Robert Krayn is the CEO and & Dr. Georgia Gaveras the CMO of Talkiatry. Robert and Georgia are quite the dynamic duo (she says, “He’s the money I’m the medicine!”). As a relative latecomer in the online mental health world, Talkiatry is trying to differentiate itself from the other big players like Lyra, Headspace, Brightside et al. It’s focusing on using psychiatrists as opposed to psychologists, counselors or coaches. This is both as an advertisement to patients but also they’ve set up a system that is much easier for psychiatrist themselves to join as employees and they showed me the way that patients get onboarded in their system, and how they get to that first appointment–in an average of 5 days!
Above the Fold
You, Me, and Our Microbiome
By KIM BELLARD
You may have heard about the microbiome, that collection of microorganisms that fill the world around, and in, us. You may have had some digestive tract issues after a round of antibiotics wreaked havoc with your gut microbiome. You may have read about the rafts of research that are making it clearer that our health is directly impacted by what is going on with our microbiome. You may even take probiotics to try to encourage the health of your microbiome.
But you probably don’t realize how interconnected our microbiomes are.
Research published in Nature by Beghini, et. al., mapped microbiomes of almost 2,000 individuals in 18 scattered Honduras villages. “We found substantial evidence of microbiome sharing happening among people who are not family and who don’t live together, even after accounting for other factors like diet, water sources, and medications,” said co-lead author Francesco Beghini, a postdoctoral associate at the Yale Human Nature Lab. “In fact, microbiome sharing was the strongest predictor of people’s social relationships in the villages we studied, beyond characteristics like wealth, religion, or education.”
“Think of how different social niches form at a place like Yale,” said co-lead author Jackson Pullman. “You have friend groups centered on things like theater, or crew, or being physics majors. Our study indicates that the people composing these groups may be connected in ways we never previously thought, even through their microbiomes.”
“What’s so fascinating is that we’re so interconnected,” said Mr. Pullman. “Those connections go beyond the social level to the microbial level.”
Study senior author Nicholas Christakis, who directs the Human Nature Lab, explained that the research “reflects the ongoing pursuit of an idea we articulated in 2007, namely, that phenomena like obesity might spread not only by social contagion, but also by biological contagion, perhaps via the ordinary bacteria that inhabit human guts.” Other conditions, such as hypertension or depression, may also be spread by social transmission of the microbiome.
Professor Christakis thinks the findings are of broad importance, telling Science Alert: “We believe our findings are of generic relevance, not bound to the specific location we did this work, shedding light on how human social interactions shape the nature and impact of the microbes in our bodies.” But, he added: “The sharing of microbes per se is neither good nor bad, but the sharing of particular microbes in particular circumstances can indeed be good or bad.”
This research reminded me of 2015 research by Meadow, et. al., that suggested our microbiome doesn’t just exist in our gut, inside other parts our body, and on our skin, but that, in fact, we’re surrounded by a “personal microbial cloud.” Remember the Peanuts character Pigpen, who walked around in his personal dirt cloud? Well, that’s each of us, only instead of dirt we’re surrounded by our microbial cloud–and those clouds are easily discernable from each other.
Dr. Meadow told BBC at the time: “We expected that we would be able to detect the human microbiome in the air around a person, but we were surprised to find that we could identify most of the occupants just by sampling their microbial cloud.”
Those researchers predicted:
While indoors, we are constantly interacting with microbes other people have left behind on the chairs in which we sit, in dust we perturb, and on every surface we touch. These human-microbial interactions are in addition to the microbes our pets leave in our houses, those that blow off of tree leaves and soils, those in the food we eat and the water we drink. It is becoming increasingly clear that we have evolved with these complex microbial interactions, and that we may depend on them for our well-being (Rook, 2013). It is now apparent, given the results presented here, that the microbes we encounter include those actively emitted by other humans, including our families, coworkers, and perfect strangers.
Dr. Beghini and colleagues would agree, and further suggest that it’s not only indoors where we’re sharing microbes.
