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Can Someone Actually Be Responsible?

By MATTHEW HOLT

I was having a fight on Twitter this week and it hit me. America 2024 is Japan 1989. 

The topic of the fight was right-wing VC Peter Thiel. In 2001 he put a ton of Paypal stock allegedly worth less than $2,000 into a Roth IRA. The Roth IRA was designed so that working stiffs could put post tax cash into an IRA, grow it slowly and take out money tax-free. (For traditional IRAs you put in pre-tax money and get taxed when you take it out). You may have read the story in ProPublica. Magically Thiel earned less that year than the max allowable income limit (around $100K) to contribute to a Roth IRA, and magically that stock was within weeks worth much more and then, later, hundreds of millions more. Since then Thiel has invested those Paypal returns in Facebook, Palantir and much more, and that Roth IRA has billions of dollars in it that can never be taxed.

My twitter adversary was saying that Thiel obeyed the law. I doubt it, but that’s not really the point. When the Roth was introduced it wasn’t meant to be a loophole that Silicon Valley types could use to hide billions from tax. But neither my twitter “friend” nor Peter Thiel want to take responsibility or pay their fair share.

Japan in 1989 was wealthy and successful and heading off a speculative cliff which it’s since taken 3 decades to dig out of. There were numerous academics pointing this out, but the most interesting analysis was The Enigma of Japanese Power written by a Dutch journalist named Karel van Wolferen. Here’s a summary from wikipedia with my emphasis added

Van Wolferen creates an image of a state where a complicated political-corporate relationship retards progress, and where the citizens forgo the social rights enjoyed in other developed countries out of a collective fear of foreign domination….Japanese power is described as being held by a loose group of unaccountable elites who operate behind the scenes. Because this power is loosely held, those who wield it escape responsibility for the consequences when things go wrong as there is no one who can be held accountable.

In Thiel’s case a collective network of tax accountants, junk philosophers, and purchased politicians like JD Vance ensure that no one has to be accountable. Ultimately Thiel doesn’t feel responsible for paying what he owes. Of course the exposure of Trump’s tax cheating shows that he doesn’t either. And many people find this OK.

Meanwhile I got into it a little with Jeff Goldsmith on last week’s THCB Gang about why hospitals are still paid per transaction when it would be much better for them to be paid some kind of global budget for the services they provide and for doctors to be paid a salary to exercise their best judgment rather than be tempted into providing care just because they get paid for it. Both COVID and the recent Change Healthcare outage put health care providers in a terrible situation financially because they depend on being paid fee-for-service via claims for individual transactions. Did the leadership of America’s hospitals and doctors come out asking for a change to the system? No, they just got a government hand out and begged for a return to standard operating procedure. No one can rationally look at how we pay for health care in America and say “give us more of the same” but there’s no leadership to change it at all.

Talking about lack of leadership, Amber Thurman died in Piedmont Henry Hospital because no-one on the medical team was prepared to give her the D&C that she desperately needed. They were scared of going to jail under Georgia’s draconian anti-abortion law. There are many, many guilty parties here.

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THCB Gang Episode 140, Thursday October 3

OK we are really back.! Following last weeks special with the Women Healthcare Leaders for Progress, the “regular” THCBGang is coming back for the Fall, mostly but not always at the 1pm PT 4pm ET timeslot on Thursdays.

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday October 3 at 1pm PST 4pm EST are futurist Jeff Goldsmith: delivery & platform expert Vince Kuraitis (@VinceKuraitis); author & ponderer of odd juxtapositions Kim Bellard (@kimbbellard);

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

The Silicon Curtain Descends on SB 1047

By MIKE MAGEE

Whether you’re talking health, environment, technology or politics, the common denominator these days appears to be information.  And the injection of AI, not surprisingly, has managed to reinforce our worst fears about information overload and misinformation. As the “godfather of AI”, Geoffrey Hinton, confessed as he left Google after a decade of leading their AI effort, “It is hard to see how you can prevent the bad actors from using AI for bad things.”

Hinton is a 75-year-old British expatriate who has been around the world. In 1972 he began to work with neural networks that are today the foundation of AI. Back then he was a graduate student at the University of Edinburgh. Mathematics and computer science were his life. but they co-existed alongside a well evolved social conscience, which caused him to abandon a 1980’s post at Carnegie Mellon rather that accept Pentagon funding with a possible endpoint that included “robotic soldiers.” 

