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Valuing Value-Based Payment
By ANISH KOKA, MD

Why “Precision Health” May Not Be the Precise Word

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By DAVID SHAYWITZ, MD

The appeal of precision medicine is the promise that we can understand disease with greater specificity and fashion treatments that are more individualized and more effective.

A core tenet (or “central dogma,” as I wrote in 2015) of precision medicine is the idea that large disease categories – like type 2 diabetes – actually consist of multiple discernable subtypes, each with its own distinct characteristics and genetic drivers. As genetic and phenotypic research advances, the argument goes, diseases like “type 2 diabetes” will go the way of quaint descriptive diagnoses like “dropsy” (edema) and be replaced by more precisely defined subgroups, each ideally associated with a distinct therapy developed for that population.

In 2015, this represented an intuitively appealing idea in search of robust supporting data (at least outside oncology).

In 2017, this represents an intuitively appealing idea in search of robust supporting data (at least outside oncology).

The gap between theory and data has troubled many researchers, and earlier this year, a pair of cardiologists from the Massachusetts General Hospital (MGH) and the Broad Institute, Sek Kathiresan and Amit V. Khera, wrote an important – and I’d suggest underappreciated – commentary in the journal Circulation that examined this very disconnect, through the lens of coronary artery disease (CAD).

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Practicing Medicine While Black
(Part II)

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By KIP SULLIVAN

Managed care advocates see quality problems everywhere and resource shortages nowhere. If the Leapfrog Group, the Medicare Payment Advisory Commission, or some other managed care advocate were in charge of explaining why a high school football team lost to the New England Patriots, their explanation would be “poor quality.”

If a man armed with a knife lost a fight to a man with a gun, ditto: “Poor quality.” And their solution would be more measurement of the “quality,” followed by punishment of the losers for getting low grades on the “quality” report card and rewards for the winners. The obvious problem – a mismatch in resources – and the damage done to the losers by punishing them would be studiously ignored.

This widespread, willful blindness to the role that resource disparities play in creating ethnic and income disparities and other problems, and the concomitant widespread belief that all defects in the US health care system are due to insufficient “quality,” is difficult to explain. I will attempt to lay out the rudiments of an explanation in this essay.

In my first article in this two-part series, I presented evidence demonstrating that “pay-for-performance” (P4P) and “value-base purchasing” (VBP) (rewarding and punishing providers based on crude measures of cost and quality) punish providers who treat a disproportionate share of the poor and the sick.

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Who Owns Your FitBit Data? Biometric Data Privacy Problems

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By JASON CHUNG

The following blog post is adapted from a talk the author gave at the “Data Privacy in the Digital Age” symposium on October 26th sponsored by the U.S. Department of Health and Human Services.

Today, I’ll be focusing on the data privacy issues posed by sports wearables, which I define to include both elite systems such as WHOOP or Catapult and more consumer-oriented products such as Fitbits, and why the U.S. needs an integrated federal regulatory framework to address the privacy challenges posed by private entities commercializing biometric data.

Sports wearables have evolved from mere pedometers to devices that monitor heart rate and sleep, tell athletes how to maximize recovery, and even track food intake and sexual activity – all uploaded to the cloud.

These technologies are now ubiquitous and have wide appeal to consumers – in fact, I’m wearing a Fitbit right now.

But these devices raise several key problems for consumers that are not yet being adequately addressed by the U.S. legal and regulatory system.

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The P.A. Problem: Who You See and What You Get

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By NIRAN AL-AGBA, MD

Recently, the New York Times published an article on excessive costs incurred by mid-level providers over-treating benign skin lesions. According to the piece, more than 15% of biopsies billed to Medicare in 2015 were done by unsupervised PA’s or Nurse Practitioners. Physicians across the country are becoming concerned mid-levels working independently without proper specialty training. Dr. Coldiron, a dermatologist, was interviewed by the Times and said, “What’s really going on is these practices…hire a bunch of P.A.’s and nurses and stick them out in clinics on their own. And they’re acting like doctors.”

They are working “like” doctors, yet do not have training equivalent to physicians. As a pediatrician, I have written about a missed diagnosis of an infant by an unscrupulous midlevel provider who embellished his pediatric expertise. This past summer, astute physician colleagues came across an independent physician assistant, Christie Kidd, PA-C, boldly referring to herself as a “dermatologist.” Her receptionist answers the phone by saying “Kidd Dermatology.”

