In the hierarchy of evidence-based medicine (EBM), randomized controlled trials (RCTs) are like Brahmins. But do Brahmins have flaws? I discuss these flaws with Dr. Anish Koka, a cardiologist, and essayist who has writtenextensivelyaboutRCTs in THCB.
Listen to our conversation at Radiology Firing Line Podcast.
About the author:
Saurabh Jha is a contributing editor to THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partners
“Healthcare is a journey for patients. Just helping them with one piece of it — it just doesn’t get the job done…”
That’s Brian Roberts of Venrock talking about how he and Bob Kocher have moved on from investing in one-trick-pony health tech point solutions. What are they favoring now? Well, they’re not alone in seeking out platforms…especially those that solve big work flow, patient journey, or systems issues.
The underlying motivator here is, of course, money. Or rather, as Roberts puts it, the fact that “no one in the healthcare system makes any real money.”
ROI is different in healthcare. And they encourage startups — and those health systems, health plans, and provider groups that buy their solutions — to really consider what that means.
Kocher explains that what’s often overlooked is how quickly relationships turn over in healthcare. Patients can change insurance plans every year, or they may switch doctors or hospitals based on when they can get an appointment. This thwarts development of any real customer loyalty, and worse for startups, creates a situation where they need to prove tangible cost savings or increased revenue in a short 1-2 years.
What’s an entrepreneur or investor to do? Listen in for more ROI talk and advice for pivoting a point solution startup.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health. Filmed at Health Datapalooza in Washington DC, April 2018.
Wow, today is the 50th Episode of Health in 2 Point 00. On today’s episode, we have something special for you: an Epic Guest Takeover at the Health 2.0 Conference from the “intellectual capital” (as Jessica puts it) that exists today in health care & health tech. Guest Starring Rasu Shrestha, UPMC; Daniel Kraft, Singularity University; Kyra Bobinet, engagedIN; Eugene Borukhovich, Bayer. I may or may not have given my two cents in the 2 minutes–Matthew Holt
Apologies on the hiatus for posting on THCB. As many of you know, I was running around getting Health 2.0 in order this past weekend. Today we are featuring a piece on understanding how machine learning can actually work in health care today-Matthew Holt
By LEONARD D’ AVOLIO, PhD
There’s plenty of coverage on what machine learning may do for healthcare and when. Painfully little has been written for non-technical healthcare leaders whose job it is to successfully execute in the real world with real returns. It’s time to address that gap for two reasons.
First, if you are responsible for improving care, operations, and/or the bottom line in a value-based environment, you will soon be forced to make decisions related to machine learning. Second, the way this stuff actually works is incredibly inconsistent with the way it’s being sold and the way we’re used to using data/information technology in healthcare.
I’ve been fortunate to have spent the past dozen years designing machine learning-powered solutions for healthcare across hundreds of academic medical centers, international public health projects, and health plans as a researcher, consultant, director, and CEO. Here’s a list of what I wish I had known years ago.
I want to tell you about the most exciting discovery I’ve made in 2+ years of research on dose individualization methods for phase 1 cancer trials. This discovery has nothing to do with any of the technical problems I’ve confronted and solved along the way. It involves no gigantic equation, no table of simulations results, and no colorful plot. Rather, it’s a discovery about sources of power to innovate in drug development.
In general, how would you describe the balance of power between Big Pharma and the individual patient? The question seems ludicrous—maybe even offensive—in light of ongoing scandals with price-hikes and shortages for critical drugs. But in the special area of trial methodology, I’ve got a real surprise for you…
One result from my DTAT research has been a clear demonstration that 1-size-fits-all dose finding in phase 1 cancer trials can cut the value of a drug in half, or even drop it to zero by setting the drug up for failure in phase 2 or 3. Although this economic argument has never been made quite so explicit and rigorous, I am certain the underlying principle comes as no surprise to anyone. (I note hardly anyone bats an eye when I detail the math.) Continue reading…
Yesterday, the White house COVID czar surprisingly doubled down on Paxlovid as the silver bullet for COVID.
I was curious because most impartial observers don’t believe the totality of evidence supports Paxlovid as some type of COVID-slayer. The problem is that Paxlovid showed great benefit in unvaccinated patients in preventing progression to severe disease, but much less benefit in vaccinated/prior infected individuals.
Dr. Jha cites a study in the New England Journal of Medicine to note Paxlovid is a home run for those over 65, and despite negative results for the under 65 group in this study, cites 3 other studies that support its use in the 50-64 age group. He goes onto thread together some other studies to support his views.
It’s a really interesting thread that says a lot more about the politics of COVID than the science of COVID because it rests heavily on flawed retrospective studies of Paxlovid that show benefit, and ignores the much stronger randomized controlled trials that suggest otherwise.
