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

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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.

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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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Health Tech Deals, on Clubhouse tomorrow (Thursday 8th) at 1 PT/4 ET

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Tomorrow we are taking a break from #THCBGang. Don’t worry it’ll be back with a vengeance next week. Instead, Jess DaMassa & I will host a new show “Health Tech Deals” on Clubhouse

So please join Jess and me in The Health Care Blog’s room for “Gossip, analysis & Sh!talking about digital health funding”.

Tomorrow, Apr 8 at 1:00 PM PDT – 4pm ET on @joinClubhouse. Join us! (And if you need an invite to Clubhouse, let me know)

And it’ll be on our podcast channel (Apple/Spotify) from Friday — Matthew Holt

#Healthin2Point00, Episode 197 | BrightInsight, SteadyMD, CirrusMD, and Cleo

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Today on Health in 2 Point 00, I’m getting my shots soon! On Episode 197, General Catalyst is throwing more money around – $101 million goes to BrightInsight for its digital health insights management platform. SteadyMD raises $25 million bringing its total to $31 million, and CirrusMD raises $20 million in a Series C bringing its total to $47 million. Is there room for more telehealth companies? Finally, fertility benefits company Cleo gets $40 million, bringing its total up to $80 million – this was a hot space last year, what’s going on now? —Matthew Holt

Firefly Health’s CEO & Exec Chairman on $40M Raise & Becoming a “Bloat-less Kaiser”

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By JESSICA DaMASSA, WTF HEALTH

Virtual-first primary care company Firefly Health is becoming a health plan! Backed by a $40M Series B, CEO Fay Rotenberg and Executive Chairman Jonathan Bush stop by to explain how they’re providing “half-price healthcare that’s twice as good.” (Or, as only Jonathan can put it: “we’re a bloat-less Kaiser.”) All kidding aside, some big-name health innovation investors are not only behind this raise (Andreessen Horowitz led, F-Prime Capital and Oak HC/FT dipped back in), but also this idea to wrap a benefit around Firefly’s digitally-driven comprehensive care model. Already in-market, the new benefit-plus-care product is aimed squarely at mid-sized/small, fully-insured employers – shops with 50-500 employees which, right now, have limited options for dramatically changing their healthcare spend or being able to build out their own benefits the same way large self-insured employers can.

Fay and Jonathan get into the details about how they’re extending their “Marie Kondo-ing” of healthcare delivery – which has thus far netted some pretty impressive health outcomes, cost savings, and a 92 Net Promoter Score – into healthcare financing.

BONUS: Tune in around 25:30​ and stick around for a few minutes as Jonathan weighs in on the health tech funding boom, how it compares to the EMR arms race days of ole, and whether or not he thinks he can beat Glen Tullman’s $14.5B valuation if/when Firefly goes public. HA!

The Art of the Chart: Documenting the Timeline

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By HANS DUVEFELT

The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.

In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:

3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)

3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.

3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.

3/8 Phone call: Now has yeast infection, prescribed fluconazole.

Each of these notes took virtually no time to create and you could see them all in one glance.

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Some Discord Could Be Good for Health Care

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By KIM BELLARD

By the time you read this, Microsoft may have already struck a deal with the messaging service Discord.  VentureBeat reported two weeks ago that Discord was in an “exclusive acquisition discussion” with an interested party, for a deal that could reach at least $10b.  Bloomberg and  The Wall Street Journal each quickly revealed that the interested party was Microsoft (and also confirmed the likely price). 

Me, I’m wishing that a healthcare company – hey, TelaDoc and UnitedHealth Group, I’m looking at you! – was in the mix. 

Let’s back up.  If you are not a gamer, you may not know about Discord.  It was launched in 2015, primarily as a community for gamers.  Originally it focused on texting/chat, but has widened its capabilities to include audio and video.  The Verge described it: “Discord is a great mix of Slack messaging and Zoom video, combined together with a unique ability to just drop into audio calls freely.”

Zoom meets Slack meets Clubhouse.

As you might infer from the potential asking price, Discord has done quite well.  It has over 140 million monthly users, and, despite having no advertising and offering a free service, generated $130 million in revenues last year (through its “enhanced Discord experience” subscription service Nitro).  OK, it still isn’t profitable, but a December funding round gave it a $7b valuation.

