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Healing at Home: Answering the $30,000 Question

By DAWN CARTER

If you’ve been working remotely for the past year, would a $30,000 raise entice you back into the office? In a recent survey of 3,000 workers at dozens of large US companies, the vast majority of respondents said they would forego the hefty raise if they could keep working in their pajamas.

I’ve spent more than 25 years in healthcare strategy and planning, and that was one of the most remarkable surveys I’ve ever seen – though not in terms of HR, because healthcare is one of the few industries where remote work never took hold during the pandemic.

Instead, I think the urgent lesson for healthcare planners is all about how – and where – services will be delivered in the future. Call it “the Covid effect”: In the same way that employees over the past year discovered the advantages of working at home, we’ve seen a huge number of new patients who discovered the advantages of so-called Hospital at Home programs.

Hospital at Home is not exactly a new model, but it’s been relatively unknown among patients until now. That’s because limited, early experiments suffered from low participation rates – just 7 to 15 patients per month. But those numbers got a huge boost over the past year as hospitals scrambled to preserve in-patient capacity for only the most extreme Covid cases. The Association of American Medical Colleges says interest in Hospital at Home “exploded” during the pandemic, and health systems from Boston to Cleveland to Seattle launched or expanded in-home programs that served thousands and thousands of new families.

It may be hard to put this genie back in the bottle. If workers won’t go back into the office for $30,000 what could possibly entice patients back into the traditional hospital setting once they’ve experienced the benefits of healing at home?

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DayTwo Scores $37M to Expand Microbiome-Based Personalized Nutrition Treatment for Diabetes

By JESSICA DaMASSA, WTF HEALTH

People with Diabetes can get ready to celebrate: “The ‘Era of Lancets’ is over.” Precision nutrition startup, DayTwo, is scaling up its microbiome-based program, which takes the guesswork (and finger pricks) out of Diabetes management by offering its members food predictions that identify how their bodies will respond to any food BEFORE they eat it. The startup just closed a fresh $37M in Series B funding (led by aMoon and Cathay Ventures) and is expanding the rollout of their fee-for-outcomes Diabetes program to health plans and large self-insured employers.

The science behind this has yielded DayTwo the largest gut microbiome dataset in the world, and years of empirical studies on exactly what happens in our bodies as our digestive systems process different foods. Josh Stevens, DayTwo’s President & Chief Commercial Officer, walks us through the research behind the offering, which uses a gut microbiome analysis to rank foods and food combinations based on how eating them will impact a person’s blood sugar – essentially revealing what foods will (or won’t) cause a member’s blood sugar to spike before they even take a bite.

Its 70,000+ members report lower A1C levels (1 point on average), sustained weight loss, and, probably most exciting, an ability to stick with the program because the app (and wrap-around telehealth support from registered dieticians) creates a completely bespoke diet that lets people learn how to eat their favorite foods and keep their blood glucose levels within range. Will this predictive approach really bring about the end of lancet-based blood glucose testing for Diabetes management? Josh says Diabetes remission is a goal made easier by this predictive approach, but how does it stack up to other food-as-medicine approaches out there? I have a gut-feeling that you’ll want to tune in and find out!

Health Care, Meet Gall’s Law

By KIM BELLARD

I can’t believe I’ve gone this long without knowing about Gall’s Law (thanks to @niquola for tweeting it!).  For those of you similarly unaware, John Gall was a pediatrician who, seemingly in his spare time, wrote Systemantics: How Systems Work and Especially How They Fail in 1975.  His “law,” contained therein, is:

Have you ever heard of anything that applied so perfectly to our healthcare system? 

As anyone who has been reading my prior articles may know, I’m a big believer in simple.  I’ve advocated that healthcare’s billing and paperwork should be much simpler, that “less is more” when it comes to design,  that healthcare should first do simple better but, above all,  that healthcare should stop doing stupid things.  I’ve equated the ever-increasing intricacies of our healthcare system to the epicycles that kept getting added to the Ptolemaic theory in a desperate attempt to justify it. 

Few would disagree that the U.S. healthcare system is complex.  Healthcare systems in general have evolved towards more complex, but the U.S. system takes complexity to extremes, with its thousands of payors, its powerful pharma/medical device industry, and its highly concentrated hospital markets (including ownership of physician practices), among other things. 

Simple isn’t always better, of course.  Life is complicated and so is our health, but, come on: how many people can explain why PBMs exist, what their heath insurance plan actually covers, how their health care bill was arrived at, or why we spend so much time in the healthcare system just waiting?  Literally no one understands our healthcare system.

It shouldn’t be that way.  It doesn’t have to be that way.  But it is.

