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Next-Gen PBM Capital Rx Becomes a Tech Co: Inside New PBA Biz, $106M Series C & Big Plans

by JESSICA DAMASSA

What’s the bigger news coming out of Capital Rx: that the next-gen PBM just closed a $106 million dollar Series C? Or, that the health tech startup’s business model has expanded significantly over the past 18 months, from PBM-only to PBM-plus-PBA, meaning that instead of just servicing the pharmacy benefits management needs of employer groups directly, that now they’re also adding to their business by selling THEIR TECH to other carriers and health systems so they can use it to administrate their benefits plans??

Capital Rx’s CEO AJ Loiacono takes those questions in stride, lets us in on which “side” of the business fueled their 200% year-over-year growth in 2021, and gives us the details on that tech that his business developed and why its standout compared to the inefficient infrastructure that currently exists to administrate and process pharmacy claims.

The big deal here is that AJ and team are tackling one of the biggest friction points in the cost of pharmacy benefits: the cost to administer a plan. They reduce that cost, and the “net cost” of every drug is reduced. AJ says its in this way that Capital Rx operates at one-seventh the cost of his competitors, the “Big Three PBMs” (CVS’s Caremark, Express Scripts, and UnitedHealth’s OptumRx) and saves its customers an average 27% on their prescription drug spend.

Now that Capital Rx has their slick enterprise software, will the business continue to operate a dual PBM-plus-PBA model, or will they double-down on the PBA side? AJ lets us know what’s next and (spoiler alert) it sounds like things might go in a surprising direction. If Capital Rx’s software is so effective at doing all the things it takes to manage pharmacy claims — underwriting sequences, implementation management and onboarding, communication, patient portals, network management, reimbursement networks, eligibility checks, etc. – what stops Capital Rx from processing other kinds of healthcare claims? Is a step into the medical claims processing side of the healthcare world on the roadmap? Tune in and find out!

HealthTechDeals Episode 41 | Cera, Birdie, Theator, Tebra, Diagnostic Robots

It’s a tale of two markets: on one side we have layoffs, sinking stock prices, and all sorts of trouble, but on the other side we’ve got some good bills passed and some pretty great fundraising! In this episode, Jess and I dive more into the dual nature of the state of health tech. Is it the best of times and the worst of times? We find out, and talk through some recent multimillion-dollar deals: Cera raises $320 million; Birdie raises $30 million; Theator raises $24 million; Tebra raises $72 million; Diagnostic Robotics raises $45 million.

-Matthew Holt

CNN myocarditis fact check by a Cardiologist (me)

BY ANISH KOKA

A recent CNN article discusses approval of the Moderna Covid-19 vaccine for people ages 6-17. The CDC director acted after its vaccine advisers on the Advisory Committee on Immunization Practices voted unanimously to support the two dose Moderna COVID-19 vaccine for kids in this age group. The goal per CDC director Walensky was to “protect our children and teens from the complications of severe COVID-19 disease”

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Virtual Care Regulatory Round-Up: Dobbs & the ‘Weaponization’ of Digital Health Data

BY JESSICA DaMASSA

How will the reversal of Roe v. Wade impact virtual care and digital health companies from a health data privacy standpoint, particularly as States crack down on the use of telehealth as a mechanism for obtaining abortions and begin to look at digital health data as potential evidence in criminal cases where abortions are illegal?

Health data privacy expert and rightfully-so-self-proclaimed HIPAA Scholar, Deven McGraw, who spent three years as Deputy Director of the Health Information Privacy Office at HHS and currently leads Data Sharing and Stewardship at Invitae, gives us her hot take on what’s happened from a health data privacy standpoint and how it will impact health tech businesses and healthcare consumers in the short and long terms.

Deven’s take: “We’ve really jumped the shark in terms of what the consequences are of health data falling into the hands of people who intend to use it in order to pursue a criminal case either against a woman (or a man) seeking a service, or the provider that performed the service…” So, what does that mean for those who are dealing with digital health data? What are the limitations as far as what HIPAA can protect for patients and what it can’t? What loopholes have Deven worried about the privacy law’s ability to stand-up to the challenges now posed by the Dobbs decision? And, what does all this mean for the telehealth-based businesses that are providing services to these patients?

We have a sweeping conversation about the shifting health data privacy landscape in the wake of Roe’s reversal in this latest episode of our special monthly Virtual Care Regulatory Round-up Series, sponsored by the health tech company powering the virtual care industry, Wheel.