The Doctors, a daytime talk show, accurately referred to Ms. Kidd on a May 7, 2015 segment as a “skin care specialist.” However, beauty magazines are not held to the same high standard; the dailymail.com, a publication in the UK, captioned a picture of “Dr. Christie Kidd”, as the “go-to MD practicing in Beverly Hills.”

The article shared how Ms. Kidd treats the Kardashian-Jenner family, “helping them to look luminous in their no-make-up selfies.”

While most of us cannot grasp the distress caused by not appearing luminous in no-makeup-selfies, this is significantly concerning for Kendall Jenner. At the tender age of 21, she inaccurately referred to Ms. Kidd as her “life-changing dermatologist.” Cosmopolitan continues the charade, publishing an article on the Jenner family “dermatologist.”

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Amazon (Probably) Is About to Lose Out

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By ROGER COLLIER

Dear Jeff Bezos:

It looked like a great idea when you started to build a team of healthcare specialists back in the summer. Despite — or perhaps because of — endless attempts to control costs and improve quality, American healthcare remains (in the words of a recent THCB post) “a version of Afghanistan…replete with tribal conflicts, warlords, corruption, a bad communication system, [and] language problems.” Surely, there must be opportunities for Amazon.

Healthcare reporters were quick to pick up on rumors of your company entering the pharmacy business. If Amazon’s purchasing, distribution, delivery and marketing skills could be applied to the Whole Foods grocery business, imagine what might be achieved in the $500 billion pharmacy market. And imagine how this base could be used to transform the entire healthcare industry. No wonder drugstore chains and drug manufacturers saw their stocks swoon as the rumors spread.

Now it seems Amazon may have been aced out.

CVS Health, the largest retail pharmacy chain and a major pharmacy benefits manager, is in talks to buy Aetna, the third largest US health insurer, for more than $66 billion. While some analysts see this as primarily a defensive maneuver to thwart Amazon, it has the potential to dramatically change the healthcare playing field.

In the short run, both CVS and Aetna would be better protected against their current weaknesses. CVS’ PBM business is increasingly vulnerable as major insurers bring drug negotiations in-house, while its retail stores face growing competition from on-line pharmacies and – more recently – from federal approval of Walgreens’ acquisition of Rite-Aid. Aetna has its own weaknesses: it lost money on the Obamacare exchanges, and the continuing move of large groups to ASO contracts means less profitable underwritten business.

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What investors are saying about the state of digital health

Health 2.0 caught up with some of our favorite investors who have a strong pulse on what’s happening in digital health care both past and present. We talked about company evaluation, unmet needs in health care, and their biggest surprises yet.

Read the full interview featuring Lisa Suennen of GE Ventures, Bryan Roberts of Venrock, Rich Roth ofDignity Health, and Brent Stackhouse of Mount Sinai Ventures.

Here’s a preview…

“Pretty much all of my investments are in first time CEOs, which is not particularly what the venture capital playbook tells you to go do. But I find those people to be very hungry and largely underappreciated by the rest of the world. They’re also very willing to bash their head against a brick wall with me for a while, in order to try to succeed at something that is hard to do.”
 – Bryan Roberts, Venrock on what he looks for in an investment.

“There are so “many tech people who want to work their way into health care venture capital. When I started in health care venture in 1998 you couldn’t give it away. I wonder how long it will be before the cycle ends?”
– Lisa Suennen, GE Ventures on what surprises her about the industry right now.

Catch up with Lisa Suennen, Bryan Roberts, and others at Health 2.0’s WinterTech event on January 10, 2018 in San Francisco where you’ll hear more on investment trends, IPO, and the rise in consumer choices. Register today for WinterTech before the early price ends.

Health Care Needs Its Rosa Parks Moment

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BY SHANNON BROWNLEE

On Wednesday, October 25, 2017 I was at the inaugural Society for Participatory Medicine conference. It was a fantastic day and the ending keynote was the superb Shannon Brownlee. It was great to catch up with her and I’m grateful that she agreed to let THCB publish her speech. Settle back with a cup of coffee (or as it’s Thanksgiving, perhaps something stronger), and enjoy–Matthew Holt

George Burns once said, the secret to a good sermon is to have a good beginning and a good ending—and to have the two as close together as possible. I think the same is true of final keynotes after a fantastic conference. So I will do my best to begin and end well, and keep the middle to a minimum.

I have two main goals today. First, I want to praise the work you are doing, and set it into a wider context of the radical transformation of health care that has to happen if we want to achieve a system that is accountable to patients and communities, affordable, effective — and universal: everybody in, nobody out.

