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Healing at Home: Answering the $30,000 Question

By DAWN CARTER

If you’ve been working remotely for the past year, would a $30,000 raise entice you back into the office? In a recent survey of 3,000 workers at dozens of large US companies, the vast majority of respondents said they would forego the hefty raise if they could keep working in their pajamas.

I’ve spent more than 25 years in healthcare strategy and planning, and that was one of the most remarkable surveys I’ve ever seen – though not in terms of HR, because healthcare is one of the few industries where remote work never took hold during the pandemic.

Instead, I think the urgent lesson for healthcare planners is all about how – and where – services will be delivered in the future. Call it “the Covid effect”: In the same way that employees over the past year discovered the advantages of working at home, we’ve seen a huge number of new patients who discovered the advantages of so-called Hospital at Home programs.

Hospital at Home is not exactly a new model, but it’s been relatively unknown among patients until now. That’s because limited, early experiments suffered from low participation rates – just 7 to 15 patients per month. But those numbers got a huge boost over the past year as hospitals scrambled to preserve in-patient capacity for only the most extreme Covid cases. The Association of American Medical Colleges says interest in Hospital at Home “exploded” during the pandemic, and health systems from Boston to Cleveland to Seattle launched or expanded in-home programs that served thousands and thousands of new families.

It may be hard to put this genie back in the bottle. If workers won’t go back into the office for $30,000 what could possibly entice patients back into the traditional hospital setting once they’ve experienced the benefits of healing at home?

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Matthew’s health care tidbits

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

In this week’s health care tidbits, a little bit of light was shone on two of the dirty tricks health insurers play. First San Diego is suing Molina, Centene (owner of Healthnet) & Kaiser for misleading patients about which providers are in their networks. Apparently Healthnet & Kaiser’s directories were 35% inaccurate and Molina 80%! Now this may be incompetence, but it is not only false advertising, it’s also a way of weeding out high cost patients who may leave when they can’t find a specialist that will take them–and of course avoiding a high cost patient is a nice earner for health plans.

The next trick is double billing. In this lawsuit unearthed by Bob Herman of Axios, Aetna which was being paid to manage an employer’s health network subbed out PT care to an Optum network. Optum then also charged an admin fee. Meaning the provider got less and the patient had to pay more. So while Aetna and United Healthgroup may appear to be fierce competitors, they’re happy to cooperate when it comes to ripping off their clients.

More bad behavior by health plans and I didn’t even mention them cheating on Medicare Advantage RAFs! But the CEO of Chenmed did.

If we are going to let health insurers profit from handling employer and taxpayer business, we should see those arrangements in the clear light of day. Time for some heavy handed Federal regulation, methinks.

THCB Gang Episode 56 – Thurs June 3

Episode 56 of “The THCB Gang” was recorded live on Thursday, June 3. Matthew Holt (@boltyboy) was joined by regulars: medical historian Mike Magee (@drmikemagee), THCB regular writer Kim Bellard (@kimbbellard) and health futurist Jeff Goldsmith; WTF Health host & Health IT girl Jessica DaMassa (@jessdamassa) snuck in later after she finished up at the Going Digital: Behavioral Health Conference across the virtual street.

We really got into it on two issues — the Wuhan lab “leak” issue and Babylon Health’s IPO — lots of fun and no little disagreement!

Then video is below. If you’d rather listen, the audio is preserved as a weekly podcast available on Fridays on our iTunes  & Spotify channels.

Matthew’s health care tidbits

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

In this week’s health care tidbits, we’re discussing hedge funds. Not those small private equity funds that are defunding small safety net hospitals and being exposed by Propublica & PBS Frontline. (Did you catch #TCHBGangster Jeff Goldsmith on the latter?). No, I’m talking about big non-profit hedge funds that also provide some health care services. This week two of them reported results.

