Arcadia.io is a population health company that helps providers and insurers in their transition to a value-based care model. Arcadia is working with several of the Blues, Cigna, Beth Israel, and more. While it started as a consulting firm, in recent years Arcadia has raised over $40m from Merck, GE, and other corporate venture funds.
Listen to Matthew Holt’s interview with Sean Carroll, CEO of Arcadia.io below.
Today, we’ve got another episode of Health in 2 Point 00—airport edition. On Episode 78, Jess is spending the last few moments before her vacation interviewing me from the airport. She asks me about lots of big raises: Redox raised $33 million for their interoperability platform; EverlyWell, which offers direct-to-consumer lab testing, raised $50 million, and Ro raised another $85 million just a year after raising $88 million. In other news, SureScripts is getting sued by the FDIC for monopolizing the e-prescriptions market and the FBI just raided uBiome for double-billing insurers. —Matthew Holt
By PHUOC LE, MD and SAM APTEKAR
Fifteen years ago, as a medical student, I learned a terrifying lesson about blindly using race-based medicine. I was taking care of Mr. Smith, a thin man in his late 60s, who entered the hospital with severe back pain and a fever. As the student on the hospital team, I spent over an hour interviewing him, asking relevant questions about his medical and social history, the medications he took, and the details of his symptoms. I learned Mr. Smith was a veteran who ran into tough times that left him chronically homeless, uninsured, and suffering from hypertension and diabetes. I performed a complete physical exam, paying particularly close attention to his back. Upon reviewing his blood tests and kidney function, I read the computer’s report: “normal.”
I felt confident as I presented Mr. Smith’s treatment plan to my attending physician: I recommended a CT scan, ibuprofen for pain, blood pressure lowering medication, and an antibiotic. My attending listened quietly, reviewed the labs herself, and then firmly corrected every aspect of my treatment proposal. “His kidney function is NOT normal. What you want to do for him can further damage his kidneys. The lab reported his creatinine as ‘normal’ because it has an algorithm that makes faulty assumptions based on race.” Mr. Smith, according to the medical record, was African American.
I almost harmed Mr. Smith because I hadn’t realized that the exact same creatinine level (the key metric for kidney function) yields two different reports based on whether you’re African American or not. The logic goes that because black people supposedly have higher muscle mass on average, healthy creatinine levels for those who check the “black” box is different from those who check other boxes. Physicians around the country continue to rely on this metric even when the black patient is thin, like Mr. Smith. This example of race-based creatinine levels to determine kidney function is a symptom of race-based medicine in general: (poorly defined) racial categories are often used as proxies to explain discrepancies in health outcomes by race, which is a potentially dangerous analysis. Mr. Smith’s case forced me to consider why race-based medicine is problematic and where our attention as healthcare providers should be directed instead.
What is certain is that health inequities persist along racial lines. African Americans and Hispanics have higher rates of diabetes, hypertension, and heart disease than other groups (Figure 1).[1] American Indians and Alaskan Natives are 2.1 times as likely to be diagnosed with diabetes as white individuals and the prevalence of obesity in this population is higher than any other group. While it would be convenient to attribute these disparities to genetic difference, this is simply not the case.
Today THCB is spotlighting Lumeris which creates a platform to help set-up and develop health plans and manage care delivery for patients. Working with its associated medical group Essence, Lumeris has been creating actionable steps to reduce Medical Cost Rates (MCRs) and is now taking that process to other health systems that want to set up Medicare Advantage plans. Lumeris is working with 12 health systems and is growing rapidly. Recently, Lumeris partnered with Cerner to bring their product to market.
Matthew Holt interviewed Matt Cox, Chief Marketing Officer at Lumeris to find out the details.
By THERESA BROWN, RN
In my mid-twenties, I was twice prescribed the common antihistamine Benadryl for allergies. However, my body’s reaction to the drug was anything but common. Instead of my hives fading, they erupted all over my body and my arms filled with extra fluid until they were almost twice normal size. I subsequently described my experience to a new allergist, who dismissed it as “coincidence.”