My second goal is to recruit you. I’m the co-founder of the Right Care Alliance, which is a grassroots movement of patients, doctors, nurses, community organizers dedicated to bringing about a better health system.  We have 11 councils and chapters formed or forming in half a dozen cities. I would like nothing more than at the end of this talk, for every one of you to go to www.rightcarealliance.org and sign up.

But first, I want to tell you a bit about why I’m here and what radicalized me. My father, Mick Brownlee, died three years ago this Thanksgiving, and through his various ailments over the course of the previous 30 years, I’ve seen the best of medicine, and the worst.

My father was a sculptor and a scholar, but he was also a stoic, so when he began suffering debilitating headaches in his early 50s, he ignored them, until my stepmother saw him stagger and fall against a wall in the kitchen, clutching his head. She took him to the local emergency room, at a small community hospital in eastern Oregon. This was the 1970s, and the hospital had just bought a new fangled machine—a CT scanner, which showed a mass just behind his left ear. It would turn out to be a very slow growing cancer, a meningioma, that was successfully removed, thanks to the wonders of CT and brain surgery. What a miracle!

Fast forward 15 years, and Mick was prescribed a statin drug for his slightly elevated cholesterol. One day, he was fine. The next he wasn’t, not because his cholesterol had changed, but the cutoff point for statin recommendations had been lowered. Not long after Mick began taking the statin, he began feeling tired and suffering mild chest pain, which was written of as angina. What we didn’t know at the time was the statin was causing his body to destroy his muscles, a side effect called rhabdomyolysis. Even his doctor didn’t recognize his symptoms, because back then, the drug companies hid how often patients suffered this side effect.

The statin caught up with Mick at an exhibit in Seattle of Chinese bronzes, ancient bells and other sculptures that my father had been studying in art books his whole career. Halfway through the exhibit, he told my brother to take him home; he was too tired to take another step.

Three days later, he was in the hospital on dialysis. The rhabdomyolysis had finally begun to destroy his kidneys. Three weeks later, he was sent home alive with one kidney barely functional. Soon his health would begin to deteriorate at a steady pace.Continue reading…

Purging Healthcare of Unnatural Acts

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BY UWE REINHARDT

In tribute to Uwe we are re-running this instant classic from THCB’s archives. Originally published on Jan 31, 2017.

Everyone knows (or should know) that forcing a commercial health insurer to write for an individual a health insurance policy at a premium that falls short of the insurer’s best ex ante estimate of the cost of health care that individual will require is to force that insurer into what economists might call an unnatural act.

Remarkably, countries that rely on competing private health insurers to operate their universal, national health insurance systems all do just that. They allow each insurer to set the premium for a government-mandated , comprehensive benefit package, but require that each insurer “community-rate” that premium by charging the company’s individual customers that same premium, regardless of their health status and even age (with the exception of children).

American economists wonder why these countries do that, given that in the economist’s eyes community-rated health insurance premiums are “inefficient,” as economists define that term in their intra-professional dictionary. 

The Affordable Care Act of 2010 (ACA, otherwise known as “ObamaCare”) also mandates private insurers to quote community-rated premiums on the electronic market places created by the ACA, allowing adjustments only for age and whether or not an applicant smokes. But within age bands and smoker-status, insurers must charge the same premium to individual applicants regardless of their health status.

As fellow economist Mark V. Pauly points out in an illuminating two-part interview with Saurabh Jha, M.D., published earlier on this blog, aside from the “inefficiency” of that policy, it has some untoward but eminently predictable consequences. It happens when healthier people disobey the mandate to purchase insurance, leaving the risk pools of those insured in the ACA market places with sicker and sicker individuals, thus driving up the community-rated premiums. As Pauly points out at length, a weakly enforced mandate on individuals to be insured can become the Achilles heel of community rating.   

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The Great American Hypertension Epidemic of 2017

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By MICHEL ACCAD, MD

On November 15, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans.  The epicenter of the outbreak was traced back to the meeting of the American Heart Association in Anaheim, CA.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.”  The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press.  Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic.  Everyone is advised not to click on any document or any link connected to this virus.  Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.

Only a strong dose of common sense packed in a few lines of text can possibly save us from an otherwise lethal epidemic of nonsense.  Please save the following text on your EHR cloud or hard-drive, commit it to memory or to a dot phrase, and copy and paste it on all relevant quality and pay-for-performance reports you are asked to submit.

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