Month: May 2023

Healthcare Data: The Disruption Opportunity + Why This Time Is Different

May 19, 2023

By SHUBHRA JAIN & JAY SANTORO

Knowledge is power. If this adage is true, then the currency of power in the modern world is data. If you look at the evolution of the consumer economy over the past 100 years, you will see a story of data infrastructure adoption, data generation, and then subsequent data monetization. This history is well told by Professors Minna Lami and Mika Pantzar in their paper on ‘The Data Economy’: “Current ‘data citizenship’ is a product of the Internet, social media, and digital devices and the data created in the digitalized life of consumers has become the prime source of economic value formation. The database is the factory of the future.” If we look no further than the so-called big tech companies and distill their business models down in a (likely overly) reductionist fashion: Apple and Microsoft provide infrastructure to get you online, and Facebook (Meta) and Google collect your data, while providing a service you like, and use that data to sell you stuff. Likely none of this is surprising to this audience, but what is surprising is that this playbook has taken so long to run its course in one of the world’s largest and most important sectors: healthcare.

Given the potential impact data access and enablement could have on transforming such a large piece of the economy, the magnitude of the opportunity here is — at face value — fascinating. That said, healthcare is a different beast from many other verticals. Serious questions arise as to whether target venture returns can be extracted in this burgeoning market with the scaled incumbents (both within and outside healthcare) circling the perimeter. Additionally, this is a fragmented ecosystem that has existed (in its infancy) for a few years now with well-funded players now solving for different use cases. Thus, another question emerges as to which areas are best suited for upstarts to capitalize. A key theme in our assessment of the space is that regulation is driving the move towards democratized data access in healthcare, but unlike in regulatory shake-ups of the past, this time start-ups will benefit more than scaled incumbents. Furthermore, we have identified some areas within each approach to this new ecosystem that particularly excite us for net new investment. Let’s dive in.

Why This Time is Different: Regulatory + Market Dynamics

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 brought about an explosion of digital healthcare data by expanding adoption of electronic medical records from ~12% to 96%.

The Disease Killing Healthcare and Causing Physician Burnout

May 17, 2023• 1

BY SCOTT MACDIARMID

We have a healthcare crisis . . . and the crisis is now. Costs are soaring out of control, threatening the financial health of individuals and our nation. Quality of care is deteriorating, in spite of “world class care” signs seemingly on every corner. And physicians are checking out and burning out. I believe it’s one of the greatest societal issues of our day.

So, you may be wondering: How in the heck did we get ourselves into such a mess? In the greatest country in the world who spends the most on healthcare and is regularly bragging on how great it is, what happened?

Experts and pundits alike tout a litany of reasons. Increasing life expectancy, our reliance on sophisticated and expensive diagnostic tests and treatments, the costs of big pharma, duplication of care, fraud and abuse—the list goes on. Although these are all important contributors, none of them points to the underlying disease that’s killing healthcare.

The healthcare system in some respects is like the human body. It has seven systems, and the health and survival of each is largely dependent on the health of the others, much like the inter-dependent relationship of the organs of the human body. For example, if your liver or kidneys fail, your body’s health is severely impacted, even if your heart and lungs are functioning normally.

Healthcare: Make Better Mistakes

May 16, 2023

BY KIM BELLARD

I saw an expression the other day that I quite liked. I’m not sure who first said it, and there are several versions of it, but it goes something like this: let’s make better mistakes tomorrow.

Boy howdy, if that’s not the perfect motto for healthcare, I don’t know what is.

Health is a tricky business. It’s a delicate balancing act between – to name a few — your genes, your environment, your habits, your nutrition, your stress, the health and composition of your microbiome, the impact of whatever new microbes are floating around, and, yes, the health care you happen to receive.

Health care is also a tricky business. We’ve made much progress in medicine, developed deeper insights into how our bodies work (or fail), and have a multitude of treatment options for a multitude of health problems. But there’s a lot we still don’t know, there’s a lot we know but aren’t actually using, and there’s an awful lot we still don’t know.

It’s very much a human activity. Different people experience and/or report the same condition differently, and respond to the same treatments differently. Everyone has unique comorbidities, the impact of which upon treatments is still little understood. And, of course, until/unless AI takes over, the people responsible for diagnosing, treating, and caring for patients are very much human, each with their own backgrounds, training, preferences, intelligence, and memory – any of which can impact their actions.

All of which is to say: mistakes are made. Every day. By everyone.

