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Lead Pipe Cinch

By KIM BELLARD

The term “lead pipe cinch” means something that is very easy or certain. Here’s two things that are lead pipe cinches: first, that ingesting lead, such as from the water or the air, is bad for us. It’s especially bad for children, whose cognitive abilities can be impaired. Second, that the Biden Administration’s latest proposal to reduce the lead in our drinking water is not going to accomplish that.

The new proposed rules would require that lead service lines be replaced within ten years; there are estimated to still be some 9.2 million such lines in the U.S. The trouble is, no one really knows how many there are or where exactly they are, making replacement difficult. So step two of the rules is for an initial inventory by next October. The “acceptable” parts per billion would drop from 15 to 10. Utilities would also have to improve tap sampling and consumer outreach.

“This is the strongest lead rule that the nation has ever seen,” Radhika Fox, the E.P.A.’s assistant administrator for water, told The New York Times. “This is historic progress.”

Erik Olson, an expert with the Natural Resources Defense Council is also hopeful, telling NPR: “We now know that having literally tens of millions of people being exposed to low levels of lead from things like their drinking water has a big impact on the population. We’re hoping this new rule will have a big impact.”

The EPA estimates the replacement will cost $20b to $30b over the next decade; the 2021 Infrastructure Act allocated $15b, along with $11.7b available from the Drinking Water State Revolving Fund. Of course, the cost will be much higher.

Chicago alone claims it will cost $10b to replace its estimated 400,000 lead pipes. The Wall Street Journal reports: “David LaFrance, CEO of the American Water Works Association, a trade group, said the total cost could “easily exceed” $90 billion. He said the average cost to replace a single lead service line is more than $10,000, nearly double the EPA’s estimate.”

If the federal funds aren’t enough, Ms. Fox says: “We strongly, strongly encourage water utilities to pay for it,” but you should probably expect customers will end up paying – or that some of those pipes won’t be getting replaced.

It’s not like any of this is catching us by surprise. You probably remember the 2014 scandal with the Flint (MI) water crisis, with all those people lining up for bottled water. You may not remember similar crises in Washington D.C., Newark (NJ), or Benton Harbor (MI). “The Washington, D.C., lead-in-water crisis was far more severe than Flint in every respect,” Yanna Lambrinidou, a medical anthropologist at Virginia Tech and co-founder of the Campaign for Lead Free Water, told AP.

The EPA issued a set of rules around lead pipes in 1991, but those rules were watered down, and little progress has been made since. Ronnie Levin, an EPA researcher at the times, also told AP: “But, you know, we’ve been diddling around for 30 years.”

Because, you know, that’s what we do, especially when fixing a problem costs too much money.

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Where is AI in Medicine Going? Ask The Onion.

By MIKE MAGEE

One of the top ten headlines of all time created by the satirical geniuses at The Onion was published 25 years ago this December. It read, “God Answers Prayers Of Paralyzed Little Boy. ‘No,’ Says God.”

The first paragraph of that column introduced us to Timmy Yu, an optimistic 7-year old, who despite the failures of the health system had held on to his “precious dream.” As the article explained, “From the bottom of his heart, he has hoped against hope that God would someday hear his prayer to walk again. Though many thought Timmy’s heavenly plea would never be answered, his dream finally came true Monday, when the Lord personally responded to the wheelchair-bound boy’s prayer with a resounding no.”

But with a faith that rivals the chieftains of today’s American health care system who continue to insist this is “the best health care in the world,” this Timmy remained undeterred. As The Onion recorded the imagined conversation, “‘I knew that if I just prayed hard enough, God would hear me,’ said the joyful Timmy,., as he sat in the wheelchair to which he will be confined for the rest of his life. ‘And now my prayer has been answered. I haven’t been this happy since before the accident, when I could walk and play with the other children like a normal boy.’”

