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John Irvine

Consider This Speculative Amazon Scenario

Amazon has many puzzled about its plans for healthcare. Arguably, Amazon is just as puzzled, but is – in effect — running a massive Delphi process to sort out the plan. Amazon is, after all, the Breaker of Industries, Destroyer of Margins. Allow rumors to float, hire some people, have meetings, seek a few regulatory approvals, start a vaguely missioned non-profit with other business titans. Fear and greed do the rest.

Stock prices gyrate as investors bet and counter bet on who is vulnerable, incumbent CEOs promise cooperation or competitive hostility, analysts speculate, “old hands” pontificate, and consultants send megabytes of unsolicited slide decks to South Lake Union. All that information gets exposed without any material commitment.

Disrupting the roadblocks to healthcare innovation

Proper strategic planning requires consideration of a few disruptive (if less likely) scenarios. Amazon getting into hospital supply or creating yet another benefits buying group is easy to imagine but conservative in scope. And we know Bezos thinks long-term and that profits are secondary to platform building.

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The Luxury to Choose

The 80 year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. But, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated and that is exactly what had happened in this case.

We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.

Back home, seeing an 80 year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers, called Gardasil, which is recommended for all pre-teens in the United States.

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A National Health Encounter Surveillance System

Trust is essential for interoperability. One way to promote trust is to provide transparency and accountability for the proposed national system. People have come to expect email or equivalent notification when a significant transaction is made on our personal data. From a patient’s perspective, all health records transactions involving TEFCA are likely significant. When a significant transaction occurs, we expect contemporaneous notification (not the expectation that you have to ask first), a monthly statement of all transactions, and a clear indication of how an error or dispute can be resolved. We also expect the issuer of the notification to also be accountable for the transaction and to assist in holding other participants accountable if that becomes necessary. Each such notification should identify who accessed the data and how the patient can review the data that was accessed. Each time, the patient should be informed of the procedure to flag errors, report abuse, and opt-out of further participation at either the individual source or at the national level.

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Fear and Loathing in Pay-For-Performance Land

Stephen Soumerai ScD
Kip Sullivan JD

Pay for performance, the catchall term for policies that purport to pay doctors and hospitals based on quality and cost measures, has been taking a bashing.

Last November, University of Pittsburgh and Harvard researchers published a major study in Annals of Internal Medicine showing that a Medicare pay-for-performance program did not improve quality or reduce cost and, to make matters worse, it actually penalized doctors for caring for the poorest and sickest patients because their “quality scores” suffered. In December, Ankur Gupta and colleagues reported that a Medicare program that rewards and punishes hospitals based on arbitrary limits on the number of hospital admissions of heart failure patients may have increased death rates. On New Year’s Day, the New York Times reported that penalties for “inappropriate care” concocted by Veterans Affairs induced an Oregon hospital to deny acute medical care to its sickest patients, including an 81-year-old “malnourished and dehydrated” vet with skin ulcers and broken ribs.

And just three weeks ago, the Medicare Payment Advisory Commission recommended that Congress repeal a Medicare pay-for-performance program, imposed by Congress in 2015, because the program is costly and ineffective.

This bad news comes on top of a decade of less-publicized research indicting policies intended to reward and penalize doctors based on measures — most of them inaccurate — of their cost and quality. That research demonstrates that penalties against doctors:

Do not improve the health of patients

Harm sicker and poorer patients

Encourage doctors and hospitals to avoid or “fire” sicker patients who drag down quality scores due to factors outside physicians’ control

Cause some doctors to stop using lifesaving treatments if they don’t result in bonuses

Create interruptions in needed medical care

Reduce job satisfaction and undermine altruism and professionalism among doctors

Cause doctors to game quality measures. For example, a Medicare program that punished hospitals for hospital-acquired infections actually induced some hospitals to characterize infections acquired after admission as “present upon admission” or to simply not report the infection rather than reduce actual infection rates.