I would be remiss if I didn’t point out new research which found that our brains, far from being sterile, are host to a diverse microbiome and that impacts to it may lead to Alzheimer’s and other forms of dementia.
Could we catch Alzheimer’s from someone else’s personal microbiome cloud? It’s possible. Could we prevent or even cure it by careful curation of the brain (or gut) microbiome? Again, possible.
The truth is that, despite decades of understanding that we have a microbiome, we still have a very limited understanding of what a healthy microbiome is, what causes it to not be healthy, what problems arise for us when it isn’t healthy, or what we can do to bring it (and us) to more optimal health. We’re still struggling to understand where besides our gut it plays a crucial role.
We now know that we can “share” parts of our microbiome with those around us, but not quite what the mechanisms for that are–e.g., touch, sharing objects, or having our personal clouds intersect.
We feel like we are where scientists were two hundred years ago in the early stages of the germ theory of disease. They knew germs impacted health, they even could connect some specific germs with specific diseases, they even had rudimentary interventions based on it, but much remained to be discovered. That led to vaccines, antibiotics, and other pharmaceuticals, all of which gave us “modern medicine,” but failed to anticipate the importance of the microbiome on our health.
Similarly, we’re justifiably proud of the progress we’ve made in terms of understanding our genetic structure and its impacts on our health, but fall far short of recognizing the vastly larger genetic footprint of the microbiome with which we co-exist.
A few years ago I called for “quantum theory of health”–not literally, but incorporating and surpassing “modern medicine” in the way that quantum physics upended classical physics. That kind of revolution would recognize that there is no health for us without our microbiome, and that “our microbiome” includes some portion of the microbiomes of those around us. We talk about “personalized medicine,” but a quantum breakthrough for health would be treating each person as the symbiosis with our unique microbiome.
We won’t get to 22nd century medicine until we can assess the microbiome in which we exist and offer interventions to optimize it. I just hope we don’t have to wait until the 22nd century to achieve that.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor
“Hospital Mergers Kill”: An Economists’ Exercise in Reality Distortion
By JEFF GOLDSMITH
In late June, 2024, two economists, Zarek Brot-Goldberg and Zack Cooper, from the University of Chicago and Yale respectively, released an economic analysis arguing that hospital mergers damage local economies and result in an increase in deaths by suicide and drug overdoses in the markets where mergers occur. Funded by Arnold Ventures their study characterizes these mergers as “rent seeking activities” by hospitals seeking to use their economic power to extort financial gains from their communities without providing any value.
The Brot-Goldberg-Cooper analysis was a spin-off of a larger study decrying the lack of federal anti-trust enforcement regarding hospital mergers. These two studies used the same economic model. The data were derived from the Healthcare Cost Institute, a repository of commercial insurance claims information from three of the four largest commercial health insurers, United Healthcare, Humana and Aetna (a subsidiary of struggling pharmacy giant CVS) plus Blue Cross/Blue Shield. HCCI’s contributors account for 28% of the commercial health insurance market.
The authors use a complex econometric model to manipulate a huge, multifactorial data base comprising hospital merger activity, employer health benefits data, county level employment data and morbidity and mortality statistics. This data model enabled a raft of regression analyses attempting to ferret out “associations” between the various domains of these data.
Using HCCI’s data, the authors construct what they termed a “causal chain” leading from hospital mergers to community damage during their study period–2010 to 2015. It looked like this: hospital mergers raise prices for private insurers-these prices are passed on to employers–who respond by laying off workers–some of whom end up killing themselves. So, according to the logic, hospital mergers kill people. Using the same methodology, the authors argued that between 2007 and 2014, hospital price increases of all sorts killed ten thousand people.
A classic problem with correlational studies of this kind is their failure to clarify the direction of causality of data elements. The model lacked a control group–comparable communities that did not experience hospital mergers during this period–because the authors argued that mergers were so pervasive they could not locate comparable communities that did not experience them.