Four years later in 2013, he was comfortably resettled at the University of Toronto where he managed to create a computer neural network able to teach itself image identification by analyzing data over and over again. That caught Google’s eye and made Hinton $44 million dollars richer overnight. It also won Hinton the Turing Award, the “Nobel Prize of Computing” in 2018. But on May 1 2023, he unceremoniously quit over a range of safety concerns.

He didn’t go quietly. At the time, Hinton took the lead in signing on to a public statement by scientists that read, “We believe that the most powerful AI models may soon pose severe risks, such as expanded access to biological weapons and cyberattacks on critical infrastructure.” This was part of an effort to encourage Governor Newsom of California to sign SB 1047 which the California Legislature passed to codify regulations that the industry had already pledged to pursue voluntarily. They failed, but more on that in a moment.

At the time of his resignation from Google, Hinton didn’t mix words. In an interview with the BBC, he described the generative AI as “quite scary…This is just a kind of worst-case scenario, kind of a nightmare scenario.”

Hinton has a knack for explaining complex mathematical and computer concepts in simple terms.

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Red Alert about Red Buttons

By KIM BELLARD

In a week where, say, the iconic brand Tupperware declared bankruptcy and University of Michigan researchers unveiled a squid-inspired screen that doesn’t use electronics, the most startling stories have been about, of all things, pagers and walkie-talkies.

Now, most of us don’t think much about either pagers or walkie-talkies these days, and when we do, we definitely don’t think about them exploding. But that’s what happened in Lebanon this week, in ones carried by members of Hezbollah. Scores of people were killed and thousands injured, many of them innocent bystanders. The suspicion, not officially confirmed, is that Israel engineered the explosions.

I don’t want to get into a discussion about the Middle East quagmire, and I condemn the killing of innocent civilians on either side, but what I can’t get my mind around is the tradecraft of the whole thing. This was not a casual weekend cyberattack by some guys sitting in their basements; this was a years-in-the-making, deeply embedded, carefully planned move.

A former Israeli intelligence official told WaPo that, first, intelligence agencies had to determine “what Hezbollah needs, what are its gaps, which shell companies it works with, where they are, who are the contacts,” then “you need to create an infrastructure of companies, in which one sells to another who sells to another.”  It’s not clear, for example, if Israel someone planted the devices during the manufacturing process or during the shipping, or, indeed, if its shell companies actually were the manufacturer or shipping company. 

Either way, this is some James Bond kind of shit.

The Washington Post reports that this is what Israeli officials call a “red-button” capability, “meaning a potentially devastating penetration of an adversary that can remain dormant for months if not years before being activated.” One has to wonder what other red buttons are out there.

Many have attributed the attacks to Israel’s Unit 8200, which is roughly equivalent to the NSA.  An article in Reuters described the unit as “famous for a work culture that emphasizes out-of-the-box thinking to tackle issues previously not encountered or imagined.”  Making pagers explode upon command certainly falls in that category.

If you’re thinking, well, I don’t carry either a pager or a walkie-talkie, and, in any event, I’m not a member of Hezbollah, don’t be so quick to think you are off the hook. If you use a device that is connected to the internet – be it a phone, a TV, a car, even a toaster – you might want to be wondering if it comes with a red button. And who might be in control of that button.

Just today, for example, the Biden Administration proposed a ban on Chinese software used in cars.

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THCB Gang Special! Women Healthcare Leaders for Progress talk about health care & the election

THCB Gang is back! (I know you’ve all missed it) and we started with a bang. I met with five powerhouse women leaders in health care who’ve just issued a public statement signed by another 500+ women leaders in support of the Harris/Walz campaign.

On the Gang are Missy Krasner, digital health veteran most recently at Amazon and Redesign Health but wayback on the founder team at ONC; Molly Coye, who ran Medicaid in NJ and CA and has had every role in health innovation know to womankind; Miriam Paramore, investor board member and operator at many, many health tech companies; (Lori Evans Bernstein, founder of Caraway, Health Reveal & many more but also at ONC back in the day, who actually couldn’t make the call); Laurie McGraw, EVP at Transcarent, formerly at AMA, Allscripts, etc; and Audrey Mann Cronin, communication advisor to CEOs and Founder, Say it Media.

Despite my obvious political leanings, this wasn’t be a push over. Do we need this group? What does Harris want to do about health care? What can she do? I am on record as saying “not much”. This was great discussion, and I was (virtually) ducking alot! — Matthew Holt

Streamlining Public Benefits Access is a Must to Address Poverty

By ALISTER MARTIN and TARA MENON

If a friend were to ask you which state, Massachusetts or Texas, has a more streamlined federal benefits enrollment program, what would your guess be?