Matthew’s health care tidbits: Health care pricing is cray-zee

May 16, 2023

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

It’s no secret that health care pricing has been out of whack for a very long time. This past week PBMs and pharma manufacturers were in front of congressional committees trying to defend the indefensible–how much drugs cost and why? Hospitals have been required to publish their fictional price lists (their chargemasters) for a few years now and more recently have been instructed to reveal what they actually get from health plans for specific procedures. You would assume that this would move overall pricing pressure down to the “best price” but that effect seems to not be happening. At least not yet. This week also did see the bankruptcy of PE-backed (or should that be PE-toppled) emergency staffing corporation Envision. But that was more because its business model depended on surprise billing and not being in insurer networks.

More typical is the recent dispute in which primary & urgent care chain Carbon Health went public with its fight against Elevance subsidiary Anthem Blue Cross in California. While it was in-network Carbon claims that it received less than Medicare rates from Anthem, while its large delivery system competitors were getting 2-4 times Medicare rates.

This sounds about right to me. Late last year I had two identical telemedicine visits for back pain with specialists. One in a private practice, another with a doctor from UCSF–my local academic medical center. Before you troll me, they were both offered to me last minute, I didn’t know which doctor would be available if I needed a procedure, and it’s always good to get a second opinion. Plus I had blown through my deductible by then so they were free to me!

My insurer paid $795 to UCSF and $219 to the private doctor. So for exactly the same thing one provider got more than 3&½ times what the other did.

There’s still lots of chatter about the growth of value-based care, but even within Medicare Advantage there’s lots of fee-for-service, and it even pops up in places it’s supposed to be dead-–like Geisinger. We are nearly 20 years on from the Bush Administration talking about transparency as the solution to health care costs yet the opacity and confusion around pricing is as bad as it’s ever been. Yes, we know some of the numbers, but the US is a long way from seeing the invisible hand working its magic and making the same thing cost the same amount across health care. The only place where that happens is under the neo-Stalinist central pricing of Medicare. Not that that seems to work well either.

There’ll be a couple more years while the “new” transparent plays out in the market, but don’t expect too much of a revolution. Then likely we’ll try something else.

The ERA – An Amendment Who’s Time Has Come

May 15, 2023

BY MIKE MAGEE

Believe it or not, The Equal Rights Amendment (ERA) was first introduced 100 years ago in 1923. But it was only adopted by Congress by a 2/3 majority vote 49 years later in 1972. That was simply step 1 in the world’s most complex and difficult national constitutional amendment process.

Step 2, approval by 3/4 of the states, seemed off to a running start with 28 of the required 38 states signing up that first year. But 1972 was also the year that Phyllis Schafly, an outspoken supporter of patriarchy and stay-at-home motherhood, began echoing her anti-ERA message on Chicago News Radio WBBM. The following year, she went national with a CBS Morning News contract, followed by a gig with CNN from 1980 to 1983.

Corny, but effective and dogged in pursuit culture war issues, she was a gifted publicist who leveraged the role of “housewife” for all it was worth. One of her gambits was to deliver homemade bread, jam and apple pies to state legislators with the message ”Preserve us from a congressional jam; Vote against the ERA sham” and “I am for Mom and apple pie.”

The irony that she had been largely “not at home” as an active conservative political warrior since signing on as a young researcher at the American Enterprise Institute in 1946, and (by now) had waged a battle for three decades to preserve “traditional American values” as a lawyer, editor, and national speaker apparently never registered with her wildly enthusiastic fanhood.

In an Ideal World, How Much Would We Spend on Health Care?

May 11, 2023• 1

BY BEN WHEATLEY

We have heard it said before, and it is no longer shocking to say, that in 2021 the United States spent $4.3 trillion on health care. To put this gaudy number in some perspective, we measure it as a share of our economy and report that health care comprised 18.3% of our gross domestic product. CMS projects that health care will approach 20% of GDP in coming years—one-fifth of everything we buy and sell in this country.

In a recent report, the Health Affairs Council on Health Care Spending and Value said that “it is unclear what percentage of GDP would represent the ideal level to devote to health care. Nevertheless, the council believes that the current expenditure and rate of growth are higher than they should be….” The council observed that the dollars devoted to health care seem “disproportionate to the health they produce” and noted that the spending places a “significant burden on families, employers, employees, and government.”

We spend approximately $12,900 per person per year on health care. By comparison, the average cost of health care per person in other wealthy countries is only about half as much.

These metrics seem to indicate that the United States is spending too much on health care, but nevertheless we struggle to identify the “right” amount. However, if someone were to ask me: “In an ideal world, how much would we spend on health care?” I would propose a very simple answer: zero. This is because, clearly, in an ideal world, no one would be sick.

