quote originally came from, but agree that if any humans believe the American public is ready to make critical choices, they’re hallucinating.

Michael L. Millenson is president of Health Quality Advisors & a regular THCB Contributor

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