Greg Whisman is the Chief Medical Officer of CareMore Health, a venerable prepaid medical group caring for seniors. It’s been part of Anthem/Elevance for many years but this year spun off as part of a larger PE backed group called Millennium. We really got into the what and the how of primary care for seniors and, yes, we delved deep into the future of primary care. This is a topic that will never die on THCB and getting a real expert to opine on it was really valuable. This is a great conversation–Matthew Holt
Sami Inkinen, Virta Health
Virta Health is in the diabetes reversal business. It’s a medical group that for a decade has been aggressively coaching people with diabetes and cardiometabolic disease to radically change their eating habits–basically to eat the right things for them, to saity. Some how in a nation obsessed with processed food and carbs they have succeeded for a lot of people. And the business is growing fast, with over $160m in annual run rate. Ten years in since it started I spoke with CEO Sami Inkinen about how and why it works, and what the future for this approach is in a world of GLP1s (and no there’s no GLP sales in that revenue number!)–Matthew Holt
Concierge Care for all: What would it look like?
By MATTHEW HOLT
A few weeks back I wrote an article on what’s wrong with primary care and how we should fix it. The tl:dr version was to give every American a concierge primary care physician paid for by the government. We would give everyone a $2k voucher (on average, dependent on age, medical status, location, etc) and have an average panel of 600 people per PCP.
My argument was that a) this would be cheaper than health care now – due to cutting back on Emergency Department visits and inpatient admissions and that b) it would enable us to pay PCPs the same as specialists (roughly $500K a year). This would mean that many current ED docs, internists, hospitalists etc would convert to being PCPs. I also think that we could and would make better use of the now 400,000 nurse practitioners in the US. We would only need about 600,000 PCPs to make this work. Although it would double spending on primary care, it would reduce health care costs overall. (OK there’s some debate about this but the Milliman study linked above and common sense suggests it would save money).
There are obviously two huge issues with my proposal. First we would have to go through the conversion process. Second, we would have to do something big with the three major players who are sucking at the teat of health care $$ right now—those being big hospital systems and their associated specialists, health insurers, and pharma and device companies.
I don’t think that there will be any problem selling this to most doctors or to the American people.
The doctors know that they are trapped in the current system. This would free them to practice as they want to practice, and to remember why they got into medicine in the first place—to care for their patients holistically.
People know all too well that accessing primary care is both good for them and also very difficult. Wait lists are way too long. In this system primary care would be abundant. And I and many others have only horror stories of how big hospital systems, insurers and big pharma treat them badly. They would much rather have an empowered PCP on their side.
The only concern about primary care for patients is if the PCP is incented to not refer them to needed specialty care. In my system there would be no global capitation or risk to the PCP, and thus no incentive not to refer out. But no reason to refer out unnecessarily. They would do the right thing because it is the right thing. (It has taken Jeff Goldsmith 30 years to convince me of this). So there would be no need for insurance companies to manage primary care at all. No claims, no bills, no utilization management. Instead we should have 600,000 primary care docs paid well and able to manage their practices to do the right thing.
And this would probably involve a ton of variation. There would be PCPs who work in groups. There would be solo. There would be those specializing in specific types of patients (think kids or people with serious diseases or geriatricians). They would all make the same amount of salary but their practice’s revenue and number of patients would be adjusted in a similar way to how we do risk adjustment for Medicare Advantage now, but without the games, and with no profit motive.
This system would create a lot of innovation. PCPs would be responsible for those with chronic conditions. They would have budget from the $2,000 per head (of which they would get roughly $800 as income) to build remote monitoring programs, to use AI, to build teams of assistants and nurses et al.
So can it be done in the US? Yes it already has. I urge you to take the time to read this ingenious ChatGPT summary of the Nuka system in Alaska. (I believe created by Steve Schutzer MD). Nuka went from being a hidebound bureaucratic expensive system–that its patients hated–to being a system with culturally appropriate care that its “consumer-owners” love today. And its costs are lower and outcomes better. There are lots of other examples of similar approaches across the US. Just ask Dave Chase. They just haven’t scaled because the current incumbents have killed them. (One great example is this case in Texas where a hospital chain bought and killed a big primary care group led by Scott Conard because it was costing them $100m a year in reduced hospital FFS admissions).
What we need is to set up the incentives, prod doctors and patients hard to get into these arrangements and let American ingenuity and medical professionalism go at it.
The other side of the equation is the need to reign in the costs of specialty and hospital care. How this would happen is up for debate.