According to the article, the child did mildly protest the decision, but God held the line, suggesting other alternatives. “God strongly suggested that Timmy consider praying to one of the other intercessionary agents of Divine power, like Jesus, Mary or maybe even a top saint,” Timmy’s personal physician, Dr. William Luttrell, said. ‘The Lord stressed to Timmy that it was a long shot, but He said he might have better luck with one of them.’”

It didn’t take a wild leap of faith to be thrust back into the present this week. Transported by a headline to Rochester, Minnesota, the banner read, “Mayo Clinic to spend $5 billion on tech-heavy redesign of its Minnesota campus.” The “reinvention” is intended to “to present a 21st-century vision of clinical care” robust enough to fill 2.4 million square feet of space.

The Mayo Clinic’s faith in this vision is apparently as strong as little “Timmy’s”, and their “God” goes by the initials AI.

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Patients are Not “Consumers”: My Cancer Story 

By JEFF GOLDSMITH

On Christmas Eve 2014, I received a present of some profoundly unwelcome news: a 64 slice CT scan confirming not only the presence of a malignant tumor in my neck, but also a fluid filled mass the size of a man’s finger in my chest cavity outside the lungs. Two days earlier, my ENT surgeon in Charlottesville, Paige Powers, had performed a fine needle aspiration of a suspicious almond-shaped enlarged lymph node, and the lab returned a verdict of “metastatic squamous cell carcinoma of the head and neck with an occult primary tumor”. 

I had worked in healthcare for nearly forty years when cancer struck, and considered myself an “expert” in how the health system worked. My experience fundamentally changed my view of how health care is delivered, from the patient’s point of view. Many have compared their fight against cancer as a “battle”. Mine didn’t feel like a battle so much as a chess match where the deadly opponent had begun playing many months before I was aware that he was my adversary. The remarkable image from Ingmar Bergman’s Seventh Seal sums up how this felt to me.

The CT scan was the second step in determining how many moves he had made, and in narrowing the uncertainty about my possible counter moves. The scan’s results were the darkest moment: if the mysterious fluid filled mass was the primary tumor, my options had already dangerously narrowed. Owing to holiday imaging schedules, it was not until New Years’ Eve, seven interminable days later, that a PET/CT scan dismissed the chest mass as a benign fluid-filled cyst. I would require an endoscopy to locate the still hidden primary tumor somewhere in my throat.  

I decided to seek a second opinion at my alma mater, the University of Chicago, where I did my doctoral work and subsequently worked in medical center administration.

The University of Chicago had a superb head and neck cancer team headed by Dr. Everett Vokes, Chair of Medicine, whose aggressive chemotherapy saved the life and career of Chicago’s brilliant young chef, Grant Achatz of Alinea, in 2007.

If surgery was not possible, Chicago’s cancer team had a rich and powerful repertoire of non-surgical therapies. I was very impressed both with their young team, and how collaborative their approach was to my problem. Vokes’ initial instinct that mine was a surgical case proved accurate.

The young ENT surgeon I saw there in an initial consultation, Dr. Alex Langerman performed a quick endoscopy and thought he spotted a potential primary tumor nestled up against my larynx. Alex asked me to come back for a full-blown exploration under general anaesthesia, which I did a week later. The possible threat to my voice, which could have ended my career, convinced me to return to Chicago for therapy. Alex’s endoscopy found a tumor the size of a chickpea at the base of my tongue. Surgery was scheduled a week later in the U of Chicago’s beautiful new hospital, the Center for Care and Discovery.

This surgery was performed on Feb 2, 2015, by a team of clinicians none of whom was over the age of forty. It was not minor surgery, requiring nearly six hours:  resections of both sides of my neck, including the dark almond and a host of neighboring lymph nodes. And then, there was robotic surgery that removed a nearly golf ball-sized piece of the base of my tongue and throat. The closure of this wound remodeled my throat.

I arrived in my hospital room late that day with the remarkable ability to converse in my normal voice.

