They’re back and I’m an Executive Producer again (don’t ask what that means!). Entries are open now and close on July 31. Awards given out at HLTH on October 20. The team even made a spiffy video about it!–Matthew Holt
How to Fix the Paradox of Primary Care
By MATTHEW HOLT
If health policy wonks believe anything it’s that primary care is a good thing. In theory we should all have strong relationships with our primary care doctors. They should navigate us around the health system and be arriving on our doorsteps like Marcus Welby MD when needed. Wonks like me believe that if you introduce such a relationship patients will receive preventative care, will get on the right meds and take them, will avoid the emergency room, and have fewer hospital admissions—as well as costing a whole lot less. That’s in large the theory behind HMOs and their latter-day descendants, value-based care and ACOs
Of course there are decent examples of primary care-based systems like the UK NHS or even Kaiser Permanente or the Alaskan Artic Slope Native Health Association. But for most Americans that is fantasy land. Instead, we have a system where primary care is the ugly stepchild. It’s being slowly throttled and picked apart. Even the wealth of Walmart couldn’t make it work.
There are at least 3 types of primary care that have emerged over recent decades. And none of them are really successful in making that “primary care as the lynchpin of population health” idea work.
The first is the primary care doctor purchased by and/or working for the big system. The point of these practices is to make sure that referrals for the expensive stuff go into the correct hospital system. For a long time those primary care doctors have been losing their employers money—Bob Kocher said $150-250k a year per doctor in the late 2000s. So why are they kept around by the bigger systems? Because the patients that they do admit to the hospital are insanely profitable. Consider this NC system which ended up suing the big hospital system Atrium because they only wanted the referrals. As you might expect the “cost saving” benefits of primary care are tough to find among those systems. (If you have time watch Eric Bricker’s video on Atrium & Troyon/Mecklenberg)
The second is urgent care. Urgent care has replaced primary care in much of America. The number of urgent care centers doubled in the last decade or so. While it has taken some pressure off emergency rooms, Urgent care has replaced primary care because it’s convenient and you can easily get appointments. But it’s not doing population health and care management. And often the urgent care centers are owned either by hospital systems that are using them to generate referrals, or private equity pirates that are trying to boost costs not control them.
Thirdly telehealth, especially attached to pharmacies, has enabled lots of people to get access to medications in a cheaper and more convenient fashion. Of course, this isn’t really complete primary care but HIMS & HERS and their many, many competitors are enabling access to common antibiotics for UTIs, contraceptive pills, and also mental health medications, as well as those boner and baldness pills.
That’s not to say that there haven’t been attempts to build new types of primary care
Continue reading…Matthew on the Inside Medtech Innovation podcast
I was a guest on Shannon Lantzy‘s podcast Inside Medtech Innovation. I went on far too long about my background but we had a very fun chat, including the real origin story of why I am in health technology, and a bit about my fascination with Japan. Plus some more health care stuff. I enjoyed it. Hopefully you will too–Matthew Holt
How to Buy and Sell AI in health care? Not Easy.
By MATTHEW HOLT
It was not so long ago that you could create one of those maps of health care IT or digital health and be roughly right. I did it myself back in the Health 2.0 days, including the old sub categories of the “Rebel Alliance of New Provider Technologies” and the “Frontier of Patient Empowerment Technologies”
But those easy days of matching a SaaS product to the intended user, and differentiating it from others are gone. The map has been upended by the hurricane that is generative AI, and it has thrown the industry into a state of confusion.
For the past several months I have been trying to figure out who is going to do what in AI health tech. I’ve had lots of formal and informal conversations, read a ton and been to three conferences in the past few months all focused dead on this topic. And it’s clear no one has a good answer.
Of course this hasn’t stopped people trying to draw maps like this one from Protege. As you can tell there are hundreds of companies building AI first products for every aspect of the health care value (or lack of it!) chain.
But this time it’s different. It’s not at all clear that AI will stop at the border of a user or even have a clearly defined function. It’s not even clear that there will be an “AI for Health Tech” sector.