Famed regional hedge fund Mayo Clinic’s health services business reported $243m profit on $3.7bn revenue for Q1 2021. Not exactly Apple margins, but a respectable 6.5%. While catholic national hedge fund Ascension eeked a $700m profit on $20bn of revenue in the nine months June 2020 to March 2021. The good news is that Mayo has $15bn in its main trading account while in those nine months Ascension made $4.3 Billion on Wall Street bringing its balance to a healthy $25.6 Bn.

And if you were concerned that these hedge funds were in trouble because of the pandemic, well not only do they avoid property, income tax and more they also got plenty of help from the taxpayer. CMS prepaid $2billion of Medicare payments to Ascension; presumably they made a tad more playing the markets with that. Then there’s the non-refundable CARES Act grants. Yes Ascension has been paid $900m since June 2020 ($1.1billion in all) and Mayo received $356m, although they were nice enough to pay $138m back.

I’m sure those Americans who lost their jobs, their houses and waited for months for government help are glad that–despite the pandemic–these hedge funds weren’t having to dip into their main reserves to keep their health services subsidiaries going…..

THCB Gang Live, Episode 41–Thurs 1pm PT – 4pm ET

THCB Gang will be held live on Thurs Feb 4 at 1pm PT -4pm ET.

Joining me, Matthew Holt (@boltyboy), will be consultant/author Rosemarie Day @Rosemarie_Day1), patient advocate/entrepreneur/author Robin Farmanfarmaian (@Robinff3), Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune), health futurist Jeff Goldsmith (@JeffcGoldsmith), Digital health futurist Fard Johnmar (@fardj).

The Biden Administration is now getting into the grist of governing. What happens next?

You can see the video below live and it’ll be on our podcast channel (Apple/Spotify) from Friday

Rehash: The Health Assurance SPAC

Not so long ago (August) Jessica DaMassa and I ran a THCB Bookclub interview with Hemant Teneja & Stephen Klasko about their new book UnHealthcare. And, just because, their friend Glen Tullman sat in…..

Fast forward to this week and the three of them plus a cast of characters from General Catalyst & Livongo (Jenny Schneider, Lee Shapiro) have put $500m of their Livongo winnings into a SPAC. The book is based on the idea of Health Assurance and so is the SPAC. So if you are interested in figuring out what they are up to and what they might do or buy, here’s the interview–Matthew Holt

Escaping COVID-19

By RAGHAV GUPTA, MD

“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”

William Osler

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.  

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How to Practice High-Quality Telemedicine in the Era of COVID-19

By ANISH MEHTA, MD

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.

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Beware the COVID-tech Cowboys

By HUGH HARVEY, MBBS

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.

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A System that Fails Migrant and Seasonal Agricultural Workers

Connie Chan
Brooke Warren
Phuoc Le

By PHUOC LE, MD, CONNIE CHAN, and BROOKE WARREN

I recently took care of Rosaria[1], a cheerful 60-year-old woman who came in for chronic joint pain. She grew up in rural Mexico, but came to the US thirty years ago to work in the strawberry fields of California. After examining her, I recommended a few blood tests and x-rays as next steps. “Lo siento pero no voy a tener seguro hasta el primavera — Sorry but I won’t have insurance again until the Spring.” Rosaria, who is a seasonal farmworker, told me she only gets access to health care during the strawberry season. Her medical care will have to wait, and in the meantime, her joints continue to deteriorate.

Migrant and seasonal agricultural workers (MSAW) are people who work “temporarily or seasonally in farm fields, orchards, canneries, plant nurseries, fish/seafood packing plants, and more.”[2] MSAW are more than temporary laborers, though— they are individuals and families who have time and time again helped the US in its greatest time of need. During WWI, Congress passed the Immigration and Nationality Act of 1917[3] because of the extreme shortage of US workers. This allowed farmers to bring about 73,000 Mexican workers into the US. During WWII, the US once again called upon Mexican laborers to fill the vacancies in the US workforce under the Bracero Program in 1943. Over the 23 years the Bracero Program was in place, the US employed 4.6 million Mexican laborers. Despite the US being indebted to the Mexican laborers, who helped the economy from collapsing in the gravest of times, the US deported 400,000 Mexican immigrants and Mexican-American citizens during the Great Depression.

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