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Matthew Holt

How About This Opportunity, Health Tech Investors? Promoting Contraception vs. Banning Abortion

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By MIKE MAGEE

Dr. Linda Rosenstock has an M.D. and M.P.H. from Johns Hopkins, and was a Robert Wood Johnson Clinical Scholar. She is currently Dean Emeritus and Professor of Health Policy and Management at UCLA’s Fielding School of Public Health, but also spent years in government, and was on President Obama’s Advisory Group on Prevention, Health Promotion and Integrative and Public Health.

In the wake of the release of Justice Alito’s memo trashing Roe v. Wade, she was asked to comment about the status of abortion in America. Here is what she said:

“The broader the access to proven family planning methods, the lower the unintended pregnancy rate and the lower the abortion rate. We can’t underestimate the role of educating and empowering women – and men – about these issues.”

These are not simply the opinions or insights of a single health expert. They are backed up by the following facts:

  1. Since 1981, abortion rates in U.S. women, age 15 to 44, have declined by nearly two thirds from 29.3 per 1000 to 11.4 per 1000.

2. Approximately half of all pregnancies in the U.S. are unintended.  Of those unintended, approximately 40% of the women chose to terminate the pregnancy by abortion – either procedural or chemically induced.

3.  The decline in the number of abortions has coincided with increased access to long-acting reversible contraception, including IUD’s and contraceptive implants. These options are now safe, increasingly covered by insurers, and more accessible to at-risk populations.

4. The increasing inclusion of sex education in middle school and high school curricula has been accompanied by a decline in high school sexual activity by 17% between 2009 and 2019.

5. There were 629,898 abortions recorded by the CDC in 2019. For every 1000 live births that year, there were 195 other women who chose to terminate their pregnancies. Almost half of the 1st trimester abortions are now chemically induced through Plan B-type pills.

What is clear from these figures is that knowledge and access to contraception is the best way to decrease the number of abortions in America.

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12 Rules for Health Tech Startups

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By MATTHEW HOLT

Last week Mark Cuban tweeted out 12 rules for tech startups and Jessica DaMassa challenged a bunch of people to respond for health care. VC and general health care wit Lisa Suennen came out with quite the list (she got to 13) but I thought someone ought to write the real rules…

1. Never start a health tech company if you can sucker someone into giving you a real job

2. When VCs at conferences say raising money isn’t a problem, throw a milkshake at them

3. Never work with a technical co-founder who won’t give you the last M&M in the packet

4. When a clinician wants to quit their job and co-found with you, remember that the good ones could be making $500K a year reading X-rays and be on the golf course at 4pm

5. Do the 50/2 diet. Starve for 50 weeks of the year then eat and drink as much as you possibly can at HIMSS & JP Morgan parties when someone else is paying

6. When the incubator/accelerator/matchmaker says that they “chose you from 700 applicants” remember that there are roughly 700 of them and every company applies to each one

7. When you get the elusive partnership deal with the big hospital system, tech company or corporate, you’re going to expect to work at the speed of the startup and the scale of the corporate. It’ll be the reverse . (I stole this from Michael Ferguson at Ayogo)

8. After your first few clients and funding rounds you’ll be losing money at a exponential rate that matches what you had for revenue on the hockey stick chart in your pitch deck

9. Hopefully you’ll eventually be able to start making the money the health care way, by establishing a monopoly that can arbitrarily raise prices to the moon and stick it to your customers. If not, start prepping for the really big Oscar/Collective/Clover type round. 

10. Pray to whatever God you follow that Softbank is still in business when #9 happens.

11. If after a decade or so of slog, you finally get the IPO, or semi decent exit, try to ignore the fact that the Instagram guys sold for $1 billion 11 months after they founded the company

12. Hope that you can disrupt health care, but remember that UnitedHealth Group’s revenue is $220 billion and CMS spends $900 billion a year and they both appear mostly powerless to make anything better.

Matthew Holt is publisher of The Health Care Blog and advises startups at SMACK.health using these principles and a few others too!

Radiology in India

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By SAURABH JHA, MD

What are the challenges of bringing advanced imaging services to India? What motivates an entrepreneur to start build an MRI service? How does the entrepreneur go about building the service? In this episode, I discuss radiology in India with Dr. Harsh Mahajan, Dr. Vidur Mahajan and Dr. Vasantha Venugopal. Dr. Harsh Mahajan is the founder of Mahajan Imaging, a leading radiology practice in New Delhi, and now a pioneer in radiology research in India.

Listen to our conversation on Radiology Firing Line Podcast here.

Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

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By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Well, you might not have noticed that my blogs were missing for the last three months but anyways, its good to be back. I was having a little time off blogs and social media as I was transitioning in my career but now I am back. Sometimes, it is very difficult to manage time for things that you must do versus things you enjoy doing, especially when these two don’t intersect. For me, these last few months the things I had to do were all bureaucratic while I couldn’t find the time for things I enjoy doing like writing these blogs. But now that we are back, let’s recap what has happened in the oncology world in the year 2019 so far. I can’t cover all of them, but will try to summarise the major events in oncology.

Hundred Foxes’ Howl versus One LION’s Roar

In my country, there is a saying that goes somewhat like the roar of one lion will scare hundreds of howling foxes away. In medicine, I guess, it translates as one good RCT trumps the results from hundreds of observational studies. For patients with advanced ovarian cancer, primary surgery to achieve complete resection is the most important treatment and prognostic factor.  However, what to do with the lymph nodes is a question that has troubled the oncology community for a long time. Logically, it makes sense to remove the lymph nodes too because they are the sanctuary sites for cancer cells. However, lymph node dissection carries high morbidity. Although multiple observational studies suggested a survival benefit with lymph node dissection, the LION trial, now published in the NEJM, shows that for women with macroscopic complete resection of primary tumour, lymph node dissection increases morbidity (postoperative complications) and post-operative mortality rates but doesn’t improve survival. I am glad that this trial was carried out and these results will now save many women with ovarian cancer worldwide from unnecessary harmful procedures, but I am also sad that we didn’t answer this question until now and thus, many patients suffered unnecessarily. I hope this LION’s roar scares us from jumping to conclusions based on logic or observational data alone and without RCT evidence in future. Another lesson here is the importance of public funds in supporting RCTs like these.

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You Lose a Child, You Lose Your Job

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By LEO LOPEZ III, MD

I’m a physician, born in McAllen, Texas. In June 2018, I returned home to demand that immigrant children who had been torn from their families as a result of the Trump Administration’s zero-tolerance policy, be safely and immediately reunited. I demonstrated at a federal detention center in McAllen at the Free the Children Protest. I marched alongside other concerned citizens, and we confronted a bus carrying the children.

With my palms pressed against the bus, I demanded that the government free them. I could not have imagined that just a few months later, I’d demand that the government find them. 

Back then, the Office and Refugee and Resettlement had just certified that over 2,600 children had been separated from their families. 

The Office of Inspector General (OIG) of the Department of Health and Human Services recently released an updated account. They actually weren’t sure how many children were separated. Turns out they didn’t count them. According to the report, HHS doesn’t know exactly if, when, or how they’ll find the lost children.

I grew up right there, along the south-Texas border, and I know that cattle are better accounted for than these infants and children.

So whose fault is it? In my opinion, the blame falls on Health and Human Services Secretary Alex Azar and Homeland Security Secretary Kristjen Nielsen, both of whom are ultimately responsible for executing the President’s policy agenda through their respective departments. The Department of Homeland Security (DHS) systematically separated families. The Department of Health and Human Services failed to identify the children who were separated. 

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Medical Education

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By SAURABH JHA, MD

What is the best way to educate medical students? In this episode of Radiology Firing Line Podcast, I sit down with Richard B. Gunderman, MD and C. Matthew Hawkins, MD to discuss medical education.

Listen to our conversation on Radiology Firing Line Podcast here.

Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

USMLE Step 1: Leveling the Playing Field – or Perpetuating Disadvantage?

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By BRYAN CARMODY

Let me show you some data.

I’m going to show you the Match rate and mean Step 1 score for three groups of residency applicants. These are real data, compiled from the National Resident Matching Program’s (NRMP) Charting Outcomes in the Match reports.

Ready?

  • U.S. Allopathic Seniors: 92% match rate; Step 1 232.3
  • U.S. Osteopathic Seniors: 83% match rate; Step 1 225.8
  • International Medical Graduates, or IMGs (both U.S. and non-U.S. citizen: 53% match rate; Step 1 223.6

Now. What do you conclude when you look at these numbers?

__

In the debate over the U.S. Medical Licensing Examination’s (USMLE) score reporting policy, there’s one objection that comes up time and time again: that graduates from less-prestigious medical schools (especially IMGs) need a scored USMLE Step 1 to compete in the match with applicants from “top tier” medical schools.

In fact, this concern was recently expressed by the president of the National Board of Medical Examiners (NBME) in an article in Academic Medicine (quoted here, with my emphasis added).

