Six competitor CEOs and one ex-CMO discuss the biggest-ever digital health merger
By JESS DAMASSA & MATTHEW HOLT
It was the news that stunned the world of health tech. And us! So we had seven of Teladoc and Livongo’s biggest competitors weigh-in on what the merger means for telehealth, digital health, the future of health care delivery–and their businesses! You’ll hear from the CEOs of Omada, Ginger, One Drop, Vida, Lark & Cloudbreak, with some spicy commentary from Lyle Berkowitz who was, until recently, CMO at MD Live. From reaction to the merger to speculation about how this will impact the future of digital health funding, fasten your seat belts for some impactful and fun infotainment about all the implications of the deal.
We are launching a new THCB program! The THCB Book Club (TM) is going to be a discussion with leading health care authors, which will be released on the third Wednesday of every month.
We are kicking off with the new book from Hemant Teneja (VC at General Catalyst who has been writing many big checks lately) and Stephen Klasko (CEO at Jefferson Health System and one of the most unusual hospital system bosses in America). Their book is called UnHealthcare: A Manifesto for Health Assurance which is a how-to for creating a platform for a revolutionary future for healthcare, Taneja said. “Health assurance is an emerging category of consumer-centric, data-driven healthcare services that are designed to bend the cost curve of care and help us stay well.” Sitting in on the interview because we can’t get rid of him we will also have Glen Tullman from Livongo (Just kidding, Glen!). He will weigh in on how this connects with his new idea of Consumer Directed Virtual Care. Matthew may say something about the Continuous Clinic too, and Jessica will keep score of all the crises, Tsunamis, the many ways the health care is broken, and how many zingers Glen & Matthew get in on each other!
We want YOU to read the book in advance and email us questions or comments for us to ask the author(s) before the show. (We record a day or two in advance so please email us or put question in the comments here or on Twitter by the 17th).
This episode of the THCB Gang included regulars Grace Cordavano (@GraceCordovano) , Deven McGraw (@HealthPrivacy), Ian Morrison (@seccurve), and special guest patient entrepreneur Robin Farmanfarmaian (@Robinff3). We talked about patient experiences, the state of play in health care business, and about new technologies and more. And after tomorrow it gets preserved as a podcast on Itunes & Spotify Enjoy! – Matthew Holt
Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.
Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.
If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt
“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”
A colleague shared an experience with me about testing one of his patients for the novel coronavirus and it left me a bit puzzled. An elderly gentleman with past medical history of severe COPD (chronic obstructive pulmonary disease) and heart failure came to the ER with shortness of breath, edema and fatigue. Chest x-day suggested pulmonary edema. He wanted to test him for SARS-CoV2 but hesitated. Eventually he was able to order it after discussions with various staff administrators. Dialogue included sentences like “why do we need testing? He has Congestive Heart Failure (CHF), not COVID-19” and “it could create panic amongst staff taking care of him”. I applauded his persistence as eventually the test was done. To not test is counter-intuitive and more like an escape from diagnosing the virus rather than escaping the virus itself.
One – the mere fact that we might hesitate before testing for a virus which is a cause of a (ongoing) pandemic should ring all the bells of concern about lack of an optimal strategy. Inadequate testing has remained the Achilles heel of our stand against COVID-19 because to have a lasting stand, we must know where to take the stand.
Two – the concern of CHF raised above is clinical and valid, but it is of grave importance to understand that CHF and COVID-19 are not mutually exclusive. We now know that even the infamous flu and COVID-19 are not mutually exclusive. Common protocols from a few months ago to test for flu in sick outpatients and not test for COVID-19 if flu was positive was like the prey closing its eyes and hoping the predator does not see it. It did defer the use of an already scarce resource at the time, testing. SARS-CoV2 is a virus and the disease caused by it is called COVID-19. Virus can be ubiquitous; disease does not have to be. A patient with CHF exacerbation can be an asymptomatic carrier of SARS-CoV2 but may not phenotypically express the disease manifestations of COVID-19. Or may be his COPD or CHF exacerbation has happened due to a milder COVID-19 inflammatory response? What we know about COVID-19 is that we don’t know enough about it and therefore we cannot rule out its presence. Especially while we are in the middle of a growing pandemic.
My practice received its first question about coronavirus from a patient on January 28, 2020. Though there were over 200 deaths reported in China by that time, no one could have imagined how drastically this would come to disrupt our lives at home.