Some pundits argue we don’t even have “a system” but, rather, thousand or even millions of smaller health-related markets that co-exist but don’t really work together.  For anyone who doubts that, try to explain the presence of workers compensation healthcare or why dental is at best a separate form of coverage (last I looked, the mouth was part of the body).  Try to explain why child care is most definitely not part of healthcare but home care is – depending, of course, on whether it is “custodial” or not.   Silos abound.

It could be argued that healthcare started with a simple system that “worked.”  Some are nostalgic for the days when people saw their family doctor, paid their doctor, and that was it.  It doesn’t get much simpler than that.  Of course, those doctors couldn’t really do all that much for their patients and didn’t really get paid all that much, so to say that it “worked” for either party is debatable. 

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Policies|Techies|VCs: What’s Next For Health Care–Virtual Conference is Sept 7-10

Policies|Techies|VCs: What’s Next For Health Care? is the conference bringing together the CEOs of the next generation of virtual & real-life care delivery, and all the permutations thereof. You can register here or learn how to sponsor.

This is a big week. We are one week out and we’ve started pre-recording a few sessions and they’ve been fascinating. Keynotes include government officials from the 3 most important agencies for digital health –Pauline Lapin (CMS), Micky Tripathi (ONC) & Bakul Patel (FDA). But wait there’s more! Keynotes from techies Glen Tullman (Transcarent), Sean Lane (Olive), Jonathan Bush (Zus Health), Jeff Dachis (One Drop) & Andrew Dudum (Hims & Hers). And we’re not forgetting the VCs sprinkled through the program, with a keynote from Andreesen Horowitz’s Julie Yoo.

Please look at the agenda for 20 power-packed panels and over 100 speakers – and then sign up!

Shout out to our sponsors – This week we welcome new Gold sponsor data privacy company Skyflow and new Silver sponsor Amwell. Thanks to both of them for supporting the conference. They join Avaneer Health (our Platinum sponsor) & exclusive Agency sponsor 120/80. Sliver sponsors are Transcarent & Lark . More sponsors are AetionMerck GHIFCrossover HealthZus HealthNewtopiaAetion & Big Health! Many of them will have sessions you can catch on the web site.

It’s going to be a great conference–no need to leave your seat as it’s happening virtually September 7-10. Register here!!Matthew Holt

Sleepless Nights For Evolutionary Biologists: A Greek Tragedy in The Making

By MIKE MAGEE

In my Jesuit high school, we were offered only one science course – chemistry. I took it in my Senior year and did pretty well. In contrast, I took four years of Latin, and three years of Greek, as part of the school’s Greek Honors tract.

Little did I know that Covid would create a pathologic convergence of sorts six decades later. Let’s review the Covid mutants:

Alpha – A variant first detected in Kent, UK with 50% more transmissibility than the original and has spread widely.

Beta – Originating in South Africa and the first to show a mutation that partially provided evasion of the human immune system, but may have also made it less infectious.

Gamma – First detected in Brazil with rapid spread throughout South America.

Delta – First seen in India with 50% more transmissibility than the Alpha variant, and now the dominant variant in America and around the world.

Our ability to track and identify mutating viruses in real time is now extraordinary. Over 2 million Covid genomes have been cataloged and published. But describing the “anatomy” of the virus is miles away from understanding the functional significance of their codes, or the various biochemical instructions they may instruct.

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Matthew’s health care tidbits

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For my health care tidbits this week, I am getting very close to home. I live in Marin County, California which is an incredibly wealthy, well-educated, liberal place. My little town voted 90% for Biden and, as you’d expect, county-wide 87% of those eligible (over 12) are fully immunized with most of the rest on the way. But Marin also has a small hard core of anti-vaxxers, and by that I mean those who reject childhood vaccinations. At one Waldorf school nearby only 22% of kids are vaccinated (MMR et al).This week the CDC released a study about how this past May an unvaccinated elementary school teacher who was sneezing but didn’t wear a mask infected 55% of their class.

I know that public schools in Marin have insisted on their teachers and students wearing masks and have highly, highly encouraged vaccinations among teachers and staff. Furthermore that school had only 205 pupils which is well below the average for elementary schools (at least in my school district). So I am prepared to bet that the maskless teacher was at a charter school or other private school. (Post newsletter update: I found out that it was a parochial school in Navato)

Clearly we need vaccines for kids ASAP. But I also am starting to wonder that, as COVID-19 becomes endemic and probably never goes away and as studies like this show how rapidly it spreads, will the majority who believe in masking, vaccines et al start to impose more medical and social mandates and bans on those who do not?

