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Explorations in French Health Care! (Or what I did on my vacation!)

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By MATTHEW HOLT

This is a personal story about this blog’s publisher (me!) but it has just enough health care stuff to keep it relevant!

This year I finally got invited on the annual week-long mountain bike ride run by my friend JB and his ex Taiwan/Hong Kong buddies. I’ve actually been practicing and training most of the summer and arrived pretty confident even though I knew it would be tough. This edition is in Provence in France.

Before it all went wrong

And then…..2 hours in on the first day it turns out I was too confident…

Back in 2002 I smashed my knee snowboarding into a tree. When I told him my dad said ” You silly twit”

I actually was a silly twit this time too. I was on a new bike (a rental) that was actually much more advanced than my usual one and had a feature I had barely practiced with (a drop seat) that requires a new technique. It had rained heavily the day before so it was wet (& living in California I have very limited experience mountain biking in the rain), and I was behind the pack as my chain had come off. (There was a guide sweeping the rear who fixed it for me). So when I got to the first challenging down hill slope I didn’t do the sensible thing of stopping & walking to the bottom to check it or do what 75% of the group did and walked their bike down it, I just thought, “I can do that’ and plunged down it. Not quite sure exactly why I fell but I went over the bars slightly to the right (luckily missed a tree) & hit the ground on the downslope hard on my right side. In any sport any one of new equipment, new environment, new technique means you should err on the side of caution and I had all 3, yet just went for it! Very bad decision!

After I got up I thought I had just badly winded myself. The guide helped me back on the bike & I rode on. For the next 5 miles or so he helped push me up the steeper bits of a climb (he had an eBike). I actually did a slightly less challenging but still tough downslope section & a friend gave me a big dose of Tylenol at the next stop point. I actually crashed again after that (slipped on a wet rock) but landed ok on my elbow which was padded (as were my knees but not my torso) and only had some slight scratches but I made it to lunch feeling sore but OK.

Continue reading…

The Society for Participatory Medicine Presents a Creative Learning Exchange: Community Health Access and Equity 

I’ve been on the board of the Society for Participatory Medicine for a few years and we are kicking off a series of “Creative Learning Events”. There’ll be two in the balance of 2022 and hopefully one a quarter thereafter. Should be great in-person AND online exchanges about getting participatory medicine into the hear of the health care system. Here’s details on the first one, October 20, in Boston and everywhere else!–Matthew Holt

Participatory Medicine is a movement in which patients, caregivers and healthcare professionals actively collaborate and encourage one another as full partners in healthcare. 

The Society for Participatory Medicine with the support of our sponsor NRC Health Presents A Creative Learning Exchange(CLE): Community Health Access and Equity

Date: October 20, 2022 Time: 12:00 noon – 4:00pm (Lunch Is Included for In-Person)

Location: Brown Advisory, 100 High Street, 9th Floor, Boston, MA 02110

For more details and to REGISTER TODAY click here.

The Society for Participatory Medicine believes that the culture of healthcare is not benefiting everyone equally and needs to change. And healthcare won’t get better until healthcare culture gets better. We want to drive this change by enabling collaboration, education, information sharing, and communication among patients, caregivers, and health care professionals. Join the movement! 

This Creative Learning Exchange, in-person and online hybrid event, will be highly interactive and participatory, using a ‘Neighbors at Each Table’ approach to engaging you in facilitated discussion and brainstorming. 

These discussions will focus on applying the Participatory Medicine Manifesto behaviors in culturally and racially diverse communities to enable access and equity in care. Your ideas, insights and solutions that emerge will be curated by SPM to build a toolkit of participatory medicine guidelines. These will be shared with you and through SPM’s social networks, website and blog. 

For more details and to REGISTER TODAY click here.


Thank you to our series sponsor NRC Health. Thanks to Massachusetts General Hospital Equity & Community Health for sponsoring the meal. Thanks for Brown Advisory for proving the venue & AV.

What does CVS’s new deal signify about Medicare Advantage?

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

Meanwhile, it’s time for Matthew’s tidbits. A quick moment’s thought of course for the Queen, her family and semi-loyal subjects, of which I am (sort of) one. In fact in the last 7 days my ancestral homeland of the UK has got a new King, a new prime minister and a new manager at Chelsea FC. Still, two of three of those changes seem to happen about every 18 months so we shouldn’t be too surprised that they all happened at once.