When I later became a nurse, I learned that seemingly “harmless” medications often cause harm, and older adults are particularly vulnerable. Every year, Americans over age 65 have preventable “adverse drug events” (ADEs) that lead to 280,000 hospital stays and nearly 5 million outpatient visits. The Lown Institute in Boston draws attention to this underrecognized problem in their recent report, Medication Overload: America’s Other Drug Problem. Policymakers, patients, and health professionals must act, because over the next decade, medication overload is predicted to cause 4.6 million hospitalizations of older Americans and 150,000 premature deaths.
Nearly half of all older adults take at least five prescription drugs, a 300 percent increase from 25 years ago. The more drugs we take, the likelier it is that one of them, or some combination, will cause serious harm. When you add in non-prescription medications, including over-the-counter drugs like ibuprofen and Tylenol, as well as vitamins and herbal supplements, the potential for harm only goes up.
I’ve seen this in my work. It is not unusual for elderly, very ill patients on hospice to have prescriptions for 20 to 30 drugs. Several of their medications may treat the same problem, amplifying any serious side effects. Blood pressure medications provide a good example. As older patients become more debilitated, lose weight, and are taxed by other health issues, the effect of these medications can intensify, severely lowering blood pressure, and causing the patients to fall. Indeed, if I am following up with a hospice patient who has fallen, the first thing I check is their prescription medications for hypertension.
By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA
Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.
Though our standard screen for safety at home had been completed long ago, I wanted to probe further, knowing that many patients with obesity, chronic pain and other chronic conditions have suffered an adverse childhood – or adulthood – experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough latitude for me to ask about a history of trauma when it can occur in so many forms, in so many ways and at different times of life? Furthermore, suppose she did report a history of trauma or adverse experience. What then? Would I be able to help her?
Nonetheless, I began: “Jenny, many patients with symptoms like yours have been abused, either emotionally, physically, or sexually, or neglected in their past. Sometimes they have suffered loss of a loved one, or experienced or witnessed violence. Has anything like this ever happened to you?”
This yielded our first breakthrough. Yes, she had experienced neglect, with parents who were separated for much of her childhood, and then later divorced. She had seen her father physically abuse her mother. With little parental oversight, she had engaged in drug and alcohol use throughout her teenage years. But, she wanted to be sure we understood that this was all behind her. She had gotten an education, was in a committed relationship, and had a stable job as a teacher. That part of her life was thankfully now closed.
By SAURABH JHA, MD
In this episode of Radiology Firing Line Podcast, I speak with Bishal Gyawali MD, PhD. Dr. Gyawali obtained his medical degree from Kathmandu. He received a scholarship to pursue a PhD in Japan. Dr. Gyawali’s work focuses on getting cheap and effective treatment to under developed parts of the world. Dr. Gyawali is an advocate for evidence-based medicine. He has published extensively in many high impact journals. He coined the term “cancer groundshot.” He was a research fellow at PORTAL. He is currently a scientist at the Queen’s University Cancer Research Institute in Kingston, Ontario.
Listen to our conversation here.
Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.
By KIP SULLIVAN, JD
At its April 4, 2019 meeting, the staff of the Medicare Payment Advisory Commission (MedPAC) asked the commission to discuss a very strange proposal: Doctors who treat patients enrolled in Medicare’s traditional fee-for-service (FFS) program must join an “accountable care organization” (ACO) or give up their FFS Medicare practice. (The staff may have meant to give hospitals the same Hobbesian choice, but that is not clear from the transcript of the meeting.)