The model focused on a subset of 304 hospital mergers from 2010 to 2015, culled from a universe of 484 mergers nationally during the same period. The authors excluded mergers of hospitals that were further than fifty miles apart, as well as hospitals with low census. The effect of these assumptions was to exclude most rural hospitals and concentrate the mergers studied in metropolitan areas and cities. The densest cluster was in the I-95 corridor between Washington DC and Boston. See the map below:
According to the model, these mergers resulted in an average increase of 1.2% in hospital prices to commercial insurers, 91% of which were passed to their employer customers in those markets. This minuscule rate increase had a curiously focused and outsized effect–a $10,584 increase in the median employer’s health spending in the merged hospitals’ market.
According to the model, local employers “responded” to this cost increase by reducing their payrolls by a median amount of $17,900, all through layoffs–70% more than the alleged merger cost increase. This large overage was not explained by the authors. Moreover, the layoffs took place almost immediately, in the same year as the merger-induced increases, even though many health insurance contracts are multi-year affairs, and lock hospitals in to rates for that period.
At the end of the “causal chain,” 1 in 140 laid off people in those communities for whatever reason killed themselves through suicide or drug overdoses. By extrapolation, the authors accuse the perpetrators of overall hospital rate increases of killing ten thousand people in the affected communities during seven years overlapping the study period.
Continue reading…Public Health Policy: At the Intersection of Law and Medicine.
By MIKE MAGEE
As 2025 kicks off, it’s wise to pause, and gather our thoughts as a nation. Few would argue that we’ve been through a lot over the past decade. And quite naturally, we humans are prone to blame individuals rather than circumstances (most of which have been beyond our control) for creating an environment that feels as if it is unraveling before our eyes.
How should we describe our condition – dynamic, tense, complex? Is peace, contentment, and security achievable in this still young nation? Have accelerationist technocrats, armed with bitcoins and Martian fantasy, short-circuited our moment in time that had been preserved for recovery from a deadly pandemic that eliminated a million of our fellow citizens seemingly overnight?
Who do we turn to for answers, now that we’ve largely lost faith and trust in our politicians, our religious leaders, and our journalists? And how exactly do you create a healthy nation? Certainly not by taking doctors and nurses offline for miscarriages, and placing local bureaucrats in exam rooms. Are they prepared to deal with life and death decisions? Are they trained to process human fear and worry? Do they know how to instill hopefulness in parents who are literally “scared to death” because their child has just been diagnosed with cancer? It certainly must require more than a baseball cap with MAHA on it to heal this nation.
Historians suggest this will take time. As Stanford Professor of Law, Lawrence M. Friedman, wrote in A History of American Law, “One hundred and sixty-nine years went by between Jamestown and the Declaration of Independence. The same length of time separates 1776 and the end of World War II.”
During those very early years that preceded the formal declaration and formation of the United States as a nation, our various, then British colonies, fluidly and independent of each other, did their best first to survive, and then to organize into shared communities with codified laws and regulations. It was “a study of social development unfolding over time” impacted by emotions, politics and real-time economics. At the core of the struggle (as we saw with the pandemic, and now the vaccine controversy) was a clash between the rights of the individual and those of the collective community.
This clash of values has been playing out in full view over the past five years of the Covid pandemic. In 2023, Washington Post columnist, Dr. Leana Wen, asked, “Whose rights are paramount? The individual who must give up freedoms, or those around them who want to lower infection risk?”
Continue reading…My Totally Wrong, Expert Predictions for Health Care 2025
By MICHAEL MILLENSON
January
In a blistering commentary, the American Medical Association’s flagship journal, JAMA, condemns the corrosive effect on patient care of the profit-seeking practices of health insurers. Separately, the organization announces that it’s selling the 13 journals in its JAMA Network to a private equity firm for $375 million “in order to enhance our mission of promoting the betterment of public health.”