Talking of changes, this week’s big American health care news was the other Matthew Holt pocketing a boatload of cash. Yes, Jess DaMassa is still hoping to upgrade her partner on Health Tech Deals without having to change the name on the intro (and ain’t shy about telling me!). The wrong Matthew Holt (from my bank balance’s perspective) has a fund called New Mountain Capital, which owns a lot of health tech assets. It was the majority owner of Signify Health–bought this week for $8bn by CVS, after being the subject of a bidding war between them, United & Amazon.

Signify is very interesting for what it does or doesn’t do. Almost all its business (having acquired and recently shut down a bundled care payments division) is now connected to sending nurses out to the homes of Medicare Advantage (MA) members on behalf of all the big payers (Aetna, United, Humana, etc) to do in-home health assessments of their members. Critics say that these assessments were used to upcode the health risk assessment factor (RAF) of those members, which causes CMS to pay more to those MA plans. MA’s defenders, including George Halvorson on THCB, say that this upcoding isn’t happening, or at least not in that way, and that the better care MA members get actually reduces overall Medicare costs.

Having read a lot and been talked at by both sides of this debate, it seems to me that both things are true. Many MA members have been “upcoded”, in many cases perhaps legitimately, and the CMS data–which is extremely murky & hard to parse–also seems to indicate that MA members’ treatment overall costs less than those in FFS. (I’ll spare you the CMS Trustees report but here is Milliman’s assessment–albeit paid for by MA proponents–using their data. MedPAC disagrees).

Signify brought in over $640m in revenue for those home evaluations in 2021 and is forecasting over $1bn in revenue this year at a healthy EBITDA. But that still means CVS is paying 8 times future revenue & maybe 30-40 times earnings. It will indeed be interesting to see if health plans remain so keen on these home evaluations if (as George Halvorson says) CMS has actually stomped on them being used for RAF upcoding. It’s also not clear if those MA plans competing with CVS/Aetna will be keen on using a company owned by one of their rivals–which might put its thumb on the scale in ways they can’t know about.

Of course, it might just be that what Signify is doing is radically improving the experience and health of those seniors in Medicare Advantage by discovering what health and social issues they have, and helping their plans and providers manage their care better. Wouldn’t it be great if all seniors could get this type of care and attention? And wouldn’t it be great if the taxpayer knew it was both helping improve seniors’ health and reducing our costs? The challenge for Medicare (and the rest of us) is to get to a place where the incentives are transparently only for improving health, and where Medicare Advantage plans are regarded across the board as actually doing only that.

We are not there yet.

#HealthTechDeals Episode 45: CVS buys Signify; Psych Hub; 98point6 & MedMinder

It’s been a week of endings for UK politicians, soccer coaches and tennis GOATs. And a big deal in health tech as CVS buys Signify Health for $8bn. Psych Hub raises $16m, 98point6 tacks on $20m more in a poss direction change & MedMinder tackles that hardest of all questions–Did I take my pill or not? Jess DaMassa almost lets me takeover, but we know who she really wants in charge! Matthew Holt

We Should Channel People Into Medicare Advantage Plans Where They Won’t Have Amputations or Go Blind (Part 2)

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By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last year arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). We also published his criticism (Part 1. Part 2. Part 3) of Medpac’s analysis of Medicare Advantage.  Now Medpac is meeting again and George is wondering why they don’t seem to care about diabetic foot amputations. We published part one last week. This is part two– Matthew Holt

We have more amputations and we have more people going blind in our fee for service Medicare program today because we buy care so badly and because we have no quality programs or care linkages for our chronically Ill patients and our low income people in that program.

We have far better care in our Medicare Advantage programs at multiple levels today, and we should be building on that better care for everyone.

The important and invisible truth is that we have major successes in providing better care to Medicare Advantage members across the entire spectrum of that package of care. The sad truth is that MedPac actually keeps those huge differences in care performance by the plans secret from the Congress and from the American public for no discernable or legitimate reason.

We have an epidemic of amputations that are causing almost a fifth of our fee for service diabetes patients who get foot ulcers to lose limbs. The number of patients in both standard Medicare Advantage and in the Medicare Advantage Special Needs Programs who undergo amputations and who have that functional and dysfunctional care failure is a tiny fraction of that number.