Manav Sevak, CEO, Memora Health: Interview & Demo

Manav Sevak is the (young and very smart) CEO of Memora Health. I must admit to thinking that their service was just a patient chatbot, but it’s a lot more than that. It’s digitizing care workflows that touch both patients and of course the clinical care teams that support them–especially outside the walls of the hospital. They also collect a lot of patient data, and then guide their patients through their complex journey. Manav dives deep into the product and shows us a tad of the secret sauce behind the relatively simple front end of the product. Memora raised $40m earlier this year ($50m total) with Transformation, A16z, Frist Cressey & more in the cap table. If you want to understand how technology is changing clinical workflows in health care, this is a fascinating session–Matthew Holt

Caring Does Not Pay

BY KIM BELLARD

Things are tough all over the job market.  With a jobless rate at 3.5%, and with millions of people who left the job market in 2020 opting to not return to work, employers are having a hard time finding workers.  Your favorite restaurant or retail store probably has a “Help Wanted” sign out.  Checking your bag for a flight has never been more problematic, in large part  due to staffing issues.  Even tech companies are having trouble hiring.

But I want to focus on a crisis in hiring for three industries that take care of some of our most vulnerable populations – teaching, child care, and nursing.  It seems that what we say we want for our kids and the sick isn’t at all what we actually do to ensure that.  

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Lou Lasagna and the MIC “Integrated Career Ladder” – More Than Just A “Revolving Door.”

BY MIKE MAGEE

The New York Times recently shined a light on the FDA’s top science regulator of the tobacco industry, Matt Holman, who announced his retirement after 20 years to join Phillip Morris. As they noted, “To critics, Dr. Holman’s move is a particularly concerning example of the ‘revolving door’ between federal officials and the industries they regulate…”

As a Medical Historian, I’ve never been a fan of the casual “revolving door” metaphor because it doesn’t quite capture the highly structured and deliberate attempts of a variety of academic medical scientists over a number of decades in the 2nd half of the 20th century to establish and reward an “integrated career ladder” that connected academic medicine, industry and the government. 

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#HealthTechDeals Episode 40 | Everside Health, Particle Health, Annexus Health, and Homeward

Am I having a staring contest with the future of digital health? Who’s gonna blink first? How has demand gotten so low? What is going on? Tune in to this episode of Health Tech Deals to hear Jess and I hash things out, and to hear more new deals: Everside Health raises $164 million; Particle Health raises $25 million; Annexus Health raises $33 million; and Homeward raises $50 million.

-Matthew Holt

THCB Gang Episode 100, Thursday August 4

Joining Matthew Holt (@boltyboy) for the 100th #THCBGang on Thursday August 4 were Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune); Consumer advocate & CEO of AdaRose, Lygeia Ricciardi (@Lygeia);  and the Light Collective’s Andrea Downing (@bravebosom). Sadly fierce patient activist Casey Quinlan (@MightyCasey) had a Mets party flare up and couldn’t join at the last minute. There was a lot of chat about data and privacy, and even some ideas about what a future where patients data flowed but patients rights were respected might look like!

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

Jenny Schneider on Homeward’s $50M Series B, 30K-Patient Partnership with Priority Health

By JESSICA DaMASSA, WTF HEALTH

Just FIVE MONTHS after launch, rural health startup Homeward is proving its potential for growth with MORE funding – today announcing its $50 million Series B (that’s $70 million total for the folks keeping score at home) – AND a huge 30,000-patient partnership with Priority Health. Co-founder & CEO Dr. Jennifer Schneider is here to breakdown both bits of news and give us some context about what they indicate about the rural healthcare market.

There are a couple surprising facts in this one that add up to why investors like ARCH Venture Partners and Human Capital (co-leads), General Catalyst (which led the Series A), and Lee Shapiro and Glen Tullman (old buddies and former Livongo colleagues who went in on this with personal funds outside of their fund 7wireVentures) were excited to jump into a quick Series B.

Surprising Fact 1: 90% of all rural Medicare beneficiaries are covered by just 7 payers, which makes the Priority Health deal a bigger deal than even that massive 30K patient population might indicate.

Surprising Fact 2: Homeward’s market of rural Americans is actually TWICE as large as the diabetes market that spurred the investment and growth of Livongo.

For all the math, the details on how the business actually works five months in, and how Homeward is actually going to market as a ‘healthcare infrastructure’ provider rather than just a next-gen medical group, you’re going to have to give this one a watch!

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