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THCB Gang, Episode 11

Episode 11 of “The THCB Gang” was live-streamed on Thursday, May 27th and you can see it again below

Joining me were three regulars, patient safety expert Michael Millenson (MLMillenson), writer Kim Bellard (@kimbbellard), health futurist Ian Morrison (@seccurve), and two new guests: digital health investment banker Steven Wardell (@StevenWardell) and MD turned physician leadership coach Maggi Cary (@MargaretCaryMD)! The conversation was heavy on telemedicine and value based care, and their impact on the stock-market, the economy and the health care system–all in a week when we went over 100,000 deaths from COVID-19.

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

What’s a diagnosis about? COVID-19 and beyond

By MICHEL ACCAD

Last month marked the 400th anniversary of the birth of John Graunt, commonly regarded as the father of epidemiology.  His major published work, Natural and Political Observations Made upon the Bills of Mortality, called attention to the death statistics published weekly in London beginning in the late 16th century.  Graunt was skeptical of how causes of death were ascribed, especially in times of plagues.  Evidently, 400 years of scientific advances have done little to lessen his doubts! 

A few days ago, Fox News reported that Colorado governor Jared Polis had “pushed back against recent coronavirus death counts, including those conducted by the Centers for Disease Control and Prevention.”  The Centennial State had previously reported a COVID death count of 1,150 but then revised that number down to 878.  That is but one of many reports raising questions about what counts as a COVID case or a COVID death.  Beyond the raw numbers, many controversies also rage about derivative statistics such as “case fatality rates” and “infection fatality rates,” not just among the general public but between academics as well.  

Of course, a large part of the wrangling is due not only to our unfamiliarity with this new disease but also to profound disagreements about how epidemics should be confronted.  I don’t want to get into the weeds of those disputes here.  Instead, I’d like to call attention to another problem, namely, the somewhat confused way in which we think about medical diagnosis in general, not just COVID diagnoses.

The way I see it, there are two concepts at play in how physicians view diagnoses and think about them in relation to medical practice.  These two concepts—one more in line with the traditional role of the physician, the other adapted to modern healthcare demands—are at odds with one another even though they both shape the cognitive framework of doctors.  

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Health in 2 Point 00, Episode 125 | Amwell, Mindstrong, Big Sky Health, Medwing

Today on Health in 2 Point 00, we have more than $300 million in deals to cover! On Episode 125, Jess asks me about Amwell raising $194 million although they haven’t gone public (yet), Mindstrong getting $100 million and a new CEO from Uber in another big raise for their mental health app, Big Sky Health landing $8 million for its intermittent fasting, meditation and alcohol consumption apps, Tava Health raising $3 million to expand its teletherapy program, and German startup Medwing getting $30 million to address Europe’s shortage of healthcare workers. Don’t miss Jess speaking at the AHIP discussion on How Digital Self-Care is Transforming Mental Health Care tomorrow at 1pm ET! —Matthew Holt

The 2020 COVID Election

By KIM BELLARD

Many believe that the 2020 Presidential election will be a referendum on how President Trump has handled the coronavirus pandemic.  Some believe that is why the President is pushing so hard to reopen the economy, so that he can reclaim it as the focal point instead.  I fear that the pandemic will, indeed, play a major role in the election, but not quite in the way we’re openly talking about.  

It’s about there being fewer Democrats.

Now, let me say right from the start that I am not a conspiracy believer.  I don’t believe that COVID-19 came from a Chinese lab, or that China deliberately wanted it to spread.  I don’t even believe that the Administration’s various delays and bungles in dealing with the pandemic are strategic or even deliberate.  

I do believe, though, that people in the Administration and in the Republican party more generally may be seeing how the pandemic is playing out, and feel less incentive to combat it to the fullest extent of their powers.  Let’s start with who is dying, where.

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Catalyst @ Health 2.0 Launches Subsidized Rapid Response Open Calls (RROCs)

SPONSORED POST

By CATALYST @ HEALTH 2.0

In collaboration with the Robert Wood Johnson Foundation, Catalyst @ Health 2.0 is proud to announce funding for health care providers with limited resources and urgent needs to identify and source digital health innovation during COVID-19 through our Rapid Response Open Calls (RROC). RROCs are streamlined calls for applications that connect health care providers to digital health solutions. Deployed as part of Catalyst’s Health Tech Responds to COVID-19 platform, RROCs can be launched within days to meet the host’s needs.