MedPac pretends the program does not exist. They did a lengthy study on the overall special needs dual eligible program for Medicare a year ago without mentioning the plans or describing any of the things that the plans to do make care better for those patients.

We know that in fee for service Medicare, 20% percent of diabetes patients routinely get ulcers and 20% of those ulcers to turn into amputations. There are far fewer amputations for Medicare Advantage plan members—and we have failed our overall Medicare population badly by not sharing that information more broadly at open enrollment time.

Medicare Advantage Five Star quality plans that have created a culture of quality improvement at many care sites. Those plans compete fiercely on quality goals and take pride in attaining and celebrating the highest scores.  We started with less than 10% of plans with the highest scores for the first enrollment periods. Now more than 90% of Medicare Advantage members are able to choose between four and five star plans.

The quality measurements that are missing from the set of consumer choices are the ones that relate to the most serious issues for the consumers—and that’s where MedPac should be putting the right set of information on the table to compare the two systems of care. Large amounts of data show that amputations caused by diabetes follow very predictable patterns.  

Roughly 33% of Medicare patients will have diabetes. 20% of diabetics will have ulcers. That number goes up to 30% for some patient groups—but you can count of at least 20% overall to have ulcers.  We know that the overarching pattern in fee for service Medicare is for 20% of those ulcers to end up needing and getting amputations.

Continue reading…

Deep-Dive Into Availity’s Acquisition of Diameter Health

by JESSICA DAMASSA

“There’s $4-$4.5 trillion dollars of annual spend in the healthcare system. A trillion of that is administrative. And, some big chunk — some BIG number that you measure in the 100’s of billions of dollars – is waste. So, the TAM for what Availity and Diameter Health are going to do together is huge.” Russ Thomas, Availity’s CEO, is clearly excited about his company’s recent acquisition of Diameter Health and we ask him – and Diameter’s President & COO Mary Lantin – why this is such a big deal.

In the end, what this comes down to is making more sense of all the data that flows between providers and payers to automate where possible, find insights to improve business processes and workflows, and, ultimately, cut out that notorious “admin expense” that adds to healthcare cost without creating any value.

For twenty years, Availity’s been in the business of “translating” data from providers into a language health plans can understand, so payors could refine their own business processes and automate pre-auths, pay claims, etc. Diameter, on the other hand, deals in the world of clinical data and “upcycles” it into concepts and “digestible bites” that a health plan can use to automate an administrative workflow process with a provider and – get this – build a longitudinal health record that now Availity’s robust supply of claims and health plan data can fully flesh out.

How excited are Russ and Mary about the idea of this comprehensive, longitudinal, fully-integrated clinical-plus-claims patient record? Much more excited than even I anticipated! Tune in for all the details on the merger and this BIG vision for scaling up the fight against healthcare’s massive spend on administrative waste.

Amazon’s Coitus Interruptus: In or out?

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By MATTHEW HOLT

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

Meanwhile, it’s time for Matthew’s tidbits and of course given their recent news-making I am going to focus on Amazon in health care. The news is of course that they are in health care in a big way, buying One Medical. The news is also of course is that they are out–shutting down Amazon Care.

This reminds me of the famous criticism delivered in the British parliament by one MP about another back the last time (in the 1970s) there was a vote about leaving the EU. “The Honourable gentleman can’t make up his mind. First he’s in, then he’s out. In, out. In, out. This is the politics of coitus interruptus.” After a moment a voice from the backbenches shouted “Withdraw.”

So is Amazon in or out?

They are out of their 4 year effort to build a hybrid telehealth-to-home medical group that helps mainstream employers manage their costs. This is despite stating their intent just a few months back to add new clinics and this year adding a decent number of employer clients including Hilton hotels–before that they only really had a few of their own employees as clients. Interestingly enough, it was the development of this platform that convinced Amazon that they didn’t need Haven–their alliance with JP Morgan and Berkshire Hathaway which was developing a similar offering.

They are in to the business of One Medical to the tune of a $3Bn acquisition as well as putting in $300m extra cash so far, and likely a lot more later. Like Amazon Care, One Medical has a hybrid telehealth and clinic approach (though no home visits as yet). When Amazon said they were killing Amazon Care, they suggested that a lack of employer uptake was the biggest problem. One Medical does have employer clients. But these aren’t mainstream low or medium wage employers to whom they are delivering capitated care at a worksite. In One Medical terms that means an employer pays their employees’ $200 per member annual fee, after which the employee can see a One Medical doctor. And curiously enough by far their biggest employer client is Google.

