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The Secret Surveillance Capitalism That Suffuses Medicare

By MICHAEL MILLENSON

Imagine a government program where private contractors boost their bottom line by secretly mining participants’ personal information, such as credit reports, shopping habits and even website logins.

It’s called Medicare.

This is open enrollment season, when 64 million elderly and disabled Americans choose between traditional fee-for-service Medicare and private Medicare Advantage (MA) health plans. MA membership is soaring; within a few years it’s expected to encompass the majority of beneficiaries. That popularity is due in no small part to the extra benefits plans can provide to promote good health, ranging from gym membership and eyeglasses to meal delivery and transportation assistance.

There is, however, an unspoken price for these enhancements that’s being paid not in dollars but in privacy. To better target outreach, some plans are routinely accessing sophisticated analytics that draw upon what’s euphemistically labeled “consumer data.” One vendor boasts of having up to 5,000 “certified variables for every adult in America,” including “clinical, social, economic, behavioral and environmental data.” 

Yet while companies like Facebook and Google have faced intense scrutiny, health care firms have remained largely under the radar. The ethical issue is obvious. Since none of this sensitive personal information is covered by the privacy and disclosure rules protecting actual medical data, it is being deliberately used without disclosure to, or explicit consent by, consumers. That’s simply wrong.

But a more fundamental concern involves the analyses themselves.

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Sylvana Sinha, CEO, Praava Health

Sylvana Sinha is CEO of Praava Health, a primary & specialty care network based in Dhaka, Bangladesh. While the average American may only think about Bangladesh when there’s some disaster on the news it’s a country of 165m+ people with a GDP per capita exceeding India’s. It lacks excellent health services for its growing middle class, and that’s the gap Praava Health is filling. I learned a lot about Sylvana, Bangladesh, and Praava in this quick interview —Matthew Holt

Pfizer’s Biotech Strategy: When a “Market Force” Partners with a “Market Mover”

by JESSICA DAMASSA, WTF HEALTH

The synergistic relationship between biotech’s and biopharma’s can dramatically change the way new drugs and vaccines are bought to market – helping advance innovation on BOTH sides in a very mutually beneficial way. I’ve got an inside look at how Pfizer is working with emerging biotech start-ups, thanks to this in-depth chat with Pfizer’s Senior Vice President of Business Innovation, Kathy Fernando.

Kathy is not only responsible for developing relationships with biotech’s on behalf of Pfizer, BUT during the pandemic she led Pfizer’s mRNA scientific strategy, which was integral to its ability to rapidly develop the Covid-19 vaccine. We geek out on the “cool science” that mRNA is – AND the new platforms that biotech’s are bringing to the table – and talk about the impact both are making on the business of Big Pharma, the hot biotech investment space, and, most importantly, patients.

We also get into a bigger conversation about innovation in the Life Sciences industry – with great insights that can be extended to the rest of healthcare quite easily. I ask point blank: Pfizer is a gigantic, global biopharma company…Why wouldn’t it do these types of innovations internally, in-house themselves? Why partner outside?

Kathy explains the magic that is unlocked when a “market force” partners with a “market mover” for the sake of innovation, and the lessons learned are far reaching and applicable no matter where you are in health innovation.

How is Pfizer looking at new models for collaborating with biotech companies? What are the key characteristics of Pfizer’s culture of innovation that have newly emerged or deepened as a result of their work on the Covid vaccine during the pandemic? We dive deep into the biopharma-biotech model and all it brings in terms of new science, breakthrough therapies, and brand-new business opportunities. Watch now!

What Does It Mean To Be Human?

By MIKE MAGEE

“These are unprecedented times.”

This is a common refrain these days, from any citizen concerned about the American experiment’s democratic ideals.

Things like – welcoming shores, no one is above the law, stay out of people’s bedrooms, separation of church and state, play by the rules, fake news is just plain lying, don’t fall for the con job, stand up to bullies, treat everyone with the dignity they deserve, love one another, take reasonable risks, extend a helping hand, try to make your world a little bit better each day.

But I’ve been thinking, are we on a downward spiral really? Or has it always been this messy? Do we really think that we’ve suddenly bought a one-way ticket to “The Bad Place”, and there are no more good spots to land – places that would surprise us, with an unpredicted friendship, a moment of creative kindness, something to make you say, “Wow, I didn’t see that coming.”

I’m pretty sure I’m right that human societies, not the least of which, America, will never manage perfection. But is it (are we) still basically good. What does it mean to be human, and more specifically American?

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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.

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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.

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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.

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