Thankfully, I had a head start.
As a doctor at an integrated telemedicine and primary care practice in New York City, nearly two out of every three of my medical encounters that month was already virtual.
I spent much of January caring for patients who had contracted seasonal viruses, like influenza or norovirus (i.e. the stomach flu). My patients reached out nearly every day with bouts of fevers, fatigue, diarrhea, and vomiting. Our team did all we could to encourage each of these patients to stay home and avoid spreading their highly contagious virus throughout the community (sound familiar?).
We are now guiding our patients through the COVID-19 outbreak using the same tools we use to guide them through any healthcare need – real-time monitoring, proactive outreach, and team-based care.
After our first COVID-19 question, our team started compiling information about every patient who reached out with symptoms that even slightly resembled COVID-19. This soon turned into a comprehensive patient registry containing the epidemiologic risk factors, clinical risk factors, symptoms, and a follow-up plan for each patient. Based on their total risk level, we follow up with these patients every 24 to 120 hours.
Every day, one provider on the team texts or schedules a video visit with each follow-up patient, reassesses their symptoms, and re-stratifies their risk. Most patients respond with a text message letting us know that their symptoms are the same or slowly improving. But for patients at higher risk, we want more information. We help these patients acquire a thermometer or pulse oximeter to follow up on their respiratory vitals. With this data, our team can provide patients and their families with thresholds on when to seek out a higher level of care.
Our job for these patients is clear: provide treatment at home and only recommend the hospital if there is no other option. By centralizing data and establishing clear triggers for a new plan of care, a single provider can follow up with over 30 COVID-19 patients in a single day.
FHIR DevDays, run by Rien Wertheim’s company Firely in conjuncion with HL7, is the premier FHIR event in the world, with editions in the US and Europe. The three pillars for DevDays are Learn, Code and Share. The event runs from 15 to 18 June, 1 to 5 PM EST. This year’s edition will be 100% virtual. Tracks include the ONC and CMS Final Rules and COVID-19 on FHIR. I will be opening and moderating that last track–Matthew Holt.
The Patient Innovator Competition at DevDays US 2020
Have you ever wondered what would happen if patients had access to their data from hospitals, labs and other sources? Some still doubt the value of data at the fingertips of patients. So, we went the extra mile to see how this would look in practice and the results were impressive.
To give some context, every year we run DevDays, which is a semi-annual conference for health data programmers working with FHIR. FHIR is the open and standardized API for healthcare. What APIs have done for other industries, FHIR is doing for healthcare. That is, enabling an app economy: apps for doctors, researchers, payers, even apps for the government and, above all, apps for patients.
A lot of these of these apps are built by EMR vendors, even more by startups, and some by patients. Last year we launched the Patient Innovator Track at DevDays to give patients a voice. The track gives the stage to tech-savvy patients who are taking control of their health using data about their disease and treatment. The track wants to prove a point: access to health data can improve our lives. It also shows the unimagined things people can do with data when their health is at stake.
Four finalists pitched for the Patient Innovator Award. In the end it was John Keyes that blew everyone away. John is a blood disease patient who created a simple app to track his blood count and ongoing test results. The app is called BloodNumbers and it consolidates test data from multiple health care providers, making it easy to view and share results if you want to.
We are looking for more tech-savvy patients, developers and IT experts like John, to apply for this year’s Patient Innovator Track. All you need to do is pitch an app, device or other technology that allows you to use your own health data to improve your wellbeing. The finalists get a free ticket to DevDays US 2020 Virtual Edition where they can learn all about FHIR and connect with the community. The winner gets to walk away with $2,500. On the jury we have Dave deBronkart (“ePatient Dave”) and Grahame Grieve, the founder of FHIR. Check out what Dave wrote about the Patient Innovator Track here.
Smart Quarantine as the next step to combat COVID-19
As the nation and the world grapple with the impact of the COVID-19 pandemic, there is growing consensus among experts that we need a sustainable system of specific lockdowns, social distancing, and extreme resource provision in terms of labor, ventilators and PPE to arm hospitals and health providers as they deal with the onslaught of patients. Even while some American states start to slowly open up, we need a system that can manage COVID-19 over the coming months and years–especially if this Fall brings a second wave.
