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It’s complicated. A deep dive into the Viz/Medicare AI reimbursement model.

By LUKE OAKDEN-RAYNER

In the last post I wrote about the recent decision by CMS to reimburse a Viz.AI stroke detection model through Medicare/Medicaid. I briefly explained how this funding model will work, but it is so darn complicated that it deserves a much deeper look.

To get more info, I went to the primary source. Dr Chris Mansi, the co-founder and CEO of Viz.ai, was kind enough to talk to me about the CMS decision. He was also remarkably open and transparent about the process and the implications as they see them, which has helped me clear up a whole bunch of stuff in my mind. High fives all around!

So let’s dig in. This decision might form the basis of AI reimbursement in the future. It is a huge deal, and there are implications.


Uncharted territory

The first thing to understand is that Viz.ai charges a subscription to use their model. The cost is not what was included as “an example” in the CMS documents (25k/yr per hospital), and I have seen some discussion on Twitter that it is more than this per annum, but the actual cost is pretty irrelevant to this discussion.

For the purpose of this piece, I’ll pretend that the cost is the 25k/yr in the CMS document, just for simplicity. It is order-of-magnitude right, and that is what matters.

A subscription is not the only way that AI can be sold (I have seen other companies who charge per use as well) but it is a fairly common approach. Importantly though, it is unusual for a medical technology. Here is what CMS had to say:

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THCB Gang Episode 26, 9/24

Episode 26 of “The THCB Gang” was live-streamed on Thursday, September 24th! Watch it below!

Joining Matthew Holt (@boltyboy) were some of our regulars: health futurist Ian Morrison (@seccurve), patient advocate Grace Cordovano (@GraceCordovano), patient & entrepreneur Robin Farmanfarmaian (@Robinff3), health care consultant Daniel O’Neill (@dp_oneill), and patient safety expert Michael Millenson (@MLMillenson). The conversation revolved around the dismantling of the ACA, conservatives causing chaos in the government, the dismissal of pre-existing conditions, and the state of women’s health rights after the passing of RBG. It was both an emotional & impactful conversation.

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan

Minding the Competition: Ginger’s Karan Singh & Russell Glass on Digital Mental Health Investments

By JESSICA DaMASSA, WTF HEALTH

Digital Mental Health startups continue to scale up — in customers, revenues, and investments — as the covid19 pandemic wears on. One of these companies, Ginger, has tripled its revenue this past year, expanded its client base to count more than 200 health plans and self-insured employers, and, for good measure, just added a fresh $50M Series D to their coffers. How much more money can investors put into digital mental health startups? Are things “frothy” in this space, or is investment just “catching up” to meet a latent demand that’s just really been brought to light? And, what is one of this category’s leaders planning to do now that they’re extra flush with cash? (Don’t forget, they’re sitting on a $35M round that closed late 2019…)

Ginger’s co-founder & COO Karan Singh and CEO Russell Glass join us to weigh in on the mental healthcare market’s state-of-play, including the buzz around their own business as both a potential acquisition target and a potential acquirer of additional behavioral health tech. We cover everything from investment to healthcare incumbent’s recent cries for more clinical validation, but my favorite part of this whole interview is when we start talking about the competition and tackle Lyra Health’s recent $100M raise and $1.1B valuation. Tune in around the 15:55-minute mark for some very DETAILED competitive analysis about Lyra-versus-Ginger from Ginger’s own CEO.

As this market gets more crowded, competition heats up, and healthcare consumers receive the benefit of more solutions to access at lower prices, Karan and Russ also help me speculate on what’s ahead, including whether or not they think we’ll see a “digital mental health equivalent” of a massive game-changing-market-moving deal like we saw when Teladoc merged with Livongo to shake up of both the virtual care and chronic condition management spaces.

Congress Is Getting the Transition to Alternative Payment Models Wrong

By TAYLOR CHRISTENSEN

Alternative payment models (APMs) are a hot topic these days, and everyone seems to agree that we need to transition toward them and away from fee for service (FFS). But how should we do it?

First, let’s think about this task as government policy makers would think about it.

They would probably start by saying, “We need to find a way to give incentives to providers and payers to try out these different APMs.” This would be fairly easy to do through Medicare, so they would create some Medicare APM programs and structure them in a way that makes the benefits of joining large enough that lots of providers will want to participate.

And for the sake of uniform provider incentives, they would also want to encourage private insurer-provider diads to start using APMs, preferably ones as similar to the Medicare APM programs as possible. And so they would probably have to offer private insurers and/or providers money to do so.

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WeChat to Many, WeDoctor to Some

By KIM BELLARD

You’ve probably heard about TikTok, especially lately.  President Trump wanted a ban on it, and seems to have endorsed a deal for a U.S.-based version of it.  The hundred million U.S. users, and probably their parents, are undoubtedly watching the sequence of events with mixed amusement and concern. 

But you may have paid less attention to what’s been going on with WeChat, another China-based app.  WeChat was part of the original proposed ban, which a federal judge blocked this weekend, hours before it was due to go into effect (the Commerce Department plans to appeal).  The ban is on “transactions,” which, in WeChat’s case, covers a lot of ground. 