February
Quickly following up on a campaign pledge to slash the federal budget, the Trump administration announces a radical consolidation of various entities at the Department of Health and Human Services. The new organization will be known as the Agency and Bureau for Children, Drugs, Explosives, Firearms, Families and Food (ABCDEFFF). Reflecting the new president’s strong personal preferences, “alcohol” will no longer be permitted in any agency name.
March
Bipartisan legislation demanding transparency from Pharmacy Benefit Managers dies in committee after industry executives explain that secret rebates to PBMs are like secret political action committee contributions to politicians: they allow you to loudly proclaim you’re an “advocate” for those supposedly paying you while actually serving the interests of those who are really paying you.
April
Pfizer announces that its once-a-day pill version of the wildly successful GLP-1 agonist weight loss drugs will shortly be submitted for government approval, and also that the company is moving its headquarters from New York to Louisiana, a state with a 40 percent obesity rate. Coincidentally, Louisiana is also the home state of Republican senators Cassidy and Kennedy, senior members of the Senate committees overseeing health care and all federal appropriations.
May
The new private equity owners of the JAMA Network say that all staff except one editor at each journal will be replaced by ChatGPT. A source at the private equity firm tells the Wall Street Journal that OpenAI won out over Gemini “because our CEO is a Leo” and over Claude “because nobody likes the French.”
June
Controversial right-wing firebrand Rep. Marjorie Taylor Greene, long the subject of rumors that she’s had cosmetic surgery, is diagnosed with a serious infection after an unspecified procedure. The House quickly schedules its first hearing on medical error in over two decades, but then cancels when the American Hospital Association points out the official term for what the Georgia Republican contracted was a “healthcare-associated infection,” so it’s entirely possible she accidentally brought the infection with her to the pristine hospital. Meanwhile, with House leadership telling Members they were free to vote their conscience, a resolution to send Greene a “Get Well” card passes unanimously after deletion of the word, “Soon.”
July
Following through on years of promises to reveal a “really great” replacement for the Affordable Care Act, President Trump on July 4 announces the “100-100-100” Make America Healthy Again plan. In keeping with the GOP’s advocacy for “skinny” plans with low premiums that encourage “consumers” to “comparison shop,” the plan will cover 100 percent of any medical bill for up to $100 a day for a premium of just $100 a month. Separately, Elon Musk tells a meeting of health insurance executives the plan can also replace both Medicare and Medicaid, enabling the federal government to cut spending by almost as much as the market capitalization of Tesla.
August
Before Congress recesses, a coalition of progressive organizations issues a press release declaring that all basic health services, whether provided by government agencies or the private sector, should be “available to the entire population according to its needs.” Shortly afterwards, the coalition is forced to make an embarrassing retraction after ChatGPT alerts the lone editor of JAMA that the coalition accidentally re-released a section of the report of the Committee on the Costs of Medical Care, formed in 1927.
September
The Business Roundtable says its members are committed to improving the quality of health care for all employees because “quality health care is good business.” An 85-year-old freelancer for The New York Times notes that this was the exact title of a September, 1997 policy paper by a Roundtable task force in which an executive for Sears, which at the time operated over 3,500 stores, declares, “We believe that quality health care is lower-cost health care.” Sears currently has about a dozen stores.
October
Medicare Advantage plans step up their advertising expenditures after public opinion polls show that nobody anymore believes the portrayal of happy and healthy seniors playing pickleball instead of writing tear-soaked letters pleading for approval of hip surgery. The trade associations for hospitals, drug and device companies and PBMs call on Congress to provide greater oversight of greedy insurers. The editor of JAMA resigns after ChatGPT writes an editorial extolling the merits of MA plans run by for-profit companies.
November
The National Rural Health Association says that in the spirit of the Thanksgiving holiday, its members will accept live turkeys in partial payment of the medical debts that now affect 99.99 percent of all Americans after passage of the administration’s “100-100-100” Make America Healthy Again plan. A KFF survey explains that the number is not 100 percent because Congress retained conventional health insurance for itself and top federal officials and because America’s billionaires had opted for self-pay.
