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The Parallel Realities of Health Care: Ratio and Intellectus

By HANS DUVEFELT

Every patient is unique, with some common basic and measurable features and parameters. For a couple of decades now, healthcare has professed to be patient centered. But the prevailing culture of “quality” (and the reality of getting paid for what you do) has us spending at least half our time documenting for outsiders, who are non-clinicians, the substance and value of our patient interactions. That means our patients get half of our attention and others get half.

But of course, if you really wanted to be patient centered, you’d have to ask what patients actually care about, like their blood pressure or their cholesterol, their anxiety or their sore knees. Their answers may not align with the payers’ priorities. And then what…

Parents raise their children and never have to file any reports on how they do it. I believe clergy can still counsel their parishioners without filing reports. But doctors, nurses, nurses aides and physical therapists are trapped in the tyrannical dichotomy of “If you didn’t document it, it didn’t happen”, which actually forces us to do less for our patients just so we will have time to document what we did do. We are, to varying degree, robotniks in a big, inhumane corporate and federal healthcare billing machine these days.

Perhaps the most striking example of the micromanaging and patient-uncentered mandates we are subjected to is the Medicare Annual Wellness Visit: Miss one thing, like offering HIV screening to 80 year old devout French speaking, monogamous Catholics in Van Buren, Maine and risk getting your payment retracted. But we are not mandated to ask about personal life goals or how to balance seniors’ independence with reliance on their children.

Which is more real? The work we do, face to face or even screen to screen, behind closed doors with our patients, or the EMR documentation we produce as a result of those encounters? I know many providers generate voluminous notes that don’t reflect in any way what happened in the visit. That is where the money is.

Right now I am reading a Swedish book by philosopher Jonna Bornemark, titled (my translation) RENAISSANCE OF THE UNMEASURABLE – battling the pedants’ world domination. Much of it is about how the professions of caring for others have been reduced to protocols and reporting systems that make it harder to do what we were trained and developed a passion for. It talks about how checklists and workflows devalue and discourage the powerful creativity that arises when professionals interact with their unique clients and with each other. She anchors all this in the writings of philosophers Cusanus, Bruno and Descartes. It talks about the unknowable, which is something pedants usually don’t want to think about.

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#Healthin2Point00, Episode 199 | Olive acquires Empiric plus raises by Medable & Papa

Today on Health in 2 Point 00, I air some of my grudges as we get into our deals for the day. In the third extension of their Series C, Medable gets another $78 million bringing their total to $217 million. Olive acquires Empiric Health, expanding into surgical data analytics – where does this fit in with Sean Lane’s five-point strategic plan? Finally, Papa gets a $60 million raise and Anthem, Blackstone and K Health launch a joint venture. —Matthew Holt

Smart Healthcare Platforms Shine a Light On Price Transparency

By MATTHEW DALE

Did you know that as of January 2021, price transparency is being mandated for hospitals? But what exactly does that mean for company healthcare plans, third-party administrators, healthcare sharing organizations, employers, and employees? 

It means U.S. hospitals are now required to provide clear, accessible pricing information online about the items and services they provide in two ways: 1) as a comprehensive machine-readable file and 2) in a display of shoppable services in a consumer-friendly format. 

The Centers for Medicare & Medicaid Services are already requiring hospitals to publicly display their negotiated rates with insurers along with the cash pay price for over 300 shoppable medical services.

For healthcare consumers, this should mean they can shop for the hospital that performs the best knee surgery or other medical procedure for the lowest cost in their area. Unfortunately, the implementation of price transparency has been difficult, to say the least.

The American Hospital Association and other industry groups have spent large amounts of money to block the rule but were unsuccessful. Now, hospitals are trying to get around the rules. A Wall Street Journal investigation found that hundreds of hospitals implemented website code to block search engines from returning results for price inquiries. 

Technically, hospitals are following the price transparency rule, but by deliberately hiding data from search engines or making it nearly impossible to find, consumers are unable to locate a hospital or surgery center they can afford. That’s just one example of how hospitals are avoiding price transparency. The AHA has made it clear they are not happy with price transparency and they’ll do whatever they can to avoid this new rule, but why? 