Having screened over 17,000 families and helped them obtain more than $1.8M in federal and state aid through our work in both Massachusetts and Texas, our experiences doing federal benefit enrollment have led us to a surprising conclusion: Texas is leading the way. While Massachusetts has room for improvement, this issue extends beyond a single state—many other states face similar challenges with complex and fragmented benefits systems.

At Link Health, where our work spans the bustling neighborhoods of Boston and Houston, this revelation has been both a surprise and a call to action. In many underserved communities, through partnerships with Federally Qualified Health Centers, our organization seeks to assist eligible people in the navigation and enrollment in benefit programs that address crucial needs like access to affordable internet, food access, healthcare support, and housing resources.

One of the main obstacles we’ve encountered is that people are often unaware of the benefits they qualify for or find the process overwhelming. In states like Massachusetts, separate applications are required for each benefit program, making it harder for families to get the help they need. Programs such as LIHEAP, which offers heating subsidies, Lifeline, which provides internet access for telehealth, and SNAP, which helps with food assistance, all come with different paperwork and requirements. This fragmentation creates unnecessary barriers.

This is not unique to Massachusetts. Across the U.S., many states have similarly disjointed systems, leaving millions of dollars in federal aid unclaimed. It’s estimated that around $140 billion in federal aid goes unclaimed each year due to these inefficiencies.

In contrast, we have found that Texas’s “Your Texas Benefits” platform is efficient and user-friendly. This centralized, comprehensive application process covers a wide range of state benefit programs, including SNAP, TANF, Medicaid, and CHIP, as well as other services like WIC, family violence support, adult education, and substance abuse prevention programs. This unified system allows users to apply for multiple programs through a single portal, streamlining the process considerably. Plus, this common application system allows groups like ours to efficiently connect patients with the help they need without the usual bureaucratic entanglements — it benefits us both.

Although Massachusetts made some progress with its limited common application for MassHealth and SNAP in 2021, it still doesn’t offer a fully unified system for all its programs. This means that many residents must continue navigating multiple applications and processes. During the recent Medicaid “unwinding,” people across the U.S. lost coverage because they couldn’t manage the renewal process. It’s estimated that between 8 million and 24 million people are at risk of losing Medicaid benefits nationwide(Center For Children and Families), not because they no longer qualify, but because of these application challenges.

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David Dyke demos Relatient scheduling

David Dyke is the Chief Product Officer of Relatient, which is one of the biggest players in the up and coming area of direct patient scheduling. As anyone who has been stuck in a phone tree or tried to reach a live human just to get an appointment at a doctor’s office knows, scheduling in health care is way behind the eight ball compared to booking a restaurant, massage, or basically anything else online. Why is it so hard? David explained that and then demos how Relatient allows provider organizations to let both new and returning patients self-schedule. There is a ton of complexity behind this including what David says is an average of infinity minus one API calls to the practice management system and EMR of all of its clients. But speaking as someone who has literally left a message and hoped that someone called me back “within 4 business days” for my last specialty appointment, I’m glad to see one company at least is taking on this challenge–Matthew Holt

Software Living in an Enterprise World: Why Digital Behavioral Health Can’t Gain Traction

By TREVOR VAN MIERLO

Let’s face it: for the past 25 years, digital behavioral health has struggled. Yet, we keep reinventing (and funding) the same models over and over again.

How It All Started

In the beginning (mid-1990s), a handful of developers, researchers, and investors envisioned high reach, lower-cost, highly tailored, anonymous interventions reaching millions of people with limited healthcare access.

The initial focus was never healthcare providers and insurers. These organizations were seen as too slow to adopt new technologies, and there was a general distrust of integrated care and insurers. Many digital health companies feared these organizations (and pharma) would leverage their power to learn from smaller companies, and then redevelop interventions internally.

Instead, the focus was on partnerships and B2C sales. Funding was easier to obtain from granting agencies, and there was ample development support flowing from sources like the tobacco Master Settlement Agreement (MSA). The primary concern was 1) whether the population could access these revolutionary tools and, 2) who would pay for them.

The Digital Divide

Back then, funders were often short-sightedly obsessed with the digital divide – the gap between people who had access to digital technology (mostly educated, higher-income earners in large cities) and everyone else. The argument was, “Why should we fund digital tools that will only benefit those who already have access to healthcare?”