This is a multi-dimensional issue.
The main AI LLMs–ChatGPT (OpenAI/Microsoft), Gemini (Google/Alphabet) Claude (Anthropic/Amazon), Grok (X/Twitter), Lama (Meta/Facebook)–are all capable of incredible work inside of health care and of course outside it. They can now write in any language you like, code, create movies, music, images and are all getting better and better.
And they are fantastic at interpretation and summarization. I literally dumped a pretty incomprehensible 26 page dense CMS RFI document into ChatGPT the other day and in a few seconds it told me what they asked for and what they were actually looking for (that unwritten subtext). The CMS official who authored it was very impressed and was a little upset they weren’t allowed to use it. If I had wanted to help CMS, it would have written the response for me too.
The big LLMs are also developing “agentic” capabilities. In other words, they are able to conduct multistep business and human processes.
Right now they are being used directly by health care professionals and patients for summaries, communication and companionship. Increasingly they are being used for diagnostics, coaching and therapy. And of course many health care organizations are using them directly for process redesign.
Meanwhile, the core workhorses of health care are the EMRs used by providers, and the biggest kahuna of them all is Epic. Epic has a relationship with Microsoft which has its own AI play and also has its own strong relationship with OpenAI – or at least as strong as investing $13bn in a non-profit will make your relationship. Epic is now using Microsoft’s AI both in note summaries, patient communications et al, and also using DAX, the ambient AI scribe from Microsoft’s subsidiary Nuance. Epic also has a relationship with DAX rival Abridge
But that’s not necessarily enough and Epic is clearly building its own AI capabilities. In an excellent review over at Health IT Today John Lee breaks down Epic’s non-trivial use of AI in its clincal workflow:
- The platform now offers tools to reorganize text for readability, generate succinct, patient-friendly summaries, hospital course summaries, discharge instructions, and even translating discrete clinical data into narrative instructions.
- We will be able to automatically destigmatize language in notes (e.g., changing “narcotic abuser” to “patient has opiate use disorder”),
- Even as a physician, I sometimes have a hard time deciphering the shorthand that my colleagues so frequently use. Epic showed how AI can translate obtuse medical shorthand-like “POD 1 sp CABG. HD stable. Amb w asst.”-into plain language: “Post op day 1 status post coronary bypass graft surgery. Hemodynamically stable. Patient is able to ambulate with assist.”
- For nurses, ambient documentation and AI-generated shift notes will be available, reducing manual entry and freeing up time for patient care.
And of course Epic isn’t the only EHR (honestly!). Its competitors aren’t standing still. Meditech’s COO Helen Waters gave a wide-ranging interview to HISTalk. I paid particular attention to her discussion of their work with Google in AI and I am quoting almost all of it:
This initial product was built off of the BERT language model. It wasn’t necessarily generative AI, but it was one of their first large language models. The feature in that was called Conditions Explorer, and that functionality was really a leap forward. It was intelligently organizing the patient information directly from within the chart, and as the physician was working in the chart workflow, offering both a longitudinal view of the patient’s health by specific conditions and categorizing that information in a manner that clinicians could quickly access relevant information to particular health issues, correlated information, making it more efficient in informed decision making. <snip>
Beyond that, with the Vertex AI platform and certainly multiple iterations of Gemini, we’ve walked forward to offer additional AI offerings in the category of gen AI, and that includes both a physician hospital course-of-stay narrative at the end of a patient’s time in the hospital to be discharged. We actually generate the course-of-stay, which has been usually beneficial for docs to not have to start to build that on their own.
We also do the same for nurses as they switch shifts. We give a nurse shift summary, which basically categorizes the relevant information from the previous shift and saves them quite a bit of time. We are using the Vertex AI platform to do that. And in addition to everyone else under the sun, we have obviously delivered and brought live ambient scribe capabilities with AI platforms from a multitude of vendors, which has been successful for the company as well.
