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THCB Gang Episode 120, Thursday March 16

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday March 16 at 1PM PT 4PM ET were futurist Ian Morrison (@seccurve); medical historian Mike Magee (@drmikemagee); patient safety expert and all around wit Michael Millenson (@mlmillenson); and delivery & platform expert Vince Kuraitis (@VinceKuraitis). Lots of discussion about the Walgreens not selling abortifacients, Silicon Valley Bank’s impact on digital health, and how hospitals are doing.

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.

Letting AI Physicians Into the Guild

BY KIM BELLARD

Let’s be honest: we’re going to have AI physicians.  

Now, that prediction comes with a few caveats. It’s not going to be this year, and maybe not even in this decade. We may not call them “physicians,” but, rather, may think of them as a new category entirely. AI will almost certainly first follow its current path of become assistive technology, for human clinicians and even patients.  We’re going to continue to struggle to fit them into existing regulatory boxes, like clinical decision support software or medical devices, until those boxes prove to be the wrong shape and size for how AI capabilities develop.

But, even given all that, we are going to end up with AI physicians.  They’re going to be capable of listening to patients’ symptoms, of evaluating patient history and clinical indicators, and of both determining likely diagnosis and suggested treatments.  With their robot underlings, or other smart devices, they’ll even be capable of performing many/most of those treatments. 

We’re going to wonder how we ever got along without them. 

Many people claim to not be ready for this. The Pew Research Center recently found that 60% of Americans would be uncomfortable if their physician even relied on AI for their care, and were  more worried that health care professionals would adopt AI technologies too fast rather than too slow.  

Still, though, two-thirds of the respondents already admit that they’d want AI to be used in their skin cancer screening, and one has to believe that as more people understand the kinds of things AI is already assisting with, much less the things it will soon help with, the more open they’ll be.    

People claim to value the patient-physician relationship, but what we really want is to be healthy.  AI will be able to help us with that.

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THCB Gang Episode 119, Thursday March 9

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday March 9 were writer Kim Bellard (@kimbbellard), benefits expert Jennifer Benz (@Jenbenz); Suntra Modern Recovery CEO JL Neptune; and special guest digital health investment banker Steven Wardell (@StevenWardell). Lots of conversation about Walgreens and the reaction to its non-sales of abortifacients and the possible outcomes. Then a round up of the latest in digital health financing.

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

What Would John Henry Rauch Do Today As A HIT Entrepreneur?

BY MIKE MAGEE

Health entrepreneurs today tend to give themselves very high grades, and seem surprised when their creations fall short of expectations due to a disconnect with funders or regulators with legal authority. But Medicine isn’t fair, and genius is not that common.

What other conclusion can you draw from the thousands of references and citations featuring Philadelphia physician Benjamin Rush and his wild ideas on how to heroically treat Yellow Fever in 1793, but likely never heard of Dr. John Henry Rauch. The former signed the Declaration of Independence but directly or indirectly contributed to many an unpleasant death.  The latter saved millions and helped the AMA and the AAMC find their way out of their post-Civil War professional wilderness.

Dr. Rauch’s career, its’ span and breadth, is startling and could well serve as a yardstick for medical imagineers today. Born in Lebanon, PA in 1828, he received his Medical Degree from the University of Pennsylvania, and then opened a practice in Burlington, Iowa. He was there in 1850 for the birthing of the Iowa State Medical Society, and with their encouragement published (just five years after Iowa achieved statehood) the epic “Medical and Economic Botany of Iowa” listing 516 species, fully 23% of the known flora of the state today.

Two decades later, he was onsite in Chicago from October 8-10, 1871, when 3.3 square miles of Chicago burned to the ground taking 300 souls with it, and managed the emergency medical aftermath for the city. By then he was all too familiar with conflagration and disaster, having earned the  imprimatur of lieutenant-colonel from the Union Army as assistant medical-director of the famed Army of Virginia during the Civil War.

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OI May Be The Next AI

In the past few months, artificial intelligence (AI) has suddenly seemed to come of age, with “generative AI” showing that AI was capable of being creative in ways that we thought was uniquely human.  Whether it is writing, taking tests, creating art, inventing things, making convincing deepfake videos, or conducting searches on your behalf, AI is proving its potential.  Even healthcare has figured out a surprising number of uses.

It’s fun to speculate about which AI — ChatGPT, Bard, DeepMind, Sydney, etc. – will prove “best,” but it turns out that “AI” as we’ve known it may become outdated.  Welcome to “organoid intelligence” (OI).

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I’d been vaguely aware of researchers working with lab-grown brain cells, but I was caught off-guard when Johns Hopkins University researchers announced organoid intelligence (a term they coined) as “the new frontier in biocomputing and intelligence-in-a-dish.”  Their goal: 

…we present a collaborative program to implement the vision of a multidisciplinary field of OI. This aims to establish OI as a form of genuine biological computing that harnesses brain organoids using scientific and bioengineering advances in an ethically responsible manner.

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Matthew’s health care tidbits: Oh, the DEA makes me sigh….

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I have always thought that the dual role of the Drug Enforcement Agency (DEA) was an anachronism that severely hampers America’s complex relationship with pharmaceuticals. Congress deems some medicines legal and regulates them via the FDA, and deems others illegal and tells the DEA and other law enforcement agencies to attempt to control their supply. Leaving aside the basic futility of this task, somehow DEA was also given the task of regulating the prescribers of legal prescription (and non-prescription) drugs–in particular those around controlled substances.

