Today on the 52nd episode of Health in 2 Point 00, Jess reports from InsurTechConnect 2018! In this episode, Jess asks Matthew about RockHealth’s $6.8 billion fundraise to date & its $3 Billion raise in Q3, Weight Watcher’s rebranding itself and pushing into the wellness space, and (just in time we might add) Maven, a women’s digital health clinic, series B round of $27 million from Oak HC/FT
4 Signs that Disruption is Accelerating in Health Care Delivery
By REBECCA FOGG
Hardly a day goes by that I don’t read the term “Disruptive Innovation” cited in relation to health care delivery. This might seem like a good thing, given that our expensive, wasteful, and in some cases frightfully ineffective traditional delivery model is in dire need of transformation. However, the term is frequently misunderstood to refer to any innovation representing a radical departure from an industry’s prior best offerings. In fact, it actually has a very specific definition.
Disruptive Innovation is the phenomenon by which an innovation transforms an existing market or sector by introducing simplicity, convenience, accessibility, and affordability where complication and high cost have become the status quo—eventually completely redefining the industry. It has played out in markets from home entertainment to teeth whitening, and it could make health care delivery more effective by making providers’ care processes, as well as individuals’ own self-care regimes easier and less costly. This, in turn, would reduce the need for both more, and more expensive, interventions over time.
Unfortunately, disruption has been slow to emerge in the health care sector. It’s been thwarted by the broader health care industry’s unique structure, which tends to prioritize the needs of commercial insurers and large employers (who pay the most for consumer care) over those of health care consumers themselves. It also stacks the deck against disruptive entrepreneurs, since established providers effectively control professional licensing requirements, and (along with insurers) access to patients & key delivery partners.
Part 2: Bypassing Prior Authorizations
By NIRAN AL-AGBA, MD
A few weeks ago, I saw a young patient who was suffering from an ear infection. It was his fourth visit in eight weeks, as the infection had proven resistant to an escalating series of antibiotics prescribed so far. It was time to bring out a heavier hitter. I prescribed Ciprofloxacin, an antibiotic rarely used in pediatrics, yet effective for some drug-resistant pediatric infections.
The patient was on the state Medicaid insurance and required a so-called prior authorization, or PA, for Ciprofloxacin. Consisting of additional paperwork that physicians are required to fill out before pharmacists can fill prescriptions for certain drugs, PAs boil down to yet another cost-cutting measure implemented by insurers to stand between patients and certain costly drugs.
The PA process usually takes from 48-72 hours, and it’s not infrequent for requests to be denied, even when the physician has demonstrated an undeniable medical need for the drug in question.
Another Round of NYC Curated Matchmaking through DHMP!
SPONSORED POST
By JOHN EL-MARAGHY
The New York City Economic Development Corporation and Catalyst @ Health 2.0 are thrilled to announce another round of Digital Health Marketplace matchmaking coming up on December 5th! Since 2013, the Digital Health Marketplace has connected digital health “Sellers” offering technology solutions to a diverse range of healthcare “Buyers” or institutions looking for tech-enabled solutions and partnerships. At the center of the Digital Health Marketplace is the successful curation of needs and solutions that lead to the development of commercialization and the rapid adoption of new health technologies. If you are an early stage startup looking for relevant pilot/commercial partners or a healthcare organization interested in adopting leading technologies, apply for your opportunity to be matched with relevant partners for one-on-one, in-person sales meetings.
Come to the Society for Participatory Medicine conference (Boston, Oct 17)
Join me at the 2nd annual Society for Participatory Medicine (SPM) conference, co-located with the Connected Health Conference at the World Trade Center in Boston. It’s magical and very inexpensive–Matthew Holt
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THCB Spotlights: TestCard
By ZOYA KHAN
A few weeks back, Matthew met with TestCard (another Brit like him) at TechCrunch Disrupt 2018. Greg, from TestCard, spoke to Matthew about how their device can test multiple different illnesses using urine and a clinical grade camera, which then spits out results (almost) immediately on your smartphone. Currently, the device can be used for detecting pregnancy, glucose, STIs, UTIs, and many more diseases. Their focus is on preventative care for patients, so they are working with insurance companies to use their product as a kit to diagnose problems that are prevalent in UK’s population. Not to mention their slogan is “A bit like Theranos, but our flagship products work.”
Zoya Khan is the Editor-in-Chief of THCB as well as an Associate at SMACK.health, a health-tech advisory services for early-stage startups.
Reducing Cancer Care Costs by Comparative and Cost-Effectiveness Research (CER)
Well, it’s time to resume our discussion of Bending the Cost Curve in Cancer Care.
We’ve reached the end of the list, on ideas to reduce oncology costs put forth by Drs. Smith and Hillner in the May 25 issue of the NEJM. Really this 10th and final point intended for oncologists is two-in-one: “The need for cost-effectiveness analysis and for some limits of care must be accepted,” they chart. So doctors should embrace studies of comparative effectiveness and cost effectiveness.
Hard to argue with reason — they’re correct, of course. They write:
… The national imperative is to empower a transparent, acceptable, equitable, politically independent agency for guidance in making tough choices in the public interest so that doctors do not have to make them at the bedside.60 Ultimately, we will have to make decisions based on some criteria, and comparative-effectiveness61 and cost-effectiveness62 analyses are good ways to align resource use with the greatest health benefit.
This sounds great, and is probably right, but I don’t think it’s realistic.