Writing in the NY Times on April 7, Harvey Fineberg and colleagues summarized an as yet overlooked issue. There are many patients who may or do have COVID-19, but are not sick enough to need hospital care, or who have been discharged from hospitals. We need to keep these patients away from hospitals but if they shelter in place in their household there is a high risk they will infect their families or housemates. This likelihood is even higher if they are homeless, incarcerated, or living in other group arrangements.
Instead of sheltering in place at home Fineberg and colleagues suggest those patients enter “smart quarantine” in temporary isolated accommodation, such as hotels or college dormitories, where they can be looked after by medical teams and tested semi-regularly. But whether they are at home or in temporary accommodation, leaving those patients with minimal support to be tested at the end of 14 days is not enough. A significant proportion of them will develop COVID-19 and some of those are going to be admitted to hospital. In addition several patients have been discharged from hospital, but still need to be monitored. We are going to need to be able to closely monitor a significant number of people even while the majority of them will need relatively limited amounts of care.
The good news is that we have had a couple of decades of development of the technologies and services required to both care for and monitor these patients, while keeping the main resources such as ventilators for those in hospitals. Pulling together available technologies and services, we will be able to quickly and accurately manage these patients, ensure their best outcomes, and spare scarce hospital resources. There are seven main components of this process, which I am calling “smart care in quarantine.”
Upon either a positive test for COVID-19 or a suspicion of those symptoms awaiting testing, patients can be admitted to isolation at home or in, say, empty hotels.
1. Monitoring equipment. Patients can be given FDA regulated monitoring devices which will work using bluetooth and WiFi (or 4G cellular). The main monitoring tools required are:
The COVID crisis has shown us clearly that major portions of the American care system are extremely dysfunctional and some are now badly broken. We need to put in place a cash flow for American health care that can help our care sites survive and ultimately thrive, and we need to put that approach to save the sites in place now because a vast majority of hospitals and medical practices are badly damaged and some are financially crippled and even destroyed by their response to the crisis.
We have learned a lot in the COVID crisis that we need to use now in building our next steps and our collective response to the crisis.
The COVID crisis has shown us all that our care sites do not have good patient data, do not have good patient linkages, usually do not have team care of any kind in place, and most are so dependent on current piecework fee volumes from patients that they quickly collapse financially when that volume is interrupted.
We should be on the cusp of a golden age of care delivery that uses all of the best patient support tools to deliver continuously improved care — and we now know that the piecework way we buy almost all of our care today will keep that golden age from happening for the vast majority of American patients for the foreseeable future until we change the way we buy care.
We need to buy care in a way that both requires the use of those tools and rewards caregivers and care teams when they use them.
We need a dependable cash flow for care to anchor that process.
We are unlike most of the rest of the industrialized world in not having a dependable cash flow now to buy care. We rely on a hodgepodge and mishmash of unlinked, unaligned and uncoordinated payment sources now and that lack of coordination in payment creates a vast and damaging lack of coordination in the delivery of care.
We can make a huge improvement in that entire process and we can give our health care system a stable and functionally useful future cash flow by becoming a much more highly skilled purchaser of coverage and care. We need a flow of money to make that happen.
We actually can create that flow relatively quickly and fairly easily by imposing a payroll tax on every employee that exactly copies the approach we use now for our Social Security payroll tax process and then using that money in a health care purchasing pool to buy health coverage for every person who is not on Medicaid.
Health tech has suddenly found its new focus in coronavirus – but are we at risk of doing more harm than good by rushing to use unproven solutions? To avoid chaos in the aftermath, we should focus on tried-and tested tech, and only use novel solutions where need is deemed greater than the acceptable risk.
The COVID pandemic is categorically not a black swan event.
Black swans are by definition unknowable and unpredictable. In contrast, a global viral pandemic was predicted by scientists decades before, from the potential impact, right down to the source of the virus. In fact, only last year The Johns Hopkins Center for Health Security in partnership with the World Economic Forum and the Bill and Melinda Gates Foundation hosted Event 201 (video below), a high-level pandemic exercise on October 18, 2019, in New York, NY to simulate and plan for this exact scenario involving a life-threatening respiratory agent. They accurately predicted the exponential spread of disease, the sudden economic crash, and the desolation it would impose on healthcare systems. Indeed, Bill Gates himself is on record in 2015 predicting at a TED event that it would be ‘microbes, not missiles’ that would would be the next existential threat to humanity.