This has led to decades of DEA-led persecution of doctors, patients and even convenience store clerks in the name of reducing the diversion of opiates and methamphetamines. Of course going after any of these folks is much easier and less risky than hunting a Mexican cartel or busting real criminals, so it’s easy to see why the DEA has taken that approach. Has it worked in reducing the supply of opiates? Maybe. Has it had any impact on the opiate crisis? Not really. Have a whole lot of patients been caught in the crossfire? Yup.

Now the DEA is moving onto the next phase–re-regulating the online prescribing of controlled substances that was liberalized at the start of the public health emergency in 2020. As you can imagine, their proposals are not exactly bursting with reason.

The DEA is essentially banning all controlled prescribing without a face to face visit first. This is despite the fact that the demand for those mental health medications increased dramatically during the pandemic as rates of depression and anxiety went up by a factor of three. While you can argue that in 2021 and 2022 some online services (notably Cerebral) may–and I stress may–have crossed the over-prescribing line for ADHD and other conditions, there’s no evidence that what happened is any worse than the in-person care that the DEA has been inadequately overseeing for decades. More importantly, those online services have already pulled out of those exact therapeutic markets the DEA is alarmed about. Who is left providing online ADHD care? Local clinicians and reputable services. And of course DEA knows full well, and is doing nothing about, the lack of access to mental health professionals that existed long before the increase in demand.

Is there any reason to suspect DEA will improve the quality of the system dealing with these medications? Highly doubtful. There are two current examples suggesting why not. First, due to the increased demand from the pandemic induced mental-health crisis and production problems at pharma company Teva, there’s a massive shortage of ADHD medication already. The DEA could help patients out here, but have declined to increase production quotas–sending millions of patients and their parents on a wild goose chase hunting down pharmacies with actual supply of Adderall and related meds.

Secondly, the DEA wants to also ban the the online prescribing of another drug, buprenorphine, which is used to help wean patients with substance use disorder off opiates and other substances. OK, so there’s a one month grace period here but essentially this is a short-sighted ban that will directly lead to patients going to the black market to acquire opiates, leading to more addiction and death.

My conclusion is that the DEA should be removed from its oversight of licensed clinicians and that role be given to FDA or HHS. At the least these proposed  regulations should be abandoned and rolled back to what we have now. The only good news is that there is still time to comment on the regulations. I went and did so and I hope you will too. Patients have suffered enough already.

THCB Gang Episode 118, Thursday March 2

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday March 2 at 1PM PT 4PM ET are DiME CEO, & Olympic rower for 2 countries Jennifer Goldsack, (@GoldsackJen); writer Kim Bellard (@kimbbellard); benefits expert Jennifer Benz (@Jenbenz); and Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune). Today we have also a special guest –former Permanente Medical Group CEO Robbie Pearl @robertpearlmd, who is not shy with his opinions!

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.

Matthew’s health care tidbits: Medicare Advantage is now a provider fracking contest

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Yes it’s time to talk Medicare Advantage (MA). It’s been a huge couple of weeks for the world of MA. On the commercial side, CVS bought the biggest pure play MA provider, Oak Street Health for $10bn. This pissed me off as if they paid $2 a share more I’d have made a profit on the stock I foolishly bought “on a dip” in 2021.

But this amazed many of us on THCB Gang, as they paid a huge premium and it works out to some $60k per patient. Now health care organizations have been overpaying for patient “lives” as long as I can remember–going at least as far back as Aetna nearly going out of business when it bought US Healthcare in 1996. So why is today’s incarnation of Aetna buying providers?

Well that’s to do with the regulatory side of MA. I have been on record since the very first post of THCB that Medicare FFS is an inefficient and expensive program–even if 80% of American hospitals say they lose money on it and have to charge commercial insurers more to make up for it. But while it’s possible to agree with George Halvorson that MA delivers better care at a lower cost than FFS Medicare, it is simultaneously possible to believe that MA costs more than it should. That’s because of aggressive RAF upcoding that’s been built both into home visits from companies like Signify and also into the EMRs doctors have been using to code MA members’ health status.

There are lots of proposals on how to fix this–including this one from Chenmed on how to change MA from paying for inputs (i.e how sick people are when they join MA) to outputs (how much better they got while in MA). But it’s clear that CMS is now officially coming after upcoding including full cross plan audits back to 2018. Even if not back to 2011. The MA plans will grumble about those past audits and tie CMS up in court but they know going forward the game is up

To make more money in MA they need to get hold and shake loose or frack some of the 85% of the premium that goes to provider organizations. Hence they are all getting into bed with them or buying them outright. UHG, Humana & now Aetna/CVS have been buying physician groups that serve MA populations at a quickening rate, and their goal is to put more of the 50% of seniors already into MA into those groups.

Will this save any money?  Well probably not, at least not yet. Humana has been reporting on the costs in its full risk capitated MA groups versus its FFS ones for a couple of years, and the difference is a rounding error. But the point is that the next war in Medicare Advantage is going to be what happens inside these plan-owned medical groups. So expect a lot more scrutiny of both costs, outcomes and patient experience within MA focused medical groups starting about now. 

THCB Gang Episode 116, Thursday February 16

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday February 16 were futurist Ian Morrison (@seccurve); delivery & platform expert Vince Kuraitis (@VinceKuraitis); and Olympic rower for 2 countries and all around dynamo Jennifer Goldsack, (@GoldsackJen). Sadly, fierce patient activist Casey Quinlan (@MightyCasey) had to cry off, and sadly never returned to THCBGang.

We really dug into distributed care and who was going to control the emerging virtual first conundrum.

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.

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