If you want to hear a little about Commons Clinic from Benjamin Schwartz, MD but rather more from me about who knows what, it’s on The Surgeon’s Record podcast — Matthew Holt
I’m on the Surgeon’s Record
Anmol Madan, RadiantGraph
Anmol Madan is CEO of RadiantGraph. He’s building an end to end solution that goes from data ingestion to applications to consumer connection via text/email and voice in order to let payers quickly roll out patient engagement plans. His idea is that plans/payers don’t need to fix their data, RadiantGraph’s AI can take the messy data and and then add an AI layer, and on that create specific applications–Anmol showed me a comprehensive demo. I also asked him if they are doing too much, or conversely if they need to do more!–Matthew Holt
Matthew Explores the Referral Process
So I thought I would try a little experiment. Following up on a recent primary care visit I got a couple of referrals. I went investigating as to what I could find out about the where to go and what the cost might be. And what the connection if any between my primary care group (One Medical), the facility & specialists I was referred to, and my health plan, Blue Shield. I hope you enjoy my little tour of this part of the online health system–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
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…Sword Health, the Hinge Health S1, and me
By MATTHEW HOLT
The big news in the comeback of digital health is that Hinge Health filed its S1 and is looking to go public soon. I suspect that they’d have preferred to get the IPO done late last year when the AI bubble was expanding rather than deflating, but timing the market is tough! Nonetheless Hinge is almost profitable and at over $350m in revenue at a growth clip of some 75% last year, in terms of a show pony to trot out, it’s about as good as the digital health field has got. The problem is that the last round in 2021 was at a $6bn+ ZIRP-era valuation with Tiger & Coatue paying the idiot price because Teladoc was trading at $15bn market cap then (albeit down from $30bn a year before that!). That is, err, no longer the case. There’s a bunch of weirdness in the IPO structure to pay those guys back, but the main point is that the likely valuation will be in the $1.5-2.5bn range.
But there’s another problem. And it’s one I have some personal experience with. I must stress that my experience is not with Hinge.
As it happens I did a video interview at Hinge’s booth at HLTH in 2022 when my back collapsed, and I got to try out their Enso device (it helped a bit but not much after the first few minutes using it). I discussed the process with PT Lori Walter and got a quick interview with President Jim Pursely (an old Livongo hand BTW).
But this past summer I used the services of their main competitor, Sword Health. As far as I can tell the two companies are very similar in their process and services, both with self-service exercises delivered via the smartphone and both moving from remote care from therapists to AI therapists. But I could be wrong. So for this article I am extrapolating from one company to the other to look at the field of MSK digital services overall.
In total, I thought the Sword experience was good as a standalone program. But the problem was that it was standalone.
My problem was with my left knee. I had a lot of knee surgery in 2002-4 as the result of snowboarding into a tree (Hint. If you snowboard, try to make sure you and the board go the same side of the tree). More than 20 years later in 2024 I managed somehow to induce terrible pain in the knee running for a ferry in January, a train in May and an airport shuttle in June. (It seems that travel and my knee disagree). This didn’t stop me strapping up, taking drugs and snowboarding in the 2024 winter season but it certainly slowed me down a whole lot. Around this time there were many reports of people much younger than me getting their knees replaced.
So I thought I should do something about it. My Blue Shield of California plan offers Solera which is an agglomeration marketplace of digital health apps and services. Sword Health is their PT app, so I selected it, enrolled and off I went.
Note that there was zero integration with my PCP, any orthopedic surgeon, any clinical person at the health plan or basically anyone. This was purely patient-driven and managed.
With Sword I had a 15 min intro call on June 6 – then was sent a box containing a generic tablet and six sensors which fit into straps that you attach to your lower and upper legs and arms.
There was a conversation in the app with a PT and then it spat out a selection of exercises for me. The example below is my second exercise session. If you want to check out more, I have put more of the exercise and the chat with the PT here.
Sword suggested, instead of regular 45-60 minute physical PT sessions, that I did four 15 minutes sessions a week. Essentially one every other day.
The end result was that I did eight sessions between June 12 & June 30.
Continue reading…Jonathan Bush, Zus Health
It’s always fun to chat with Jonathan Bush. You kids today may not remember that he was the first CEO to take a cloud-based (Health 2.0!) company public back in 2007! Athenahealth didn’t end up challenging Epic because a cosmically evil hedge fund took it (and him) down as it was on its way to try to do that, but Jonathan has moved on and is now building a clinical data integration company called Zus Health. We talked Zus, digital health, whether there will ever be value-based care and more. 20 mins of digital health gold right here–Matthew Holt
Brad Kittredge, Brightside Health
Brad Kittredge is CEO of Brightside Health, which he co-founded with CMO Mimi Winsberg. They are a large online mental health group that aims a providing more access with higher quality. They have built their own technology stack and medical group, and are in network for about 135m lives. They also take patients from the emergency departments of health systems–as well as direct patient outreach for “standard” mental health conditions. Brad talked to me about measurement, quality and care improvement, including how they are using their algorithms to improve their clinicians’ prescribing accuracy. I also asked him where Brightside were in the process to, err, return at least some of the $150m they’ve raised back to their investors. Matthew Holt
PatientsUseAI: Hugo, Gilles and e-Patient Dave on the race to patient autonomy — THCB Gang Special Episode 149, Thursday December 19
Joining Matthew Holt on #THCBGang on Thursday December 19 at 1pm PST 4pm EST are three leaders in the patient movement Hugo Campos (@HugoCampos); Gilles Frydman (@GillesFrydman); and ePatient Dave deBronkart (@DavedeBronkart). They will be bring us up to speed on the very latest in patients using AI.
You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