Catalyst created the RROC to address an urgent need from Brigham and Women’s Hospital (BWH) Emergency Department for provider-facing, text-based platforms to help healthcare professionals self-monitor symptoms of coronavirus, report burnout, and access helpful resources. Within one day, the Brigham and Women’s Health RROC was launched. In a 7-day application period, Catalyst received an overwhelmingly positive response with more than 80 quality submissions. BWH was able to evaluate the submissions through a streamlined process and 5 innovators were selected to demo their solutions to the BWH ED team. BWH began pursuing a potential partnership with one of the semi-finalists. 

If you are a healthcare provider with limited resources during COVID-19 (e.g. FQHCs, community health centers, etc.), apply for a subsidized RROC HERE!

How to Practice High-Quality Telemedicine in the Era of COVID-19

By ANISH MEHTA, MD

My practice received its first question about coronavirus from a patient on January 28, 2020. Though there were over 200 deaths reported in China by that time, no one could have imagined how drastically this would come to disrupt our lives at home.

Thankfully, I had a head start.

As a doctor at an integrated telemedicine and primary care practice in New York City, nearly two out of every three of my medical encounters that month was already virtual.

I spent much of January caring for patients who had contracted seasonal viruses, like influenza or norovirus (i.e. the stomach flu). My patients reached out nearly every day with bouts of fevers, fatigue, diarrhea, and vomiting. Our team did all we could to encourage each of these patients to stay home and avoid spreading their highly contagious virus throughout the community (sound familiar?).

We are now guiding our patients through the COVID-19 outbreak using the same tools we use to guide them through any healthcare need – real-time monitoring, proactive outreach, and team-based care.

After our first COVID-19 question, our team started compiling information about every patient who reached out with symptoms that even slightly resembled COVID-19. This soon turned into a comprehensive patient registry containing the epidemiologic risk factors, clinical risk factors, symptoms, and a follow-up plan for each patient. Based on their total risk level, we follow up with these patients every 24 to 120 hours.

Every day, one provider on the team texts or schedules a video visit with each follow-up patient, reassesses their symptoms, and re-stratifies their risk. Most patients respond with a text message letting us know that their symptoms are the same or slowly improving. But for patients at higher risk, we want more information. We help these patients acquire a thermometer or pulse oximeter to follow up on their respiratory vitals. With this data, our team can provide patients and their families with thresholds on when to seek out a higher level of care.

Our job for these patients is clear: provide treatment at home and only recommend the hospital if there is no other option. By centralizing data and establishing clear triggers for a new plan of care, a single provider can follow up with over 30 COVID-19 patients in a single day.

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A Vigilante in Statistical Badlands

By ANISH KOKA, MD

Something didn’t seem right to epidemiologist Eric Weinhandl when he glanced at an article published in the venerated Journal of the American Medical Association (JAMA) on a crisp fall evening in Minnesota. Eric is a smart guy – a native Minnesotan and a math major who fell in love with clinical quantitative database-driven research because he happened to work with a nephrologist early in his training. After finishing his doctorate in epidemiology, he cut his teeth working with the Chronic Disease Research Group, a division of the Hennepin Healthcare Research Institute that has held The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) contract for the United States Renal Data System Coordinating Center.  The research group Eric worked for from 2004-2015 essentially organized the data generated from almost every dialysis patient in the United States.  He didn’t just work with the data as an end-user, he helped maintain the largest, and most important database on chronic kidney disease in the United States. 