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Stephanie Strong, CEO, Boulder

Stephanie Strong is the CEO of Boulder, which has been blazing a trail in the virtual treatment of substance use disorder. She left venture capital to start the company and has been steadily building its capabilities and reach. We talked in depth about how Boulder helps its patients, who are predominantly on Medicaid and in general tend–as you’d expect–not to have easy circumstances. One remarkable thing Stephanie has done is spearhead resistance to the DEA’s proposal to ban telehealth prescribing of the anti-addiction drug Buprenorphine. And it looks like that campaign has been successful. that alone will save many lives. Watch this interview of a young female CEO who is making a real difference, and totally impressing me in the process—Matthew Holt

THCB Gang Special: Episode 138, Thursday 30 November 2023 with Jen Goldsack

On #THCBGang today we have a special solo episode with Olympic rower for 2 countries and Digital Medicine Society CEO Jennifer Goldsack, (@GoldsackJen) joining Matthew Holt (@boltyboy). It’s at at 1pm PST 4pm EST on Thursday November 30. Find out about what DiME is and does, and what projects it is pushing forward in the future of health tech.

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.

Health Innovation & Data: Five Common Missteps (and How to Interrupt Them)

By MARIE COPOULOS

I’ve had the great fortune of spending much of my career at the intersection of health care innovation and the underlying data that drives new models.

For those of us who’ve worked in this space for a long time, there’s a certain pattern recognition that comes with this work that is often immediate and obvious – both in terms of really cool developments but also gotchas. “Ah, you’re stumbling here. Everyone does that.”

The challenge, I’ve found, is that these ‘gotchas’ that can be so visible to the folx who’ve worked in health tech for the past few decades can be counterintuitive in the business and even met with resistance. Why?

I’m going to focus here on pattern recognition, with the goal of highlighting common stumbling blocks and, critically, ways you can interrupt them if you see them.

Pattern #1: Lacking a Clear-Eyed View of Market Data Gaps
Key Question: Do you understand how the market you’re in informs your ability to measure your work and use data to drive insight?

For those of you building models that change the status quo – this is for you. By nature these innovations break from existing care and financial models with the goal to improve them. We need this in health care. However, it’s common to overlook the fact that breaking with the status quo also breaks with the ways that we capture and serve up health data.

To this end, don’t assume you will be able to measure and show success, and that the data you need must be out there. The true differentiator is for both to align. Design with intention.

If you’re at the stage of thinking about a productized solution to a health care problem, then it is also the right time to look at the market with a lens toward data availability. In your problem space, what’s the data set you’re likely to lean on? Is it sufficient?

If the answer is that the data is not available or notoriously problematic in your market space for the problem you’re solving, this merits a pause. Can you find a way to survive in this reality? Can you create the data set you need? Can you adjust what you’re doing in some way to align with what is available? Is qualitative feedback ok?

Pattern #2: Accumulating Non-Technical Roadblocks Key Question: Do you have a good handle on the non-technical challenges impacting your data business?

A decade ago I would have approached this question differently. Technical challenges were often paramount as we tried to figure out how to solve the basics. Today, however, it’s often the opposite, in that business challenges are more likely to slow down technical progress than the other way around.

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Amazon Can Still Surprise Me

By KIM BELLARD

It’s Cyber Monday, and you’ve probably been shopping this weekend. In-stores sales on Black Friday rose 2.2% this year, whereas online sakes rose almost 8%, to $9.8b – over half of which was via mobile shopping. Cyber Monday, though, is expected to outpace Black Friday’s online shopping, with an estimated $12b, 5.4% higher than last year. 

Lest we forget, Amazon’s Prime Day is even bigger than either Cyber Monday or Black Friday.  

All that shopping means lots of deliveries, and here’s where I got a surprise: according to a Wall Street Journal analysis, Amazon is now the leading (private) delivery service. The analysis found that Amazon has already shipped some 4.8 billion packages door-to-door, and expects to finish the year with some 5.9bn. UPS is expected to have some 5.3bn, while FedEx is close to 3bn – and – unlike Amazon’s numbers — both include deliveries where the U.S. Postal Service actually does the “last mile delivery.” 