The concept of Google and the partnership remains strong. The results are clear with the vision that we had for Expanse Navigator. The progress continues around the LLMs, and what we’re seeing is great promise for the future of these technologies helping with administrative burdens and tasks, but also continued informed capacities to have clinicians feel strong and confident in the decisions they’re making.
The voice capabilities in the concept of agentic AI will clearly go far beyond ambient scribing, which is both exciting and ironic when you think about how the industry started with a pen way back when, we took them to keyboards, and then we took them to mobile devices, where they could tap and swipe with tablets and phones. Now we’re right back to voice, which I think will be pleasing provided it works efficiently and effectively for clinicians.
So if you read–not even between the lines but just what they are saying–Epic, which dominates AMCs and big non-profit health systems, and Meditech, the EMR for most big for-profit systems like HCA, are both building AI into their platforms for almost all of the workflow that most clinicians and administrators use.
I raised this issue a number of different ways at a meeting hosted by Commure, the General Catalyst-backed provider-focused AI company. Commure has been through a number of iterations in its 8 year life but it is now an AI platform on which it is building several products or capabilities. (For more here’s my interview with CEO Tannay Tandon). These include (so far!) administration, revenue cycle, inventory and staff tracking, ambient listening/scribing, clinical workflow, and clinical summarization. You can bet there’s more to come via development or acquisition. In addition Commure is doing this not only with the deep pocketed backing of General Catalyst but also with partial ownership from HCA–incidentally Meditech’s biggest client. That means HCA has to figure out what Commure is doing compared to Meditech.
Finally there’s also a ton of AI activity using the big LLMs internally within AMCs and in providers, plans and payers generally. Don’t forget that all these players have heavily customized many of the tools (like Epic) which external vendors have sold them. They are also making their AI vendors “forward deploy” engineers to customize their AI tools to the clients’ workflow. But they are also building stuff themselves. For instance Stanford just released a homegrown product that uses AI to communicate lab results to patients. Not bought from a vendor, but developed internally using Anthropic’s Claude LLM. There are dozens and dozens of these homegrown projects happening in every major health care enterprise. All those data scientists have to keep busy somehow!
So what does that say about the role of AI?
First it’s clear that the current platforms of record in health care–the EHRs–are viewing themselves as massive data stores and are expecting that the AI tools that they and their partners develop will take over much of the workflow currently done by their human users.
Second, the law of tech has usually been that water flows downhill. More and more companies and products end up becoming features on other products and platforms. You may recall that there used to be a separate set of software for writing (Wordperfect), presentation (Persuasion), spreadsheets (Lotus123) and now there is MS Office and Google Suite. Last month a company called Brellium raised $16m from presumably very clever VCs to summarize clinical notes and analyze them for compliance. Now watch them prove me wrong, but doesn’t it seem that everyone and their dog has already built AI to summarize and analyze clinical notes? Can’t one more analysis for compliance be added on easily? It’s a pretty good bet that this functionality will be part of some bigger product very soon.
(By the way, one area that might be distinct is voice conversation, which right now does seem to have a separate set of skills and companies working in it because interpreting human speech and conversing with humans is tricky. Of course that might be a temporary “moat” and these companies or their products may end up back in the main LLM soon enough).
Meanwhile, Vine Kuraitis, Girish Muralidharan & the late Jody Ranck just wrote a 3 part series on how the EMR is moving anyway towards becoming a bigger unified digital health platform which suggests that the clinical part of the EMR will be integrated with all the other process stuff going on in health systems. Think staffing, supplies, finance, marketing, etc. And of course there’s still the ongoing integration between EMRs and medical devices and sensors across the hospital and eventually the wider health ecosystem.
So this integration of data sets could quickly lead to an AI dominated super system in which lots of decisions are made automatically (e.g. AI tracking care protocols as Robbie Pearl suggested on THCB a while back), while some decisions are operationally made by humans (ordering labs or meds, or setting staffing schedules) and finally a few decisions are more strategic. The progress towards deep research and agentic AI being made by the big LLMs has caused many (possibly including Satya Nadella) to suggest that SaaS is dead. It’s not hard to imagine a new future where everything is scraped by the AI and agents run everything globally in a health system.