Health Insurance is a Stumbling Block in Many Patients’ Thinking

By HANS DUVEFELT

I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their technicians’ (not mere mechanics) time. A routine service costs several hundred dollars, which he seems more okay with than the cost of his own healthcare visits.

His new Mercedes is under warranty, but his body is not. He is risking financial disaster if he gets seriously ill with no insurance coverage.

I have another patient who needed a muscle relaxer for a short period of time. His insurance wouldn’t cover it without a prior authorization. The cash cost was about $14. We suggested he pay for the medication and told him his condition would have resolved by the time a prior auth might have been granted. He elected to go without.

The brutal truth is that a primary care doctor’s opportunity cost, how much revenue we can potentially generate by seeing patients, is around $400/hour or $7/minute. There is no way I could request a prior authorization in under two minutes. So it would have been more cost effective to pay for his medication than to do the unreimbursed paperwork (or computer work, or phone work) on his behalf. But, of course, we can’t do that.

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THCB Gang Episode 64 – Thurs August 26, 1pm PT- 4pm ET

THCB Gang is back from its summer break. Joining me Matthew Holt (@boltyboy) for an hour of topical and sometime combative conversation on what’s happening in health care and beyond will be patient safety expert and all around wit Michael Millenson (@MLMillenson); fierce patient activist Casey Quinlan (@MightyCasey), medical historian Mike Magee (@drmikemagee), WTF Health host & Health IT girl Jessica DaMassa (@jessdamassa); and making a rare but welcome appearance cardiologist & provocateur Anish Koka (@anish_koka). Watch it live below.

If you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

Inside 1-Year-Old Calibrate’s $100M Raise for ‘Rx + Behavior Change’ Weight Loss

By JESSICA DaMASSA, WTF HEALTH

Just ONE-year in market, and Calibrate has already closed a $100M Series B co-led by Founders Fund and Tiger Global, with participation from Optum Ventures, Forerunner Ventures, Threshold Ventures, and Redesign Health. Why is this virtual care startup getting so much attention (and funding) from so many notable health tech investors? Founder & CEO Isabelle Kenyon is here to introduce us to the telehealth-plus-prescription-drugs business she’s building to help people lose weight.

This is NOT a Noom. Calibrate’s business model is built around a class of $700-$1,300-per month, prescription weight loss drugs called GLP-1s, which it helps its members sort through for both fit AND health insurance coverage (Isabelle says 90% of Calibrate members get the drugs covered by their health plan.) Once the drug is prescribed, the Calibrate member is wrapped in a telehealth-driven, lifestyle intervention program that addresses sleep, eating, exercise, and emotional health to help support the reset of their metabolism. As a result, Calibrate members are losing an average of 14% of their body weight, a significantly better, more sustainable outcome than achieved in clinical research when the drugs were prescribed without support.

There are lots of compelling aspects to the Calibrate story here, and we get through all of them: the 175M-person total addressable market of Americans diagnosed with obesity… the recent FDA-approval of Novo Nordisk’s new GLP-1 drug called Wegovy… and how Calibrate will use its fresh funding to build-out an Enterprise program aimed at meeting the shifting thinking employers, Medicare Advantage plans, and other health insurers have about obesity treatment as “preventative care” against more costly chronic diseases.

What else could this “behavior change + drug” framework – and its unique de-coupled payment model – be applied to? Diabetes, cholesterol, and hypertension sound like they’re all on the table, but how defensible is this? What stops a pharma company from doing this themselves? Isn’t this digital therapeutics?? A VERY interesting discussion about the often-taboo subject of weight loss, pharma, and the disruption of the healthcare delivery system behind both.

The FDA’s Culture: Should Safety Dominate All Practices?

By STEVEN ZECOLA

An organization’s culture is an internal set of shared values, attitudes and practices. The cohesiveness of the organizational culture will affect whether the entity will meet its vision, purpose, and goals.

One type of organizational culture is hierarchical in nature.   Unlike a risk-taking culture, this structure features policy, process and precision. It is best suited for mature and stable organizations.

The disadvantage of a hierarchal culture is that its stability and control can turn into rigidity. In many cases, the organization develops a negative attitude towards ideas supplied by third parties. It paints itself as having the perfect answer for every issue, no matter how large or small.

My interactions with the FDA suggest that its cultural practices are focused on safety, seemingly to the exclusion of all other issues.  This practice may be appropriate in the regulation of food, but not for drug research where flexibility and creativity are required to cure complex diseases.

Over the past decade, I have witnessed an excessive adherence to its existing practices in the context of BRCA1-related breast cancer, metastatic cancer, precision medicines, “Big Data” and Parkinson’s disease. While the rulings were directed at me, the FDA’s position on these issues has impacted millions of people for the worse.

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