One Medical says that they lower overall costs for their employer clients, but to use another British political line, “they would say that wouldn’t they.” In reality One Medical does very little specialty or hospital care management, and via its relationships with local high-priced health systems is able to charge insurers very high prices for primary care which they seem to actually pay! (And yes I have lots of personal experience here..). Putting aside the fact that One Medical somehow is contriving to still lose loads of money–a big reason why it put itself up for sale–it is not an organization trying to manage costs for employers in value-based care arrangements, unlike say Firefly Health or even Crossover Health (of which Amazon is a big client for its lower paid workers).

You’ll notice that I am conveniently ignoring the Iora Health part of One Medical which they inexplicably bought last year. Iora focuses on capitated services for Medicare Advantage plans, and it is trying to manage costs. Though given the amount it’s losing, that effort isn’t going so well either.

It’s possible that Amazon is going to surprise us and try to turn Iora + One Medical into a capitated giant to work with and steal the margin of the big Medicare Advantage plans. Then later, move that strategy into mainstream employers.

But if they were going to try that it would probably have been easier and more culturally aligned to merge Iora with Amazon Care. My suspicion is that Amazon means what it says and is finding it too hard to manage costs for employers. My guess is it will jettison Iora, keep using Crossover and others to manage costs for its own lower-paid employees, and try to turn One Medical into a Whole Foods-like national brand for the cost- unconscious top 25% of Americans….and somehow make it profitable.

If they manage that it would be great for Amazon’s business. But it would be very disappointing for those of us hoping that Amazon was going to have a serious go at providing a low-cost, innovative service that was trying to lower overall health care costs for employers and make a serious dent in the market power of America’s high priced, under-delivering hospital systems.

“You’ve Gotta Shoot Some Sacred Cows:” MSU Health Care’s CIO On Health Systems & Tech Transformation

By JESSICA DAMASSA

“If I continue to hear how difficult it is for hospitals to make money, I would like for them to see what it’s like to operate a real business. They are overstaffed…they are overpaying…they are not responsible for quality or outcomes…there are no guarantees on their services…they can block competition from entering their markets…they can buy up market share – that’s not a real business.”

Well, lesson learned. If you ask Roger Jansen, Michigan State University Health Care’s Chief Innovation & Digital Health Officer, how he think things are going in US health systems when it comes to digital transformation and the integration of technology and value-based business models in hospitals, be prepared for a blunt conversation about how US healthcare model is failing and how the lack of incentive for change is keeping us all stuck in the same-old, same-old.

From digital health and telehealth to EMR and value-based care business models, we cover a lot of health innovation ground in this chat and get a reality check on whether or not things are really evolving inside health systems – and which stakeholders Roger believes hold the key to driving that change. (Hint: He identifies them as those who are already “footing the bill for the lavish lifestyles that healthcare administrators live that are probably well out-of-balance with the value that they actually bring to their corporations.”)

Roger on digital health? There’s better adoption and receptivity when it’s combined with “a service component that doesn’t add additional burden to the clinical component.” On virtual care and telehealth?

Down 70% since the pandemic’s lockdown days and more of a “behavior change problem” at this point than anything else.

When we get to EMRs around the 19-minute mark, things get extra spicy and we take a turn into “all this gibberish about volume versus value” and how value-based care models aren’t gaining meaningful traction either. It’s a big, bold reality check on the state-of-play of health tech, virtual care, and healthcare payment model innovation in health systems… watch now and let us know what you think!

Keycare raises $24m & Dr Lyle thinks he’s found a virtual care niche!

Lyle Berkowitz has been very well known as a techy doc for years. He’s ran an innovation center at Northwestern, written books, been featured at tons of conferences (including Health 2.0), had a stint at MDLive and was founder and Exec Chair at HealthFinch which was bought by Health Catalyst. But instead of lying on the beach drinking MaiTais, Lyle has decided that there’s room for yet another virtual care play, and today his new company Keycare is announcing a $24m round and a deal with Spectrum Health (Michigan). What is it? It’s a virtual medical group that’s going to be supporting traditional health systems with care after-hours, out of state and much more. Is there room in the telehealth market for yet another niche play? You may guess that I asked and Lyle explained why!–Matthew Holt

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