THCB Quickbite: Aditya Bansod, Luma Health

May 10, 2023

Aditya Bansod is the CTO & co-founder of Luma Health. Matthew Holt spoke to him about their new offerings, following up on an interview with CEO Adnan Iqbal about 18 months ago. To their operational workflow tools which help providers route and manage the patient journey (think appointments, communications and much more), they have now added some data intelligence based on collating all the anonymized data they have access to and seeing what works best in actually getting patients to engage with their care.

Today (i.e. since this video was shot) Luma announced a new deal with major EMR player Meditech, which should get their tech into more hospital systems

Would You Picket Over AI?

May 9, 2023

By KIM BELLARD

I’m paying close attention to strike by the Writers Guild Of America (WGA), which represents “Hollywood” writers. Oh, sure, I’m worried about the impact on my viewing habits, and I know the strike is really, as usual, about money, but what got my attention is that it’s the first strike I’m aware of where impact of AI on their jobs is one of the key issues.

It may or may not be the first time, but it’s certainly not going to be the last.

The WGA included this in their demands: “Regulate use of artificial intelligence on MBA-covered projects: AI can’t write or rewrite literary material; can’t be used as source material; and MBA-covered material can’t be used to train AI.” I.e., if something – a script, treatment, outline, or even story idea – warrants a writing credit, it must come from a writer. A human writer, that is.

John August, a screenwriter who is on the WGA negotiating committee, explained to The New York Times: “A terrible case of like, ‘Oh, I read through your scripts, I didn’t like the scene, so I had ChatGPT rewrite the scene’ — that’s the nightmare scenario,”

The studios, as represented by the Alliance of Motion Picture and Television Producers (AMPTP), agree there is an issue: “AI raises hard, important creative and legal questions for everyone.” It wants both sides to continue to study the issue, but noted that under current agreement only a human could be considered a writer.

Still, though, we’ve all seen examples of AI generating remarkably plausible content. “If you have a connection to the internet, you have consumed AI-generated content,” Jonathan Greenglass, a tech investor, told The Washington Post. “It’s already here.” It’s easy to imagine some producer feeding an AI a bunch of scripts from prior instalments to come up with the next Star Wars, Marvel universe, or Fast and Furious release. Would you really know the difference?

Sure, maybe AI won’t produce a Citizen Kane or The Godfather, but, as Alissa Wilkinson wrote in Vox: “But here is the thing: Cheap imitations of good things are what power the entertainment industry. Audiences have shown themselves more than happy to gobble up the same dreck over and over.”

THCB Quickbite: Michael Gould, ZeOmega

May 8, 2023

Michael Gould is AVP of Interoperability Strategy at ZeOmega, a utilization/care management company that predominantly helps payers manage population health for about 50m covered lives including AmeriHealth Caritas, home care company HealPros and more. Since 2016 they have also been in the interoperability game since they bought Health Unity. Since Michael came over to ZeOmega from Independence Blue Cross a few years back he’s been helping the data/API integration that replaces a lot of the fax and phone-based prior-auth. He told me about the cross-sell between the two sides of the company, in part driven by the new CMS regulations about prior auth–Matthew Holt

Burden of Pain

May 5, 2023

BY JAY JOSHI

We’re seeing a trend of late, where matters in healthcare once deemed to be civil in nature are turning criminal. We see it for nearly every polarizing health issue, from abortion to opioids. And it’s affecting vulnerable patients the most.

We have two separate systems in place, civil and criminal, because we have different standards of behavior. Civil laws determine whether undue harm was caused by one party to another. Criminal laws determine whether someone committed a crime. The threshold is distinctly different. If someone is caught driving ten miles over the designated speed limit, that person committed a civil infraction of traffic laws. But if someone is caught speeding well in excess, say thirty or forty miles over the speed limit, while driving recklessly, that person committed a crime. The extent of the violation determines the applicable law. That’s why traffic laws have distinct civil and criminal laws.

The same logic applies to healthcare. We have civil penalties for undue harm or malpractice and we have criminal penalties for crimes that transpire in the clinical context. The difference between the two, for something to go from civil to criminal, is mens rea, or a requirement of criminal intent.

Criminal intent implies certain violations were committed deliberately – literally as an act of crime. Normal civil violations, such as malpractice claims, offer physicians protection against liability. That protection doesn’t apply for criminal violations. And that’s the point. It explains why the sudden push by regulators, prosecutor offices, and federal agents to investigate otherwise civil matters as criminal is so pernicious.