Data was available, so academics armed themselves with ANOVA and relentlessly examined variables such as hardware costs, processing speed, age, gender, race, ethnicity, geography, income, and education. If you check Google Scholar, you can see the prevailing sentiment was that it would take decades for the digital divide to narrow, and new policy was desperately required to fix the problem (see: here, here, here, and here).

No More Excuses

Fast forward to 2024. According to a recent article in Forbes, there are 5.4 billion internet users worldwide (66% of the global population). In the U.S., 94.6% of Americans have internet access. Most US households have multiple devices, and according to Pew Research Center Research, 97% own a cellphone, of which 90% are smartphones.

As a Gen X’er who used a typewriter in college before upgrading to a Compaq Deskpro 286 from Future Shop (for about $400), my adult life has been a witness to the rapid progression of digital. Now, my 9-year-old daughter is teaching me how to play Fortnite (Epic Games), my 11-year-old is the only kid on his hockey team without a smartphone (this won’t last), and STARLINK allows me to chat face-to-face with my parents in rural Northern Ontario.

All aspects of technology are pervasive and accessible – but if you search Google or Bing for immediate, evidence-based behavioral help, you can’t get it. If you can find access it’s behind a paywall: through your employer (contact HR), health plan (call to see if you’re covered), or subscription ($19.99 per month).

That’s not meeting the original vision – and we have the technology. So, what’s the problem?

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Moving the bar(rier) forward: the benefits of de-risking cytokine release syndrome

By SAMANTHA McCLENAHAN

Every breakthrough in cancer treatment brings hope, but it also comes with a staggering price, raising a critical question: how do we balance groundbreaking advances with the financial reality that could limit access for many patients? 

Developing new cancer medications involves extensive research, clinical trials, and regulatory approvals; a lengthy process that requires substantial financial investment. Within clinical trials, this includes maintaining stringent safety protocols and managing a variety of adverse events, from mild reactions requiring little to no care to extremely severe events with hefty hospital stays and life-saving medical intervention. Take Cytokine Release Syndrome (CRS), for example. CRS is a common adverse event associated with chimeric antigen receptor (CAR) T cell therapy and other immunotherapies that presents across this spectrum with flu-like symptoms in mild cases of CRS to organ damage, and even death, in severe cases. The median cost of treating CRS following cancer-target immunotherapy is over half a million dollars in the United States. Tackling that large price tag – in addition to another $500,000 for CAR-T cell therapies – and reducing associated risks are necessary to break down barriers to care for many patients – especially those who are uninsured or with limited resources hindering the ability to travel, miss work, or secure a caregiver.

Unlocking Cost Efficiency in Clinical Trials with Digital Health Technologies

Integration of digital health technologies (DHTs) including telehealth, wearables such as smart watches, remote patient monitoring, and mobile applications in oncology care and clinical trials has shown immense value in improving patient outcomes, despite the slow uptake within the field. General benefits during clinical trials are captured through: 

  1. Reducing clinical visits and shortening trial length – Remote patient monitoring and virtual consultations minimize the need for physical visits, accelerating trial timelines. 
  2. Enhancing recruitment, diversity, and participant completion – Targeted outreach supported by big data analytics and machine learning algorithms helps to effectively identify and engage with eligible candidates, leading to faster recruitment and lower dropout rates. Digital technologies also overcome traditional barriers to participation, such as location, transportation, language barriers, and information access.  for a broader representation of patient demographics and more generalized findings and improved healthcare equity. 
  3. Increasing availability of evidentiary and safety requirements – Continuous data collection and monitoring in the setting most comfortable to patients – extending beyond clinical walls. This provides a pool of data to support clinical endpoints and enhances patient safety by enabling early detection of adverse events. 

While the exact cost of these digital interventions varies by study, there is significant evidence that cost-saving measures are emerging.

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Everything you ever want to know about birth control and much more — Sophia Yen, Pandia Health

Dr. Sophia Yen is the Chief Medical Officer (and Founder) of Pandia Health. She is about as expert as it comes on the topics contraception, emergency contraception, medication abortion, menopause and lots more. Her PR peeps asked if I’d interview her about Pandia Health, which is a fantastic online clinic & pharmacy for women at basically all ages. But I couldn’t have her on THCB without having her tell all about the world of contraception, menopause and of course reproductive health. I promise you that if you are a woman or somone who knows a woman, this is a fascinating interview. You will learn a lot, and there are lots of suggestions for how to manage many aspects of your health–Matthew Holt