December
A Washington Post editorial declares, “The bottom line is that if we want to contain spending, we will have to make critical choices about how care is delivered, to whom, and under what conditions.” Different chatbots differ on where that quote originally came from, but agree that if any humans believe the American public is ready to make critical choices, they’re hallucinating.
Michael L. Millenson is president of Health Quality Advisors & a regular THCB Contributor
“Comparisons Are Toxic.” True or False?
by MIKE MAGEE
THCB is back from its end of year break, but we are starting with a little catchup from December from Mike Magee.
As my wife often reminds me, “Comparisons are toxic.” And, in general, I agree and try to respect this cardinal rule. But these are extraordinary times. So grant me this exception.
On December 9, 2024, in my early morning survey of the news, two articles demanded my attention. The first was an editorial in the New York Times with the self-explanatory title, “My Last Column: Finding Hope in an Age of Resentment” by Paul Krugman. The second was an article published that morning in Nature titled “Quantum error correction below the surface code threshold” authored by “Google Quantum AI and Collaborators,” a blanket label for a team of 300+ engineers led by Founder and Leader, Hartmut Neven. More on him in a moment.
As a loyal reader of Krugman, I read his “last column” carefully – twice. Over 25 years I’ve admired this specialist’s (global economics) willingness and interest to wander often into generalist, cross-sector, liberal arts territory. No match for his Nobel winning intellect or pure-bred education at MIT, Yale and Princeton, I do share a history of common geography (upstate New York in our early years, and the New York metropolitan area later on); an upbringing in religious households (Jewish and Catholic); and more than two uninterrupted decades of weekly published columns.
Though I have not always agreed with his take on every issue, I count myself as an admirer. The issues that have interested him, both pro and con, over the years, are more often than not the same issues that have troubled or encouraged me. So I was not surprised that he chose, in his “last column,” to reflect on the recent election, and the current levels of anger, violence and resentment in our society. And while I agree with the findings in his examination of the body politic, we arrived at a different diagnosis.
Krugman writes, “What strikes me, looking back, is how optimistic many people, both here and in much of the Western world, were back then (25 years ago) and the extent to which that optimism has been replaced by anger and resentment. . . some of the angriest, most resentful people in America right now . . . are billionaires who don’t feel sufficiently admired.”
As for the diagnosis, in response to the question he himself raises (“Why did this optimism curdle?”), he answers, “As I see it, we’ve had a collapse of trust in elites.” And the treatment for this disease? “if we stand up to the kakistocracy — rule by the worst — that’s emerging as we speak, we may eventually find our way back to a better world.”
Now that sent me back to Hartmut and the Nature article for a reality check. Were American oligarchs and technocrats, with wild wealth and even wilder ideas, the cause of every day people jumping aboard the Trump cult train?
Nevin is 9 years younger than Krugman. He is a German-trained PhD physicist who came to the University of Southern California as an entrepreneurial research professor in computer science in 1998. His several start-ups which were focused on “face recognition technology and real-time facial feature analysis for avatar animation” helped make him famous and rich when they were purchased by Google in 2006. But his fantastical dream was to create a “quantum chip” that would outperform anything that currently existed.
Six years later, he launched the Quantum Artificial Intelligence Laboratory, and by 2016, he had come up with an experiment (still ongoing) to prove “quantum supremacy.” Starting his own chip fabrication factory in Santa Barbara, his dream became concrete. He took a world view in 2020, stating: “It’s not one company versus another, but rather, humankind versus nature — or humankind with nature.”
Nevin believes he is in the right place at the right time. The AI Arms Race is full on and relies on ever increasing data consumption to support generative self-learning. That demands enormous consuming power. In his words, “Both (quantum computing and AI) will prove to be the most transformational technologies of our time, but advanced AI will significantly benefit from access to quantum computing. This is why I named our lab Quantum AI.”