The phrase ‘consumer health’ doesn’t mean what it used to. And, when you really think about it, neither does the word ‘consumer.’ We’ve changed. Wielding the power of our smart phones, wearable devices, and proximity to CVS Minute Clinics – and armed with expectations of near-instant gratification thanks to the Amazons and Ubers of the world – we’re more demanding, exacting and impatient of the health system than ever before.
As all of this starts to change demand, supply, and (fingers crossed) our entire industry, it’s tempting to focus on what the new guys are doing. I’m as guilty as any for being fixated on the doings of the big tech companies and sexy little startups that are coming into our space. But, the reality is that the greatest amount of change will have to come from those stalwarts of the ‘healthcare establishment’ – the health systems and the payers that ARE the system in and of itself.
So, how are they thinking about the consumerization of healthcare? What does it mean to ‘empower consumers’ when your organization is bearing the risk associated with caring for their lives? Lucky for us, Dr. Rasu Shrestha, Chief Innovation Officer of health-system/payer-system giant UPMC can break it down.
Warning: This interview is long and heady, but, man, is it ever worth it. Rasu talks about the macroeconomics of shifting risk from insurers to providers and consumers, business model implications for all players involved, and how the ‘free the data’ movement feeds into all this. Last but not least, he talks about the kinds of startups he’s hoping will help payers and providers usher in this new consumer-driven era.
If you’re doing any kind of business in healthcare today, you’ll want to give this a listen. And, if Rasu wants to add another doctorate to his name, this interview analyzing ‘the macroeconomics and shifting risk environment of the consumerization of healthcare’ might be the start of his dissertation. We’ll look for our @wtf_health footnote.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health. Filmed at the Bayer G4A Accelerator Launch in NYC, May 2018.
Jessica DaMassa asks me about what I saw at Techcrunch Distrupt, Clarify Health Solutions’s $57m round, what Wellth will do with its $5m & a whole lot about next weeks Health 2.0 Conference–Matthew Holt
If you’re a health tech startup, should you be building for your exit? Does that really lead to the greatest possible success for your business…if you know how to get out?
Here’s some advice from someone who should know. Glen Tullman is ‘the guy’ who took Allscripts public via a wildly successful IPO in the late-90s. He’s now the CEO of Livongo, a chronic condition management startup that rang in 2018 with a $105M mega-round raised internally among its current pool of investors – at more than two times the company’s previous valuation.
When I caught up with Glen earlier this year, it was just after his round closed, the company acquired Retrofit, and rumors had started swirling about Livongo going public. Needless to say, our conversation turned toward ‘the exit’ and I had the chance to ask what he would tell other startup founders about going IPO. What comes next is a passionate discourse about what it takes to not only exit – but raise and scale – a startup in healthcare. For being a money guy, Glen is no sell-out; young startups would be wise to take his two cents and invest them.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health. Filmed at HLTH in Las Vegas, May 2018.
The hottest medical school in the country right now is the New York University School of Medicine thanks to the gift of a generous benefactor that promises to make medical school free for all current and future medical students. The news was met with elation from the medical community of physicians that groans frequently about student debt loads routinely north of $200,000 upon matriculation. Not surprisingly, the technocrat class of public health experts and economists did not share in the jubilation. The smarter-than-the-rest-of-us empiricists are, after all, trained to think in terms of social justice and net benefits to society. The needs of medical students are far down the list of priorities when forming this social justice utopia.
Contemporary arguments for social justice in some form or the other trace their roots to the philosopher John Rawls and his 1971 magnum opus – “A Theory of Justice”. In words that would infuse liberal thought for a generation, Rawls laid out a blueprint for a just society by proposing a thought experiment called “the original position”. This was a hypothetical scenario where a group of people are asked to form the rules of a society which they will then occupy. The catch is that the people making the decision do so behind a ‘veil of ignorance’ not knowing the disadvantages conferred by any number of attributes (age, sex, gender, intelligence, beauty, etc. ) they may be reincarnated with. Rawls posited that under conditions in which there was a possibility of being born as a disadvantaged member of society, social and economic inequalities would be arranged to be of greatest benefit to the least advantaged members of society.
At first glance, it would seem that the objections to tuition-free medical school rest on a social justice framework that does not seem to comport with gifts to the soon-to-be-wealthy. After all, the $200,000 investment for medical school pales in comparison to the lifetime earnings of the average physician who is assured at least a six-figure income in seeming perpetuity. But it is not entirely clear that one has to even combat Rawlsian ideals to rebut the social justice do-gooders with strong opinions on how other people should spend their money. A Rawlsian framework never intended that everyone in society would be able to achieve the same outcome regardless of starting position. Rawls actually went out of his way to argue that inequalities were justified in society as long as the operating rules served to raise the position of those worst off in society. A rising tide should lift all boats – the rich may become richer, as long as the poor become richer as well.