This leads to a real problem for every player in the health care ecosystem.
If you are buying an AI system, you don’t know if the application or solution you are buying is going to be cannibalized by your own EHR, or by something that is already being built inside your organization.
If you are selling an AI system, you don’t know if your product is a feature of someone else’s AI, or if the skill is in the prompts your customers want to develop rather than in your tool. And worse, there’s little penalty in your potential clients waiting to see if something better and cheaper comes along.
And this is happening in a world in which there are new and better LLM and other AI models every few months.
I think for now the issue is that, until we get a clearer understanding of how all this plays out, there will be lots of false starts, funding rounds that don’t go anywhere, and AI implementations that don’t achieve much. Reports like the one from Sofia Guerra and Steve Kraus at Bessmer may help, giving 59 “jobs to be done”. I’m just concerned that no one will be too sure what the right tool for the job is.
Of course I await my robot overlords telling me the correct answer.
Matthew Holt is the Publisher of THCB
Patrick Quigley, Sidecar Health
Patrick Quigley is the CEO of Sidecar Health. It’s a start up health insurance company that has a new approach to how employers and employees buy health care. Sidecar is betting on the radical pricing transparency idea. Instead of going down the contacting and narrow network route, Sidecar presents average area pricing and individual provider pricing to its members, and rewards them if they go to lower cost providers (who often are cheaper). How does this all work and is it real? Patrick took me through an extensive demo and explained how this all works. There’s a decent amount of complexity behind the scenes but Sidecar is creating something very rare in America, a priced health care market allowing consumers to choose–Matthew Holt
Medicaid Should be Abolished. But Not Like This!
By MATTHEW HOLT
A long time ago in a different country, there was a landslide election from a population looking for change. And change they got. Americans had been campaigning for national health care since 1917. There had been failures in 1933 and 1946 and 1961. But in 1965 they got it. Sort of.
But a weird thing happened in the Congress. Out of the political sausage making came a plan that “Cared” for those over 65. While another plan came out that “Aid”ed the poor. (Stole that from the wonderful Adimika Arthur). Weirder still, the Medicare program was and is a Federally-funded program. The Medicaid program was a state-administered program, even though it was at least half funded by the Feds.
That meant that Medicaid was always vulnerable to the whims of states. Of course many states already had demonstrated dismal records in how they treated their poorer and minority populations in the past (think slavery, Jim Crow, KKK, separate schools, drinking fountains, buses…you get the idea).
So while Medicare became the savior program for anyone who made it to 65, and later for those who were disabled or had kidney disease, Medicaid was a program for poor people that then got treated poorly. (Stole that from Jonathan Cohn). And right now in 2025 it is under severe threat yet again.
Before we get to that threat, it’s worth looking at the program. Medicaid has evolved and now covers most nursing home care (for “poor” seniors), care for the disabled, and even pays Medicare Part B premiums for people too poor to pay their own. It also covers health insurance for poor people under 65 and in those states that accepted ACA Medicaid expansion, that’s a considerable number. Of course these are people under an imaginary line that makes them too poor to buy on the exchanges set up by the ACA. And usually Medicaid includes the CHIP program, an insurance program that covers poor children set up under Clinton in 1997.
This chart from the venerable KFF shows that while 75% of people on Medicaid are, poor, under 65, and not classified as disabled, 50% of the money goes to those who are not.
This all results in a bizarro world in which there is one Federal government program for people over 65 and the disabled, and then an entirely different state-based one, which spends 1/2 of its money on people who are over 65 and disabled and who are also in the Federal program. This is plain stupid and always has been.
Of course there is more to it than that.
Continue reading…League Connect Digital Summit is WEDNESDAY
It’s Matthew Holt and I am looking forward to MC-ing the #LeagueConnectDigitalSummit THIS Wednesday May 7.