Here is how MedPAC staffer Eric Rollins laid out the proposal:
“Medicare would require all fee-for-service providers to participate in ACOs. The traditional fee-for-service program would no longer be an option. Providers would have to join ACOs to receive fee-for-service payments. Medicare would assign all beneficiaries to ACOs and would continue to pay claims for ACOs using standard fee-for-service rates. Beneficiaries could still enroll in MA [Medicare Advantage] plans. (p. 12 of the transcript)”
The first question that should have occurred to the commissioners was, Are ACOs making any money? If they aren’t, there’s no point in discussing a policy that assumes ACOs will flourish across the country.
But only two of the 17 commissioners bothered to raise that issue. They asserted that Medicare ACOs are saving little or no money. Those two commissioners – Paul Ginsburg and commission Vice Chairman Jon Christianson – did not mince words. Ginsburg said ACO savings were “slight” and called the proposal to push doctors into ACOs “hollow” and premature. (pp. 62-63) Christianson was even more critical. He said the proposal was “really audacious,” and that no “strong evidence” existed to support the claim that ACOs “can reduce costs for the Medicare program or improve quality.” (pp. 73-74) Ginsburg and Christianson are correct – ACOs are not cutting Medicare’s costs when Medicare’s “shared savings” payments to ACOs are taken into account, and what little evidence we have on ACO overhead indicates CMS’s small shared savings payments are nowhere near enough to cover that overhead.
By PHUOC LE, MD and SAM APTEKAR
A friend of mine told me the other day, “We’ve seen our insured patient population go from 15% to 70% in the few years since Obamacare.” As a primary care physician in the Midwest, he’s worked for years in an inner-city clinic that serves a poor community, many of whom also suffer from mental illness. Before the Affordable Care Act (ACA), the clinic constantly struggled to stay afloat financially. Too often patients would be sent to an emergency room because the clinic couldn’t afford to provide some of the simplest medical tests, like an x-ray. Now, with most of his patients insured through the Medicaid expansion program, the clinic has beefed up its staffing and ancillary services, allowing them to provide better preventive care, and in turn, reduce costly ER visits.
From the time Medicaid was established in 1965 as the country’s first federally-funded health insurance plan for low-income individuals, state governments have only been required to cover the poorest of their citizens. Before the ACA, some 47 million Americans were uninsured because their incomes exceeded state-determined benchmarks for Medicaid eligibility and they earned far too little to buy insurance through the private marketplace.
The ACA reduced the number of uninsured Americans by mandating that states increase their income requirement for Medicaid to 138% of the federal poverty line (about $1,330 per month for a single individual), and promising that the federal government would cover the cost to do so. However, in a 2012 decision, the Supreme Court left it to the states to decide if they wanted to increase their Medicaid eligibility. If they agreed to adopt Medicaid expansion, the federal government offered to cover 100% of the increased cost in 2014 and 90% by 2021.
By ADRIAN GROPPER, MD
Many of you have received the email: Microsoft HealthVault is shutting down. By some accounts, Microsoft has spent over $1 Billion on a valiant attempt to create a patient-centered health information system. They were not greedy. They adopted standards that I worked on for about a decade. They generously funded non-profit Patient Privacy Rights to create an innovative privacy policy in a green field situation. They invited trusted patient surrogates like the American Heart Association to participate in the launch. They stuck with it for almost a dozen years. They failed. The broken market and promise of HITECH is to blame and now a new administration has the opportunity and the tools to avoid the rent-seekers’ trap.
The 2016 21st Century CURES Act is the law. It is built around two phrases: “information blocking” and “without special effort” that give the administration tremendous power to regulate anti-competitive behavior in the health information sector. The resulting draft regulation, February’s Notice of Proposed Rulemaking (NPRM) is a breakthrough attempt to bend the healthcare cost curve through patient empowerment and competition. It could be the last best chance to avoid a $6 Trillion, 20% of GDP future without introducing strict price controls.
This post highlights patient-directed access as the essential pro-competition aspect of the NPRM which allows the patient’s data to follow the patient to any service, any physician, any caregiver, anywhere in the country or in the world.
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