Modeling readmissions
The current intent to judge hospital performance and modify hospital payments based on relative rates of readmissions is not wise. Contrary to President Obama’s characterization that readmitting a patient to the hospital is equivalent to bringing a car back to the mechanic after a repair, rates of readmissions are based on a number of factors, of which a significant portion are services not provided by the hospitals and environmental conditions not controlled by the hospitals.
But let’s put my objections aside and determine how we would model an “appropriate” rate of readmissions. Well, a new article in JAMA* explores existing models, noting that robust models are needed “to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison.” The article concludes that the capability for doing these things does not yet exist.
In “Risk Prediction Models for Hospital Readmission,” the authors state as their objective: “To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use.” Their conclusion, after reviewing two dozen such models, was that “Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly.”
The Journey We Take Together
Yesterday it became real. I was choking just listening to an hour of horrifying instructions over the phone. You want to scream out: “Stop. No. I’ve changed my mind.”
But how can I? My husband will die.
The heart transplant coordinator is telling us every unpleasant detail to come, now that he has been formally added to the National Register for a double transplant. Things that you really did not want to know about.
There will be a comatose donor, nearly brain dead, and a family in agony. No goody-byes. No more life to share with them.
How will we face stealing a life that is no more, so my husband may live? Maybe.
While our minds can’t help but wander to these ethical, life-and-death issues for a split second, the heart coordinator continues on through her list. The phone will likely ring in the middle of the night, she says, waking us from a deep sleep and beginning the final phase of this latest medical odyssey. Frightened for our lives together, there’s not time to think. We absolutely must get to the hospital within four hours.
We’ve never been big believers in telephones. We’re notorious for just letting calls go to voicemail. Our argument was unassailable―we never ever missed an offer of a million dollars, an authentic call from Elvis or a Presidential appointment because we didn’t pick up the phone.
But not anymore. If you miss one call for a donor that matches, that could be the ballgame. So we’ve now got to be packed and ready. And jump to answer every call.
Now she’s saying “so the first surgery will last ten to fourteen hours.” (10 to 14 hours??) And I’m immediately thinking: Oh my God…what will I do, waiting to hear?
But she’s still talking. When the surgery’s over, she says, Mrs. Prisant you will see your husband connected to ventilators, monitors and more.
I’ve seen all this before with Sandy―twice now, but this time I will have to wait all alone. There are no more lifelong doctor friends around and no family. So there’ll be no one putting their arms around me; no one offering kisses and hugs.
And then, within 36 hours, the next agony will begin―the second surgery. The kidney transplant. That should take about nine hours more.
The coordinator is still reading all the rules and instructions. Not cold, but very business-like. Is she slightly detached? After all there are dozens of candidates who get this far and need to know these rules even though some will never get that transplant.
And every few minutes I can’t listen anymore. We’ve lived with this illness for over four decades, but none of it felt as daunting as this―after eight months of evaluation, we’re now facing hospital testing and blood draws almost every other day for weeks or maybe months after surgery.
This phone call is now becoming suffocating. Our throats are dry as we listen and grunt acknowledgment of each instruction. And then, “Mrs. Prisant you have to get your own accommodations for the two weeks or more Mr. Prisant will be in hospital. And then three days a week he will have to come back for checkups. You will be responsible for room, board, meals parking, etc. (She forgot about the cost of kenneling the dogs and other incidentals.) You stop listening to her for a second as your internal calculator starts throwing up big numbers. Very big numbers.
Having been through these near-death experiences before, you might think I wouldn’t find this overwhelming. But it’s almost a year now since Sandy has been so sick. And all those months since we started the grueling transplant evaluation.
It tells you all you need to know about saga to learn that on the very night, December 28, we got good news: my husband formally went on the National Transplant Register. And bad news: he was ordered back into hospital for kidney failure problems. Hope and heartache. Hand in hand.
And that left me in a hotel room nearby. The next morning this very charming lady in the hotel café asked if she could share my table. Her husband was also in the hospital. It’s easier to talk with a stranger when they’re sharing similar pain. But Karen’s situation was different. Her husband had already been on life support and just died. Our pain was one. We held each other, no longer strangers. Two women sharing a moment of peace.
And then Karen stopped her story in mid-stream and made an astonishing offer. She learned slightly forward and said to me: “Can I offer you my husband’s kidney?”
Susan Prisant’s husband is awaiting a kidney and heart transplant after a lifelong struggle with a congenital kidney ailment. The both blog about their experiences at My Story Lives.
Two Former Obama Health Advisors Whistle in the Dark about End of Health Insurance Companies
Ezekiel Emanuel and Jeffrey Liebman, a regular contributor to the New York Times and professor of public policy at Harvard, respectively, say health insurers will disappear by 2020.
In their opening paragraph in a January 30 blog in the New York Times, “The End of Insurance Companies”, they assert:
“Here’s a bold prediction for the new year. By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by accountable care organizations — groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.”
They presume this development will leave no room for insurers.
They continue, “A new system is on its way, one that will make insurance companies unnecessary.” The new system, they confidently predict, will consist of accountable care organizations, made up of collaborating hospitals and doctors. ACOs will offer bundled payments. Fee-for-service payments will cease to exist.
ACOs, the two Obamanites imply, will sprout, flourish, and metastasize across the land from sea to shining sea.
Their prediction may be bold, but I believe it is wrong.