Subjecting doctors and hospitals to carrots and sticks hasn’t worked for several reasons. The most fundamental one: Clinician skill is not the only factor that determines the quality of care. Consider one widely used performance measure: the percent of patients diagnosed with high blood pressure whose blood pressure is brought under control. Doctors who treat older, sicker, and poorer patients with high blood pressure will inevitably score worse on this so-called quality measure than doctors who treat healthier and higher-income patients.

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A Health Tech’s Secret Weapon: The People Under The Hood

The recently-announced acquisition of the oncology data company Flatiron Health by Roche for $2.1B represents a robust validation of the much-discussed but infrequently-realized hypothesis that technology entrepreneurs who can turn health data into actionable insights can capture significant value for this accomplishment.

Four questions underlying this deal (a transaction first reported, as usual, by Chrissy Farr) are: (1) What is the Flatiron business model? (2) What makes Flatiron different from other health data companies? (3) Why did Roche pay so much for this asset? (4) What are the lessons other health tech companies might learn?

The Flatiron Business Model

To a first approximation, Flatiron has a model that can be seen as similar to tech platforms like Google and Facebook – delight (or at least offer a useful service to) front-end users, and then sell the data generated to other businesses. For Flatiron, the front-end users are oncologists (mostly community, some academic), and the data customers are pharma companies. In contrast to Google (and also in contrast to the less successful Practice Fusion, recently acquired at a loss), Flatiron doesn’t sell access to front-end users themselves (e.g. through targeted ads), but rather access to de-identified, aggregated clinical information.

Success of this model requires that the Flatiron platform is attractive to oncology practices, who must feel that they’re getting distinct value from it and believe that it helps them fulfill their primary mission of taking care of cancer patients. If this is true, then the Flatiron platform will enjoy continued traction from its current base, and may more easily win over new users (including practices that use a different EMR system, like Epic, but still want access to the Flatiron network and analytics).

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CMS Quietly Launches an Offensive Against Direct Primary Care

Our healthcare system is self-destructing, a fact made more obvious every single day.  A few years ago, a number of brave physicians who were fed up with administrative burden, burnout, and obstacles to providing care for patients started a movement –known as Direct Primary Care (DPC.)  This is an innovative practice model where the payment arrangement is directly between a patient and their physician, leaving third parties, such as insurance or government agencies, completely out of the equation. 

The rapidly growing number of DPC physicians have organized into a group called the DPC Coalition (DPCC); suddenly, the Centers for Medicare and Medicaid (CMS) is paying attention.  As of February 2018, there are 770 DPC practices across the United States with new clinics opening each week as brave physicians leave the “system” behind, never looking back. Breaking free from the chains of insurance and government, this group is restoring the practice of medicine to its core, a relationship between a physician and their patient.    

CMS understands there is a problem with the way Medicare services are being delivered to tax payers; it turns out their idyllic version of “high quality” care is not as affordable as they predicted.  All evidence indicates the DPC model is not only capable of generating significant cost reduction, but also saving the federal government billions if administered on a large-enough scale.  As fewer physicians accept Medicare and convert to DPC practices, CMS wants a piece of the pie. 

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The Healthcare.gov Rescue and the Hawaii False Alarm . When Good Government Tech Goes Bad.

By now, you’ve heard of the Hawaii False Alarm, and about the blowback and blame as people try to sort out how this could have happened. In government circles, however, there have been empathy and knowing cringes. It is the norm, not the exception, that government systems are confusing and hard to use. Horrible mistakes happen when people use clunky government systems — they just usually don’t make the news.

In fact, the last time a government technology failure was so thoroughly plastered across the news was when healthcare.gov failed to launch. At the time, I was working for the Chief Technology Officer of the United States in the White House. It was a difficult, frustrating time — but the media glare and public outrage opened up an opportunity to make some critical progress on changes that government workers had been asking for, for years, to prevent it from happening again. Government design is news right now, so I thought I’d share some thoughts on what people working on this problem could do next.