For all these reasons this particular study published in JAMA that sought to examine the association between dialysis facility ownership and access to kidney transplantation piqued Eric’s interest.  The provocative hypothesis is that for-profit dialysis centers are financially motivated to keep patients hooked to dialysis machines rather than refer them for kidney transplantation.  A number of observational trials have tracked better outcomes in not-for-profit settings, so the theory wasn’t implausible, but mulling over the results more carefully, Eric noticed how large the effect sizes reported in the paper were. Specifically,  the hazard ratios for for-profit vs. non-profit were 0.36 for being put on a waiting list, 0.5 for receiving a living donor kidney transplant, 0.44 for receiving a deceased donor kidney transplant.  This roughly translates to patients being one-half to one-third as likely to get referred for and ultimately receiving a transplant.  These are incredible numbers when you consider it can be major news when a study reports a hazard ratio of 0.9.  Part of the reason one doesn’t usually see hazard ratios that are this large is because that signals an effect size that’s so obvious to the naked eye that it doesn’t require a trial. There’s a reason there are no trials on the utility of cauterizing an artery to stop bleeding during surgery. 

But it really wasn’t the hazard ratios that first struck his eye.  What stuck out were the reported event rates in the study. 1.9 million incident end-stage kidney disease patients in 17 years made sense. The exclusion of 90,000 patients who were wait-listed or received a kidney transplant before ever getting on dialysis, and 250,000 patients for not having any dialysis facility information left ~1.5 million patients for the primary analysis.  The original paper listed 121,000 first wait-list events, 23,000 living donor transplants and ~50,000 deceased donor transplants.  But the United Network for Organ Sharing (UNOS), an organization that manages the US organ transplantation system, reported 280,000 transplants during the same period. 

The paper somehow was missing almost 210,000 transplants.

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The New Normal is Still Unknown, on Earth as it is in Healthcare

By HANS DUVEFELT, MD

From the vantage point of our self-quarantined shrunken universes, we cannot see even the immediate future, let alone what our personal and professional lives will look like some years from now.

Factories are closed, luxury department stores are in bankruptcy, hospitals have stopped performing elective procedures and patients are having their heart attacks at home, unattended by medical professionals. New York office workers may continue to work from home while skyscrapers stand empty and city tax revenues evaporate.

Quarantined and furloughed families are planting gardens and cooking at home. Affluent families are doing their own house cleaning and older retirees are turning their future planning away from aggregated senior housing and assisted living facilities.

In healthcare, procedure performing providers who were at the pinnacle of the pecking order sit idle while previously less-valued cognitive clinicians are continuing to serve their patients remotely, bringing in revenues that prop up hospitals and group practices.

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Post-Pandemic Solutions: A Public Option for Universal Healthcare

By ROSEMARIE DAY

As the coronavirus pandemic overtook the tail end of the Democratic primary season, attention rapidly shifted from examining the nuances of the differences between the candidates’ healthcare platforms to simply demanding a response to the pandemic. Beyond addressing the immediate crisis, however, lie many questions about the weaknesses of our current healthcare system, and how we will address them in the long run.  These questions should be at the forefront of voters’ minds as we head into the election this fall. 

One of the major weaknesses in our system is that we do not have universal healthcare. Importantly, virtually all of the Democratic candidates called for making healthcare a right in the U.S. This is a key first step toward universal healthcare.  Their approaches to achieving this varied, however. Bernie Sanders and Elizabeth Warren called for “Medicare for All,” but most of the other candidates, including Joe Biden, have pushed for some kind of public option. The public option has faced criticism that it will simply maintain the status quo. This criticism inspired me to write this blog, because a large-scale public option program could actually help to reshape the US healthcare system and result in improvements in access to care in this country, ultimately getting us to universal healthcare.

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THCB Gang, Episode 10 LIVE 1PM PT/4 PM ET 5/21

Episode 10 of “The THCB Gang” was live-streamed on Thursday, May 21th

Joining me were regulars: writer Kim Bellard (@kimbbellard), policy expert Vince Kuraitis (@VinceKuraitis), patient advocate Grace Cordovano (@GraceCordovano), radiologist Saurabh Jha (@RogueRad), employer consultant Brian Klepper (@bklepper1), Deven McGraw (@healthprivacy) and a guest, former ONC Consumer head Lygeia Riccardi, now at Carium Health (@Lygeia)! The conversation moved onto the new normal of telehealth, how much things would change in the future, and what the story with testing and opening up would look like. You can see the video below

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

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