Quantum computing is measured in “qubits” (which are the size of a single atom) versus the binary digit measure of standard computers, called the “bit.” As the New York Times explained, “Quantum bits, or ‘qubits,’ behave very differently from normal bits. A single object can behave like two separate objects at the same time when it is either extremely small or extremely cold.” The test using exotic metals cooled to 460 degrees below zero, reported out on October 9th that Hartmut’s quantum chip “performed a computation in under 5 minutes that would take one of today’s fastest supercomputers 10,000,000,000,000,000,000,000,000 (10 septillion) years to compute.”
But that’s not the amazing part. In past experiments, the device was error prone, and the more qubits, the less reliable the computations. But now, for the first time, this group was able to demonstrate the more qubits in play, the more accurate the outcome. As Nevin explained, “This historic accomplishment is known in the field as ‘below threshold’ — being able to drive errors down while scaling up the number of qubits.” How big was that? According to Javad Shaman, director of the Center for Quantum Information Physics at NYU, “one of the highlights of the recent decade.”
Nevin doesn’t seem to “worry about being admired.” In his blog this week he tied his qubit “below threshold” accomplishment to “helping us discover new medicines, designing more efficient batteries for electric cars, and accelerating progress in fusion and new energy alternatives.” That seems a far cry from Paul Krugman’s highlighting of “the pettiness of plutocrats who used to bask in public approval and are now discovering that all the money in the world can’t buy you love.”
Gallup has been conducting an annual survey of “Americans Satisfaction With The Way Things Are Going In The U.S.” for roughly a half century. Currently only 22% say they are satisfied. Back in 1986, that number peaked at 70%. That was the year that Robert Fulcrum wrote a little book that remained on the New York Times Best Seller list for nearly two years. Some criticized the book as “trite and saccharine,” but 17 million copies of his books remain in circulation.
The 1986 book was titled, “All I Really Need To Know I Learned in Kindergarten.” Here are his top ten learnings:
- Share everything.
- Play fair.
- Don’t hit people.
- Put things back where you found them.
- Clean up your own mess.
- Don’t take things that aren’t yours.
- Say you’re sorry when you hurt somebody.
- Wash your hands before you eat.
- Flush.
- Warm cookies and cold milk are good for you.
I was trying to figure how members of my own family could vote for a man to lead our nation who routinely and deliberately breaks most of these rules. I’ve come up with two reasons:
- Greed. They simply don’t want to share any of their wealth or good fortune with others.
- Religious certainty. They do not believe in separation of Church and State, and do not respect individual self-determination and free will. And yet values can not be enforced on human beings. They must be freely embraced to become permanently embedded.
Comparisons may be toxic, but Hartmut and Paul point us toward the truth. We (not our leaders regardless of their human deficits) are responsible. And we as citizens of America need to get our act together. As Nevin the information scientist teaches, optimism flows from purpose and the promise of service. And Krugman, the Nobel economist, teaches that money alone can not buy you love – or peace, or lasting joy, or contentment.
Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Health Industrial Complex. (Grove/2020)
John Zutter, Lantern
John Zutter is the CEO of Lantern which is a company managing specialty care. It has evolved from a centers of excellence model, and changed its name from Employer Direct Healthcare earlier this year. The trick is product expansion into the expensive stuff, especially cancer care, infusion and specialty surgery. John has thought a lot about where there is money to be saved–and how health care can be structured, and how cost and quality can be managed. This is a fascinating and in-depth conversation about how employers can save money, and how that might make the overall market evolve–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.
Danielle Vaeth, Qbtech
Danielle Vaeth is Head of Growth and Strategic Development at Qbtech, a company that helps diagnose ADHD, working mostly with virtual providers. They use facial recognition and tracking to do this. Qbtech can diagnose 50% more patients than self-reporting and has approval from a big NHS study, the FDA and many peer-reviewed studies. They raised $6.8m in 2022 & have just tested their millionth patient. Plenty more to go!–Matthew Holt