TikTok was overlooked by authority figures for a long time because it was mostly used by young people and mostly for what seemed, to them, to be trivial purposes.  Not so with WeChat; it is deeply engrained in users’ lives, including for their health.  

WeChat is owned by Tencent Holdings, one of China’s internet giants.  It has been described as a “Swiss Army knife” app, able to do many tasks – not just messaging and social networking, but also games, shopping, and payments.  You can order food or book travel.  For many users it is a primary source of news, which is part of the problem. 

It is also important to users’ health.  WeChat is, according to CMI Media, “fast becoming the #1 online healthcare destination in China.”  It offers, among other things, health content (some in partnership with U.S. firms), health products, telehealth, a network of “trusted” doctors, a form of health insurance, and WeDoctor.  The latter provides online health enquiry service, psychological support, prevention guidelines and real-time pandemic reports,” and is free to the user.  It is available “24/7 for people all over the world.”

Most notably, WeDoctor is preparing for an IPO for late this year/early 2021, which could value it as high as $10b.  I would again note the “24/7 for people all over the world.”

If we’re worried about what information China might glean from the video-watching habits of teenagers, think about how worried we should be about China having access to what health information users sought, what medical advice they got, and what health products they ordered.

China is famed for its “Great Firewall,” which restricts which outside internet platforms – like Google or Facebook – can be used within its borders.  Equally important, the Chinese government monitors what happens on WeChat and other internet platforms/apps, and does not allow news or opinions it finds objectionable, or subversive.  You might think you are in your own Facebook or Twitter bubble in the U.S., but in China – or on WeChat – that bubble is shaped and controlled by the government. 

As a result, Politico reported, “Now young online Chinese, once conduits for new ideas that challenge the power structure, are increasingly part of Beijing’s defense operation.”  Even U.S. users find their worldview shaped by the content they are allowed to see.  As The New York Times said, “it has helped bring Chinese censorship to the world.”

“All of a sudden I discovered talking to others about the issue didn’t make sense,” one user told The New York Times.  “It felt like if I only watched Chinese media, all of my thoughts would be different.”

There are estimated to be 19 million U.S. users, out of WeChat’s 1.2 billion users; most are people with family or friends in China, who rely on the app to stay in touch.  The U.S. may argue it is worried about what financial and personal information might be going to the Chinese government, but it should be equally worried about what “information” is being served to U.S. users. 

Think, for example, what it might tell U.S. users about COVID-19 vaccines.

The U.S. moves make some worry that we’re becoming more like China, leading to the “splinternet” where, as Vox explained, “your experience of the internet increasingly depends on where you live and the whims of the ruling parties there.” 

Vox goes on to note:

Nations are increasingly pursuing various forms of internet sovereignty, from Russia building a walled-off intranet to India regularly shutting down the internet in areas of social unrest to some European nations introducing a right to be forgotten from search engines.

It is the opposite of the open access, no borders version of the internet that most of us have believed in for the past thirty years.  Aaron Levie, CEO of cloud-computing company Box Inc, warned in The Wall Street Journal: “U.S. tech companies have far more to lose if this becomes a precedent.  This creates a Balkanization of the internet and the risk of breaking the power of the internet as one platform.”

One Congressional official told Wired:

We are finally having the debate China had two decades ago, when it put in the Great Firewall because it found foreign technology threatening its political system. Only now is America catching up with foreign technology that is a direct threat to our open system.

But Jason Healey, an expert on cyber conflict, competition and cooperation at Columbia University, told The New York Times: “The vision for a single, interconnected network around the globe is long gone. All we can do now is try to steer toward optimal fragmentation.”

Somehow, “optimal fragmentation” isn’t how I want to think of my internet experience; I suspect that fragmentation won’t be so optimal.

Even if some version of the ban on WeChat goes through, it’s not clear how effective it would be.  Options like using VPNs or downloading the app from non-store channels may allow users to continue to use it.  In any cases, The Washington Post reported that “the administration does not intend to prosecute anyone for finding new ways to use the apps.” 

In discussing the effect of potential WeChat bans with The New York Times, Fang Kecheng, a professor at the Chinese University of Hong Kong, said: “Information is like water. Water quality can be improved, but without any flow, water easily grows fetid.”  He didn’t carry the analogy further, but I will: information is like water, in that, eventually, it will get to where it wants to go. 

We don’t have a U.S. platform as versatile as WeChat; we don’t even have a health platform as capable as WeChat’s health capabilities.  But, if we’re not careful, WeChat might become that platform.   

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

Now Is Not the Time to Forget About the AIDS Epidemic

By SOMA SEN

I keep hearing the voices of colleagues and friends that have been part of the AIDS epidemic compare it to the current COVID-19 pandemic. In fact Dr. Kathy Creticos, Director of Infectious Disease at Howard Brown Health spoke about the politicization of both the pandemics. 