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THCB Gang Episode 50, Thursday April 15

Well the half-century is up for #THCBGang and it’s been a lot of fun bantering with some of the cognoscenti of health tech, business & policy over most of the last year.

For #50 we had a special guest. Robert Pearl, (@RobertPearlMD) former CEO of The Permanente Medical Group, noted commentator, and author. He joined me, along with regular gang members policy expert consultant/author Rosemarie Day (@Rosemarie_Day1), policy & tech expert Vince Kuraitis (@VinceKuraitis), and Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune).

There was a little discussion of Robert’s new book Uncaring (although there’ll be more about that on THCB later) and a lot of discussion about his experience at Kaiser Permanente, what went right, what went wrong and why it never traveled nationwide–and what that all means for a new generation of medical groups. And we didn’t forget the vaccine rollout, and even whether it was safe to be on a plane!

You can see the video below live and the audio will be on our podcast channel (Apple/Spotify) from Friday — Matthew Holt

The Pain Is In Your Brain: Your Knees Know Next to Nothing

By HANS DUVEFELT

A “frozen shoulder” can be manipulated to move freely again under general anesthesia. The medications we use to put patients to sleep for such procedures work on the brain and don’t concentrate in the shoulder joints at all.

An ingrown toenail can be removed or an arthritic knee can be replaced by injecting a local anesthetic – at the base of the toe or into the spine – interrupting the connection between the body and the brain.

An arthritic knuckle can stop hurting and move more freely after a steroid injection that dramatically reduces inflammation, giving lasting relief long after any local anesthetic used for the injection has worn off.

The experience of pain involves a stimulus, nerve signaling and conscious interpretation.

Our brains not only register the neurological messages from our sore knees, shoulders, snake bites or whatever ails us. We also interpret the context or significance of these pain signals. Giving birth to a long awaited first baby has a very different emotional significance from passing a kidney stone, for example.

I have written before about how we introduce the topic of pain to our chronic pain patients in Bucksport. Professor Lorimer Moseley speaks entertainingly of he role of interpretation in acute pain and also explains the biochemical mechanisms behind chronic pain.

TREATING PAIN WITH ANALGESICS

Even when we are awake, we can reduce orthopedic pains with medications that work on the brain and not really in our joints. A common type of arthritis, such as that of the knees, is often treated with acetaminophen (paracetamol), nonsteroidal anti-inflammatory drugs (NSAIDS) like ibuprofen or even opioids.

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#Healthin2Point00, Episode 198 | Microsoft buys Nuance & lots of IPO rumors

Today on Health in 2 Point 00, Jess claims to be blameless for the drama between Jonathan Bush and Glen Tullman. On Episode 198, we talk about Microsoft buying Nuance for $16 billion and $3 billion in debt – is Microsoft taking over healthcare, and is this going to slow Nuance down? Cohere Health raises $36 million in a Series B, working on improving prior authorizations between health plans and providers. We wrap up with a lightning round of IPO rumors regarding Privia Health, VillageMD, and Bright Health. —Matthew Holt

To Add is Expected, To Subtract is Design

By KIM BELLARD

A couple years ago I wrote about how healthcare should take customer experience guru Dan Gingiss’s advice: do simple better.  Now new research illustrates why this is so hard: when it comes to trying to make improvements, people would rather add than subtract. 

That, in a nutshell, may help explain why our healthcare system is such a mess.

The research, from University of Virginia researchers, made the cover of last week’s Nature, under the catchy title Less Is More.  Subjects were given several opportunities to suggest changes to something, such as a Lego set-up, a geometric design, an essay or even a travel itinerary.  The authors found: “Here we show that people systematically default to searching for additive transformations, and consequently overlook subtractive transformations.”

In the Lego picture here, for example, when asked how to strengthen the upper platform, most people wanted to add new columns, instead of simply removing the existing column.  The researchers note: “The subtractive solution is more efficient, but you only notice it if you don’t jump to an additive conclusion.”