Continue reading…AAAA (the four A)
By JACOB REIDER
I haven’t blogged this yet, which kinda surprises me, since I find myself describing it often.
Let’s start with an overview. We can look at health information through the lens of a lifecycle.
The promise of Health Information Technology has been to help us – ideally to achieve optimal health in the people we serve.
The concept @ the beginning of the HITECH act was: “ADOPT, CONNECT, IMPROVE.”
These were the three pillars of the Meaningful Use Incentive programs.
Adopt technology so we can connect systems and therefore improve health.
Simple, yes?
Years later, one can argue that adoption and even connection have (mostly) been accomplished.
But the bridge between measurement and health improvement isn’t one we can easily cross with the current tools available to us.
Why?
Many of the technical solutions, particularly those that promote dashboards, are missing the most crucial piece of the puzzle. They get us close, but then they drop the ball.
And that’s where this “simple”AAAA” model becomes useful.
For data and information to be truly valuable in health care, it needs to complete a full cycle.
It’s not enough to just collect and display. There are four essential steps:
1. Acquire. This is where we gather the raw data & information. EHR entries, device readings, patient-reported outcomes … the gamut of information flowing into our systems. Note that I differentiate between data (transduced representations of the physical world: blood pressure, CBC, the DICOM representation of an MRI, medications actually taken) and information (diagnoses, ideas, symptoms, the problem list, medications prescribed) because data is reliably true and information is possibly true, and possibly inaccurate. We need to weigh these two kinds of inputs properly – as data is a much better input than information. (I’ll resist the temptation to go off on a vector about data being a preferable input for AI models too … perhaps that’s another post.)
2. Aggregate. Once acquired, this data and information needs to be brought together, normalized, and cleaned up. This is about making disparate data sources speak the same language, creating a unified repository so we can ask questions of one dataset rather than tens or hundreds.
3. Analyze. Now we can start to make sense of it. This is where clinical decision support (CDS) begins to take shape, how we can identify trends, flag anomalies, predict risks, and highlight opportunities for intervention. The analytics phase is where most current solutions end. A dashboard, an alert, a report … they all dump advice – like a bowl of spaghetti – into the lap of a human to sort it all out and figure out what to do.
Sure … you can see patterns, understand populations, and identify areas for improvement … All good things. The maturity of health information technology means that aggregation, normalization, and sophisticated analysis are now far more accessible and robust than ever before. We no longer need a dozen specialized point solutions to handle each step; modern platforms can integrate it all. This is good – but not good enough
A dashboard or analytics report, no matter how elegant, is ultimately passive. It shows you the truth, but it doesn’t do anything about it.
Continue reading…Avasure: Tech for helpful watching & remote care in hospitals
Lisbeth Votruba, the Chief Clinical Officer and Dana Peco, the AVP of Clinical Informatics from Avasure came on THCB to explain how their AI enabled surveillance system improves the care team experience in hospitals and health care facilities. Their technology enables remote nurses and clinical staff to monitor patients, and manage their care in a tight virtual nursing relationship with the staff at the facility, and also deliver remote specialty consults. They showed their tools and services which are now present in thousands of facilities and are helping with the nursing shortage. A demo and great discussion about how technology is improving the quality of care and the staff experience–Matthew Holt
Lynn Rapsilber on Nurse Practitioners
There are a lot of nurse practitioners in the US–over 400,000 (compared to around 900,000 MDs & DOs), and we are training 40,000 a year. But how they are going to be used is not entirely clear. Lynn Rapsilber is an NP whose organization, the National Nurse Practitioner Entrepreneur Network, is working to help her fellow NPs with their professional and business development. She came on THCB to discuss how NPs are developing and how she thinks NPs will contribute in the future as we deal with the current crisis in primary care–Matthew Holt
TytoCare–The Last Few Inches of Telehealth?