“Here we are in 2020 with this disease that kills people, that we don’t have any treatments for, that we really don’t understand the full manifestation and presentation biology of the virus,” Creticos said In the final segment of an interview with Contagion during International AIDS Society (IAS) AIDS 2020 Virtual Sessions. “We’re really dealing in the same situation as in the HIV epidemic.” 

Her words make me reflect on the levity with which the Raegan administration treated the AIDS epidemic and it’s parallel to the Trump administration’s treatment of the current pandemic. However, she makes an important distinction between the two when she says, “I think a lot of it has to do with the fact that COVID affects everybody, but HIV was certainly perceived as not affecting everybody.”

As an Asian American researcher with more than 15 years of experience in this area, whenever, I bring up the issue of the scourge of HIV/AIDS in our community, the common response both from inside and outside the community is “It’s not a problem in this community.” 

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Health in 2 Point 00, Episode 152 | 2 IPOs, At-Home Care, & Youtube for Employees?

With 2 IPOs this week, On Episode 152 of Health in 2 Point 00, Jess asks me about Amwell’s IPO with a market cap at $5B for its telehealth solutions, Outset Medical’s IPO with a market cap of $1.5B for its kidney dialysis technology, Ready raising $54M for its care at- home platform, Lifespeak getting $42M for its “YouTube” like platform for employee mental health and wellness training program.Matthew Holt

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If I Can Be Safe Working as An ER Doctor Caring for COVID Patients, We Can Make Schools Safe for Children, Teachers, and Families

By AMY CHO

We need to stop arguing about whether schools should reopen and instead do the work to reopen schools safely. Community prevalence of COVID-19 infection helps to quantify risk, but reopening decisions should not be predicated on this alone. Instead of deciding reopening has failed when an infected student or teacher comes to school, we should judge efforts by our success in breaking transmission chains between those who come to school infected and those who don’t. We should judge our success by when we prevent another outbreak. We should pursue risk and harm reduction by layering interventions to make overall risk of transmission in schools negligible. This CAN be done, as healthcare workers all over the United States have shown us. Unlike politics, we should avoid thinking this is a binary choice between two polarized options. At the heart of these decisions about tradeoffs should be the assumption that the education of our children is an essential, public good.

I advocated for school closures in March. We had little understanding of the risks and transmission of COVID-19 and faced massive shortages of personal protective equipment (PPE). The closures were a blunt force instrument but bought precious time to learn and prepare. Pandemic control, by flattening the curve and buying time for discovery of more effective therapeutics, care and a vaccine, remains a critical tool to save lives. But COVID-19 will not be eradicated. We must come to terms with the reality that COVID-19 will circulate among us, likely indefinitely. Shutdowns slow spread but at a great cost, disproportionately paid by vulnerable groups including children, women, minorities, and those with the least financial resources. Getting children safely back to in-person school should be among our highest priorities.

Hospitals never considered closing. As healthcare workers, we cannot physically distance from patients. We watched in horror as hot spots like Bergamo suffered high nosocomial and staff infection rates as they were quickly overwhelmed. In response, we worked tirelessly and collaboratively to protect one another while continuing to provide care.

The good news is that we seem to have learned how to prevent in-hospital transmission of COVID-19. A recent study showed that at a large US academic medical center, after implementation of a comprehensive infection control policy, 697 of 9,149 admitted patients were diagnosed with COVID-19. But only TWO hospital-acquired patient infections were detected. COVID-19 is not “just the flu,” but it isn’t Ebola either. I no longer worry that I will become infected with COVID while working in my emergency department. It is not easy, comfortable nor cheap, but a bundle of universal masking and eye protection, appropriate PPE use, sanitation, improved room ventilation, and protective policies have proven effective at preventing in-hospital outbreaks. 

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THCB Gang Episode 25 9/17

Joining Zoya Khan (@zoyak1594) on Episode 25 of “The THCB Gang” were regulars patient advocate Grace Cordovano (@GraceCordovano), writer Kim Bellard (@kimbbellard), policy & tech expert Vince Kuraitis (@VinceKuraitis), data privacy expert Deven McGraw (@healthprivacy), and guest Rosemarie Day, Founder & CEO of Day Health Strategies (@Rosemarie_Day1). Rosemary’s book “Marching Towards Coverage” is out now. The conversation revolved around new health technology policies, Medicaid Expansion programs, the 2020 election, and the steps to get to universal health coverage. Oh, and you can take Rosemary’s quiz about what type of a health activist you are!

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan

Doctors Urge Caution in Interpretation of Research in Times of COVID-19

September 9, 2020

To:      

American College of Cardiology

American College of Chest Physicians

American College of Physicians

American College of Radiology

American Heart Association

American Society of Echocardiography

American Thoracic Society

European Association of Cardiovascular Imaging

European Society of Cardiology

European Society of Radiology

Heart Rhythm Society

Infectious Disease Society of America

North American Society of Cardiovascular Imaging

Radiologic Society of North America

Society of Cardiovascular Magnetic Resonance

Society of Critical Care Medicine

Society of General Internal Medicine

Society of Hospital Medicine


Dear Society Leadership:

We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.

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