Giving cognitive nudges – like explicitly mentioning the option of deleting something – improved the likelihood that people would come up with subtractive options, but increasing cognitive load (through additional tasks) decreased it.  Co-author Benjamin Converse said:    

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Our Healthcare System Needs More Than Policy Overhaul: It’s Time for Private Sector Innovation to Kick into High Gear for Our Health’s Sake

By SACH JAIN

Last year I was heading to a meeting on a Fortune 500 business campus and stumbled upon a bake sale. It was odd to see someone selling cupcakes and breads on the grounds of a major corporation, so I inquired. As it turns out, Judy, an employee, was selling baked goods to finance her insurance deductible for spinal fusion surgery. 

Is this what our system has come to?” I asked myself, “Fundraisers for fusions?” If so, our health system is broken.

No matter how you slice it, Americans spend more on healthcare than any other advanced economy, with households responsible for 28% of that spend according to CMS. The Affordable Care Act (ACA) attempted to address long-standing deficiencies inherent in our fractured healthcare system. However, creating an insurance marketplace hasn’t solved the problem of affordability or the reality of limited access to quality providers. The concept is great, but without private sector buy-in it will never succeed.

President Biden is taking long-overdue steps to address some of the ACA’s shortcomings with Executive Orders. During his campaign, he suggested other actions, like capping marketplace premiums at 8.5% for all income levels with the goal of spurring enrollment and strengthening the ACA with an affordable public option. The recently passed $1.9 trillion stimulus package also incorporates an increase in government subsidies to health insurers for covering workers laid off due to COVID-19 and those purchasing their own coverage. 

This is a start. But it’s not enough. We can’t afford to waste time waiting for policymakers to negotiate rules that may be overturned when a party majority flips.

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Doxepin, a Little Known Super Drug in My Personal Black Bag of Tricks

By HANS DUVEFELT

A while back I was able to completely stop my mastocytosis patient’s chronic hives, which the allergist had been unable to control.

I did it with a drug that has been on the market since 1969 and is taken once a day at a cost of 40 cents per capsule at Walmart pharmacies.

Hives are usually treated with antihistamines like diphenhydramine (Benadryl). My super drug has a 24 hour duration of effect and is about 800 times more potent than diphenhydramine, which has to be taken every fours hours around the clock.

Histamine is involved in allergic reactions, but it also plays a role in stomach acid production. The allergic response happens mostly through stimulation of Histamine 1 receptors and the stomach acid output is regulated mostly via Histamine 2 receptors. Typical antihistamines are blockers of the H1 receptor, or binding site; they don’t do anything except sit there and prevent the real histamine from attaching and starting the allergic chain reaction. While diphenhydramine sits there for 4 hours, loratadine and the other modern, nonsedating (and less itch-decreasing) antihistamines work for 24 hours. Because there is some overlap between H1 and H2 blocking effects, H2 blockers like famotidine can boost the antiallergy effect of the typical H1 blockers. My mastocytosis patient still had hives on diphenhydramine, loratadine and famotidine combined.

But, wait, there’s more…

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Jean Drouin, Clarify Health, on the new data stack.

By MATTHEW HOLT

Clarify Health has linked (but anonymized) data on about 300m Americans, including their claims, lab, (some) EMR data and their SDOH data. They then use it to help providers, plans and pharma figure out what is going on with their patients, and how their doctors et al are behaving. CEO Jean Drouin, a French-Canadian who incidentally at one point ran strategy for the NHS in London, explained to me what Clarify does, how it’s going to help improve health care, where these data products are going next–and why they needed to raise $116m in March to build it out. Jean thinks about creating a single source of truth, and I asked him a couple of tricky questions about whether his customers would want to know the answer. A fascinating discussion. (Full transcript below)

Matthew Holt:

Hi, Matthew Holt here with another THCB Spotlight. And I’m with Jean Drouin, who has a French Canadian name, but is an American who’s lived in London–a bit like me–who is the CEO of Clarify Health. So Jean, Clarify Health is one of the new startups. You guys raised over a $110 million a couple of weeks back, which I guess is a small round these days considering what everyone else is doing.

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