“Students and U.S. medical graduates (USMGs) from elite medical schools may feel that their school’s reputation assures their successful competition in the residency application process, and thus may perceive no benefit from USMLE scores. However, USMGs from the newest medical schools or schools that do not rank highly across various indices may feel that they cannot rely upon their school’s reputation, and have expressed concern in various settings that they could be disadvantaged if forced to compete without a quantitative Step 1 score. This concern may apply even more for graduates of international medical schools (IMGs) that are lesser known, regardless of any quality indicator.”

The funny thing is, when I look at the data above, I’m not sure why we would conclude that IMGs are gaining advantage from a scored Step 1. In fact, we might conclude just the opposite – that a scored Step 1 is a key reason why IMGs have a lower match rate.

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When Health Care Organizations Are Fundamentally Dishonest

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By BRIAN KLEPPER

A class action legal ruling this month, on a case originally filed in 2014, found that UnitedHealthCare’s (UHC) mental health subsidiary, United Behavioral Health (UBH), established internal policies that discriminated against patients with behavioral health or substance abuse conditions. While an appeal is expected, patients with legitimate claims were systematically denied coverage, and employer/union purchasers who had paid for coverage for their employees and their family members received diminished or no value for their investments.

Central to the plaintiff’s argument was the fact that UBH developed its own clinical guidelines and ignored generally accepted standards of care. In the 106 page ruling, Judge Joseph C. Spero of the US District Court in Northern California wrote, “In every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.” He concluded that the emphasis was “pervasive and result[ed] in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.” Judge Spero found that UBH’s cost-cutting focus “tainted the process, causing UBH to make decisions about Guidelines based as much or more on its own bottom line as on the interests of the plan members, to whom it owes a fiduciary duty.”

In a statement to FierceHealthcare, UnitedHealth said it “looks forward to demonstrating in the next phase of this case how our members received appropriate care…We remain committed to providing our members with access to the right care for the treatment of mental health conditions and substance use disorders.”

It is important to be clear about what transpired here. Based on evidence, a subsidiary of UnitedHealthCare, America’s second-largest health care firm, has been found in a court of law to have intentionally denied the coverage of thousands of patients filing claims. The organization justified the restrictions in coverage using internal guidelines tilted to favor financial performance rather than accepted standards of care. In other words, UBH’s leaders (as well as those at UHC) knowingly defrauded their customers and devised a mechanism to rationalize their scheme. In his ruling, Judge Spero described testimony by UHC representatives as “evasive — and even deceptive.”

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Build-Your-Own ‘Squad’ – YourCoach Redefines Health Coaching

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By JESSICA DaMASSA, WTF HEALTH

Health coaches are playing an ever-more important role in healthcare, but there’s no one single authority when it comes to finding one — or vetting them for that matter — until now.

Marina Borukhovich, CEO of startup YourCoach, talks about how she hopes to disrupt health coaching after she learned the value of having a ‘squad’ of experts help her through her breast cancer journey.

In fact, ‘Squads’ are the value-add that YourCoach is hoping will set them apart. The app’s signature feature is that it lets you build-your-own team of experts who can work together to tackle any aspect of health and wellness.

“We’re connecting coaches from around the world who are going to lead the client holistically,” explains Marina. “So, it could be diabetes support, it could be pull[ing] somebody in who does meditation, they could bring in a business coach. It just really depends on the person…and what you need as a person.”

“We’re building ‘Team YOU.”

Joining in on the fun in this interview is Eugene Borukhovich, who some of you will recognize as the face of Bayer’s G4A program.

Eugene serves as an advisor to YourCoach and is also Marina’s husband — possibly making them the “Beyonce & Jay-Z” power couple of digital health. Is this a blessing or a curse? Apparently, there are 3am pitch practices that sound like the solid foundation of any marriage.

Listen in to meet them both.

Filmed at JP Morgan Healthcare Conference, January 2019.

The Cruelty of Managed Medicare

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By HANS DUVEFELT MD

Jeanette Brown had lost twenty pounds, and she was worried.

“I’m not trying,” she told me at her regular diabetes visit as I pored over her lab results. What I saw sent a chill down my spine:

A normal weight, diet controlled diabetic for many years, her glycosylated hemoglobin had jumped from 6.9 to 9.3 in three months while losing that much weight.

That is exactly what happened to my mother some years ago, before she was diagnosed with the pancreatic cancer that took her life in less than two years.

Jeanette had a normal physical exam and all her bloodwork except for the sugar numbers was fine. Her review of systems was quite unremarkable as well, maybe a little fatigue.

“When people lose this much weight without trying, we usually do tests to rule out cancer, even if there’s no specific symptom to suggest that,” I explained. “In your case, being a former smoker, we need to check your lungs with a CT scan, and because of your Hepatitis C, even though your liver ultrasounds have been normal, we need a CT of your abdomen.”

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