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Time to Reboot “Medicare-For-All”

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By MIKE MAGEE

In the fog of the Covid pandemic, many are wondering what ever happened to prior vocal support for universal coverage and Medicare-for-All. Expect those issues to regain prominence in the coming months. A bit of recent history helps explain why.

The January 6th insurrection, followed by the past weeks two mass shootings, have served to remind our citizens that we must address a range of issues while continuing to confront the pandemic threat.

Modern civilized societies rely on a double-armed approach to maintain order, peace and security. The first arm is laws. But laws are of little value without even and unbiased enforcement.

The second guardrail of civility is culture. MIT professor Edgar Schein described it this way: “Culture has three layers: the artifacts of a culture — our symbols and signs; its espoused values — the things we say we believe; and, most important, its underlying assumptions — the way things really are.”

In the Senate chamber this week, and in Republican controlled state houses across the nation, Americans witnessed a colossal collision of reality and ideals in the form of new Jim Crow laws to suppress minority voting rights, and refusal to address gun violence.  In the wake of a constant stream of racial animus and mass shootings, this lethal epidemic demands a response as well.

Were these the only flashing alerts signaling danger ahead, that would be enough to cause sleepless nights. But unenforced or unevenly enforced laws, and value dissonance in America, do not occur in isolation, but are supported by an even more erosive underpinning – greed-induced economic inequality.

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The Medicaid Plan of the Future: Sean Lane on Building Circulo on Top of Olive’s AI Platform

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By JESSICA DaMASSA, WTF HEALTH

What’s better than being the CEO of one blazing-hot disruptive health tech company that’s raised $450M to build “the internet of healthcare”? How about becoming the CEO of a second company – a new managed Medicaid health plan company – that’s to be built on top of your first company’s machine learning platform, which is chock-full of hospital data and learning how to automate healthcare admin expertise? So is the fate of Sean Lane, CEO of Olive and now, also CEO of Circulo.

What does a built-from-scratch, tech-first Medicaid plan look like? Sean talks through the strategy behind the new health insurance co, which is aiming to use Olive’s tech to automate every aspect of the way a payer functions in effort to 1) strip away health plan admin costs and 2) create a never-before-seen relationship between patient, payer, and provider. On this latter point, it’s the fresh approach to payer-provider relations that seems to really have Sean excited. With Olive already built into hundreds of health systems, and conveniently located on the desktops of those providers, Sean says Circulo will be poised to take advantage of that network’s data and distribution to forever alter the healthcare payment model. Submitting claims goes away. Denials go away. Costs drop. Care improves.

Backed by a fresh $50M from Olive’s investors (Drive Capital and General Catalyst led Circulo’s Series A with participation from Oak HC/FT and SVB Capital) the new plan is currently building team and tech and aiming “to cover one life, bring on one provider, and earn one dollar of revenue by the end of the year.” It’s early days, but we dive into the details behind the strategy and also explore how this fits into the “health assurance thesis” that’s lurking behind General Catalyst’s latest investments, particularly those spearheaded by Hemant Taneja, who literally co-wrote the book on the subject with Jefferson Health’s Steve Klasko, and is the CEO of the Health Assurance Acquisition Corporation ($HAACU) SPAC that’s just out there waiting to take a health tech business public.

Playing Poker With the Devil: “Prior Authorizations” are Paralyzing Patients and Burning out Providers

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By HANS DUVEFELT

The faxes keep coming in, sometimes several at a time. “Your (Medicare) patient has received a temporary supply, but the drug you prescribed is not on our formulary or the dose is exceeding our limits.”

Well, which is it? Nine times out of ten, the fax doesn’t say. They don’t explain what their dosage limits are. And if it isn’t a covered drug, the covered alternatives are usually not listed.

So the insurance company is hoping for one of a few possible reactions to their fax: The patient gives up, the doctor tries but fails in getting approval, or the doctor doesn’t even try. In either case, the insurance company doesn’t pay for the drug, keeps their premium and pays their CEO a bigger bonus.

First problem: This may be in regards to a medication that costs less than a medium sized pizza. And the pharmacy generally doesn’t even bother telling the patient what the cash price is.

Second problem: A primary care physician’s time is worth $7 per minute (we need to generate $300-400/hour). We could spend half an hour or all day on a prior authorization and there is absolutely zero reimbursement for it.

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