Just a few years ago, WSJ reminds us, the idea that Amazon would deliver the most packages was considered “fantastical” by its competitors. “In all likelihood, the primary deliverers of e-commerce shipments for the foreseeable future will be UPS, the U.S. Postal Service and FedEx,” the then-CEO of Fed Ex said at the time. That quote didn’t age well.

Amazon’s growth is attributed in part to its contractor delivery program, whose 200,000 drivers (usually) wear Amazon uniforms and drive Amazon-branded vehicles, although they don’t actually work for Amazon, and a pandemic-driven doubling of its logistics network. WSJ reports: “Amazon has moved to regionalize its logistics network to reduce how far packages travel across the U.S. in an effort to get products to customers faster and improve profitability.”

It worked.

But I shouldn’t be surprised. Amazon usually gets good at what it tries. Take cloud computing.  Amazon Web Services (AWS) in its early years was considered something of a capital sink, but now not only is by far the market leader, with 32% market share (versus Azure’s 22%) but also generates close to 70% of Amazon’s profits. 

Prime, Amazon’s subscription service, now has some 200 million subscribers worldwide, some 167 million are in the U.S. Seventy-one percent of Amazon shoppers are Prime members, and its fees account for over 50% of all U.S. paid retail membership fees (Costco trails at under 10%). There’s some self-selection involved, but Prime members spend about three times as much on Amazon as nonprime members.

The world’s biggest online retailer. The biggest U.S. delivery service. The world’s biggest cloud computing service. The world’s second largest subscription service (watch out Netflix!).  It’s “only” the fifth largest company in the world by market capitalization, but don’t bet against it. 

I must admit, I’ve been a bit of a skeptic when it comes to Amazon’s interest in healthcare. I first wrote about them almost ten years ago, and over those years Amazon has continued to put its feet further into healthcare’s muddy waters.

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How Patient Activation Made It Possible to Thrive with Kidney Disease

By DAVE WHITE

It had been 10 years since I’d seen a doctor when I arrived at the Emergency Room at George Washington University Hospital in October 2009. I was able to climb the first flight of stairs, but after I froze on the second, they brought me in on a wheelchair.

That was the first time I heard the dreaded words, “Your kidneys aren’t working.” I was put on dialysis immediately, and my life transformed into a series of tests and procedures. But even after three weeks at the hospital, it didn’t sink in that there was no cure.

I checked most risk factors for kidney disease: I ate the wrong foods, smoked more than a pack of cigarettes a day, drank too much beer, and didn’t exercise much. But the biggest risk to my health was not getting regular check-ups. I didn’t think I needed them, or that I had a part to play in my own health.

I hated going to dialysis three times a week. Since I could no longer work, the $20 cab fare each way was an expense my wife and I struggled to afford, so I skipped often. When a nurse warned me that if I missed three sessions in a row I would have to be dialyzed at the hospital, I decided this meant I could get away with one session a week.

The care plan I received from my providers called me “non-compliant” seven times. I felt they had written me off as a lost cause and saw no point in working with them either.

Finally, I was called into a meeting with six nurses, social workers, and clinic staff. When I said I skipped dialysis because money was tight, the charge nurse said, “We’re going to get you resources for transit and help you plan good meals.”

I was shocked – I didn’t know how support services worked. The nurse continued “But you have to do your part or you’re not going to be around much longer.”

No one had said this in such blunt terms before. I left the room, went home, looked at myself in the bathroom mirror, and said, “They’re right. You can do better. You have to do better.”

Fourteen years later, I am lucky to be alive to see the Centers for Medicare and Medicaid Services (CMS) include measures that place the patient’s voice at the center of clinical care. CMS has recognized that supporting patient activation, building a person’s knowledge, skills, and confidence around managing their health, and addressing social needs is critical to helping people like me get the support we need to get and stay healthy.

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Engage with Grace

Alex Drane started this movement in 2008 & named it Engage with Grace. What are your loved one’s wishes at the end of life? Are you with them this Thanksgiving weekend? This one slide can help you start the conversation