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On Data and Informatics For Value-Based Healthcare

Introduction

Value-based healthcare is gaining popularity as an approach to increase sustainability in healthcare. It has its critics, possibly because its roots are in a health system where part of the drive for a hospital to improve outcomes is to increase market share by being the best at what you do. This is not really a solution for improving population health and does not translate well to publicly-funded healthcare systems such as the NHS. However, when we put aside dogma about how we would wish to fund healthcare, value-based healthcare provides us with a very useful set of tools with which to tackle some of the fundamental problems of sustainability in delivering high quality care.

What is value?

Defined by Professor Michael Porter at Harvard Business School, value is defined as a function of outcomes and costs. Therefore to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets. Sir Muir Gray expands on the idea of technical value (outcomes/costs) to specifically describe ‘personal value’ and ‘allocative value’, encouraging us to focus also on shared decision making, individual preferences for care and ensuring that resources are allocated for maximum value.
This article seeks to demonstrate that the role of data and informatics in supporting value-based care goes much further than the collection and remote analysis of big datasets – in fact, the true benefit sits much closer to the interaction between clinician and patient.

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2018 Forecast: Another Theranos, Hospital Hiring Slows & Successful HIT Exits

Bryan Roberts
Bob Kocher MD

For what is now an annual tradition, we are once again attempting to be healthcare soothsayers. We are proud to share with you our 10 healthcare predictions for 2018. In 2017, amaz-ingly, eight of our predictions came true.

For 2018, we are betting on the following:

1. Another Theranos

We think at least one healthcare information technology company with an enterprise value of more than $1 billion (not including Outcome Health, which we could not have predicted tanking so spectacularly quickly) will be exposed as not having product results to support their hype. It will also expose embarrassed investors who did not do careful diligence and founders with poor integrity.

2. Hospital hiring slows

After a decade of sustained hiring every month, hospitals will stop. Many will downsize their administrative staffs as admissions continue to slowdown and reimbursement pressures intensify. We expect multiple months with net healthcare job losses which would be the first time this has occurred since the Bureau of Labor Statistics started tracking the data.

3. Successful HCIT exits

After a long wait, and more than $10 billion of venture capital invested in startups over the past five years, we will begin to see successful IPO and M&A exits. These will reassure growth investors to keep pouring money into companies with traction.

4. Amazon does not disrupt PBMs

Despite daily rumors, we think Amazon will not shake up the PBM sector. Instead, Amazon will limit its healthcare market footprint to its existing consumer products and distributing non- regulated healthcare goods to healthcare providers (adopting a B2B and not B2C strategy).

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Questioning the Link Between Sports-Related Concussions and CTE

Peter Cummings MSc, MD
Uzma Samadani MD, PhD
Jason Chung

On Jan. 18, an article by Dr. Lee Goldstein of Boston University and colleagues in Brain, a leading neurological journal, was released and touted as proving the link between subconcussive hits to the head and chronic traumatic encephalopathy (CTE) (“Real risk of CTE comes from repeated hits to the head, study shows,” Feb. 4). That same day the CTE advocacy group — the Concussion Legacy Foundation — announced a national campaign called F14G Football to convert all under-14 football into flag football, thereby eliminating tackle football.

The message sent to assembled media and onlookers was that eliminating tackle football for youth is the key to safeguarding the brains and futures of America’s youth.

The truth is not so simple.

The scientific evidence linking youth casual sports play to brain injury, brain injury to CTE, and CTE to dementia is not strong. We believe that further scientific research and data are necessary for accurate risk-benefit analysis among policymakers for two reasons.

First, evidence-based science calls for research to be conducted under generally accepted principles. The case series presented by the Boston University group, primarily due to its ascertainment bias, is weaker than the evidentiary standard sufficient to demonstrate an association or causation and conflicts with pathologic findings in other studies.

CTE pathology in the brain has been shown by British pathologists to be present in approximately 12 percent of normal healthy aged people who died at an average age of 81 years (Ling et al. Acta Neuropathologica). The presence of CTE pathology in the brain on autopsy has not been shown to correlate with neurologic symptoms before death.

To be clear, CTE pathology could be present in a normal person.

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