This one-day virtual event brings together leaders across health care, tech, and consumer experience to explore what it really takes to deliver personalized, digital-first, AI-powered care. I’ll be guiding the day’s key transitions and themes. There’s also strategy & implementation tracks with the likes of Google, Highmark Health, Accenture, Amwell, Deloitte, SCAN, Gainwell Technologies Health, and startups like SimpliFed, Healthily, Linus Health and so many more.
Join me and League for a FREE day of conversations, connection, and actionable insights that move health care forward.
Oh, yes and Moneyball, The Blind Side and Liar’s Poker author Michael Lewis is the keynote.
Glen Tullman, Transcarent
A couple of weeks back Transcarent completed its $630m acquisition of Accolade. But CEO Glen Tullman calls it a merger for a reason because Accolade brings people, products and clients that Transcarent didn’t have. Glen got in deep about Transcarent’s new product set in terms of its AI fueled navigation, primary care, weight management, cancer care and partnerships. Where is it going in terms of more with employers (yes!), Medicare (not yet) and aggressive expansion of services? And what can employers and their employees expect in terms of improving customer service from the health care system? Glen and his team have a big vision, big capital backing, and he is definitely intending to move the needle on care access, quality and cost.–Matthew Holt
Roon – the Demo and Interview
I was a little surprised that in the days of limitless content, AI, and all types of medical information being online a company could raise $15m to create a platform where actual doctors could answer specific questions that patients might have. Vikram Bhaskaran, the CEO is ex Pinterest and knows the consumer world well. Rohan Ramakrishna is a neurosurgeon who is worried about the level of misinformation that he saw showing up in his clinic daily. So Roon is trying to build what might be the impossible, a free personalized (mostly video) guide for health powered by the world’s best experts. They gave me a tour of what they have built so far, and it’s both impressive, ambitious and has a way to go. It’s an interesting demo and it raises some interesting questions about how that knowledge will be shared in the very near future–Matthew Holt
We Need to Nationalize to Prevent Fraud
By MATTHEW HOLT
Two weeks ago I wrote an April Fool’s piece that claimed that Elon Musk and DOGE were going to nationalize American health care to save some money. That piece was half-joking but full-serious.
If you look at what Musk is complaining about there are two major areas of “waste, fraud and abuse” in government spending.
One is people directly employed by government agencies. Most of the people I’ve ever met in government work damn hard and for much less money than they’d get in the private sector. But you can of course find stories about useless government bureaucrats, who don’t do any work and pad their expense accounts. Those stories are probably about as true as Reagan’s pink Cadillac driving welfare queen in that there is some basis in reality for there being a tiny minority of bad actors, but the politics has far outrun the truth. (BTW that Welfare Queen article by Josh Levin in Slate is remarkable and very long!)
The other major area where Musk claims to be finding fraud is in work contracted out. There are of course lots of types of government work contracted out. If, like me, you’re old enough to remember the Iraq war, you probably are thinking of beltway bandits like Halliburton supplying any number of services to the military. (Remember when the Cheneys were baddies?). Another is the Blue Cross & Blue Shield plans who were the original contractors processing Medicare & Medicaid claims. Funnily enough they couldn’t actually deliver on that so in turn they outsourced it to Ross Perot at EDS and others like ACS, later Conduent. But there’s a ton more across every agency.
Musk & DOGE have been running around in the most ham-fisted way imaginable, axing both actual employees–including 20,000 of the 80,000 working at HHS– and allegedly slashing $150 billion in contracts. Of course on closer examination, many of the “contracts” were already over, or were made up. DOGE has been a pathetic piece of performance art that would be funny if it hadn’t ruined so many careers of people doing great work, or killed so many desperately poor children in poor countries.
The clever people at Brookings, (Elaine Kamarck and Paul Light) in a detailed piece on the topic, came up with an estimate of the ratio between direct employees and contractors.
Continue reading…