Tamir Gottfried, the Chief Commercial and Strategy Officer at TytoCare came on THCB to show us how their remote device works to deliver the last few inches of telehealth. Most telehealth is just a video call but with Tyto’s device, the patient can asynchronously (and/or synchronously) take their vital signs including videos and pictures of the skin, ears, mouth, heartbeat et al, and share it with their doctor. It actually amazes me that they haven’t been more popular but in the last few years Tyto has made significant inroads with health plans and providers delivering their devices, as well as adding chronic care management module, with a forthcoming smart clinic (AI) companion. Tamir explained who, how what and why to me, and gave a not too gruesome demo–Matthew Holt
Penguin–The Flightless Bird of Health AI
Fawad Butt and Missy Krasner started a new AI company which is building a big platform for both plans and providers in health care. Penguin Ai has a cute name, but is serious about trying to provide an underlying platform that is going enable agents across the enterprise. They are health care only, as opposed to the big LLMs. But does health care need a separate AI company? Are the big LLMs going to give up health? And what about that Epic company? Join us as we discuss how this AI thing is going to be deployed across health care, and how Penguin is going to play. Oh and they raised $30m series A to start getting it done–Matthew Holt
Boulder Care: Stephanie Strong & Marianna Zaslavsky
Stephanie Strong, CEO & Marianna Zaslavsky, the (relatively new) Head of Growth at Boulder Care came on THCB to tell Matthew Holt about their service which delivers medication assisted treatment for those suffering from substance used disorder, via telehealth. Stephanie has been one of the leading advocates for getting patients, especially those on Medicaid, access to treatment. She led a campaign to get the DEA to continue to allow substance abuse treatment using medication via telehealth. Marianna joined this summer with the goal of helping patients get access via managed care plans. We discussed a lot about the potential for Boulder to continue its harm reduction strategy for patients, and also the potential limits that might be coming via Medicaid reductions as part of the BBB. Stephanie & Boulder are supporting a campaign called Majority for Medicaid which is raising awareness about the impact of Medicaid cuts on these patients. Some of those stories are here
You can also text MAJORITY to 50409 to urge your representative to protect the promise of Medicaid.
New Bereavement Cost Calculator shows that grief is expensive
by EMMA PAYNE
Grief is expensive. In addition to the significant human impacts, research shows that bereavement leads to a 20%-30% increase in health care utilization.
Grief is also common. While we may not like to talk about it, 37% of Americans are grieving a recent death. The U.S. averaged 3.26 million deaths per year over the last five years and data suggests that an average of nine people grieve a single death. The CDC started measuring bereavement for the first time in 2021, but most health plans aren’t yet measuring the incidence or cost of grief.
So we decided to take a look. Here’s just some of what we found.
When a member is bereaved, health plans — especially those serving older adults — see significant jumps in utilization and costs across multiple claims categories. Examples include:
● 51% increase in Emergency Department visits and 43% increase in hospitalizations for bereaved spouses whose partners died in hospital
● 67% higher risk level for psychiatric hospitalization in the first year of bereavement for parents who have lost a child
● 74% of husbands and 67% of wives are hospitalized at least once in the nine years following the death of their spouse
● 463% higher odds of antidepressant use for people who have a prolonged grief disorder diagnosis
These increases lead to escalating claims costs that add up quickly, especially in populations 65+. But what are these costs? And what can insurers do to mitigate them?
To make these hidden costs visible, my team at Help Texts created a tool that health plans can use to model bereavement’s financial impacts. With just member numbers, the Bereavement Cost Calculator from Help Texts will estimate a health plan’s:
● Projected Per Member Per Month (PMPM) cost increase after bereavement
● Total cost impact of grief when no intervention is provided
● Estimated savings when plans provide Help Texts’ clinically sound, scalable, grief support for bereaved members
Consider a Medicare Advantage Plan with 250K members ages 65+. It should expect:
● Potential year one cost reduction (with intervention): $22.8M
● 11,500 members to be grieving the death of a partner or child
● 81,500 members to be grieving other losses (eg. parent, sibling, friend)
● Average PMPM increase (without intervention): $120
● Total estimated year one cost impact (without intervention): $134M *
What can a health plan do to save money and improve care and outcomes for its members? The numbers are powerful, showing that grief is expensive, but also that bereavement presents a clear opportunity to provide an impactful upstream intervention that can save millions, while also caring for people during what is often the loneliest time in their lives.
Help Texts is a clinically sound, scalable, bereavement intervention. With subscribers in 59 countries and all 50 states, Help Texts delivers affordable, multilingual grief support via text message. With extraordinary acceptability (95%) and 6-month retention (90%) rates, Help Texts’ light-weight solution makes it easy for health plans and others to improve health and community outcomes, while also realizing significant cost savings for those in their care.
Health Plans, particularly Medicare Advantage plans, can use the new bereavement cost calculator from Help Texts to estimate the true cost of bereavement and their cost savings when grief support is provided. The Bereavement Cost Calculator from Help Texts uncovers the savings potential when caring for grieving members. In less than a minute, you can start to see how much bereavement is costing, and how much could be saved by supporting members grieving the loss of a loved one.
Because the true cost of bereavement isn’t only emotional, it’s also financial. And for health plans, addressing both is the smartest investment you can make.
Emma Payne is the CEO of Help Texts
