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Investment State-of-Play in Big Pharma: Bayer’s Eugene Borukhovich Weighs In

By JESSICA DaMASSA, WTF HEALTH

Bayer’s G4A team launched their 2019 program today, so here’s a little help for anyone curious about the state of pharma startup investment and what it takes to land a deal there these days.

I had the chance to pick the brain of Bayer’s Global Head of Digital Health, Eugene Borukhovich, during JP Morgan Healthcare Week and pulled out these three gloriously thought-provoking soundbites from our conversation to give you some insight as to the mindset over at big Bayer.

  • “Digital therapeutics are shining light on the convoluted, complex mess of digital health”

If you’ve wondered what lies ‘beyond the pill’ for Big Pharma, wonder no more. It seems the answer is digital therapeutics. Eugene predicts that “within the next couple of years, ‘digital health’ as a term will disappear,” and calls out organizations like the Digital Therapeutics Alliance for their efforts to set standards around evidence-base and behavior modification so regulators and strategic investors alike can properly evaluate claims made by health tech startups. As time goes on, it looks like efforts to ‘pharma-lize’ the ways startups take their solutions to market will increase, pushing them into more traditional go-to-market pathways that have familiar and comforting guidelines in place. As Eugene says, “Ultimately, what we say in my team, is that it’s about health in a digital world today.” Sounds like that’s true for both the products he’s seeking AND the way pharma is looking to bring them to market… 

  • “These multi-hundred million [dollar] press releases are great to a certain extent, but what happened to the start-up style mentality?”

When asked about Big Tech getting into Big Health, in the end, it seems, Eugene shakes out to be in favor of the ‘Little Guy’ – or, at least, in their approach. Don’t miss his comments about “cockiness in our healthcare industry” and how Big Tech is working around that by partnering up, but the salient point for startups is that big companies still seem very much interested in buddying with smaller businesses. It’s for all the same reasons as before: agility, the ability to iterate quickly, and the opportunity to do so within reasonable budgets. Eugene offered this telling rhetorical musing: “Just because it’s a combination of two big giants…do you need to do $500 million? Or, do you give some…traction, milestone, [etc.]…to prove it, just like a start-up would?”

  • “In large organizations, transformation equals time, and…we don’t have time.”

“To me,” says Eugene, “the biggest challenge is actually landing these inside the organization.” He’s talking about novel health solutions – digital therapeutics or otherwise – after learning from previous G4A cycles. Culture, precedent, and years of market success loom large in big healthcare companies across the ecosystem, which is one reason why innovation inside them is so challenging. Eugene says he’s “a big believer in a small team – even in large organizations – to take something by the cojones, and get shit done, and move it forward, and push the envelope from the bureaucracy and the process.” There’s a sense of urgency to ‘innovate or die’ in the face of the growing competition in the healthcare industry. “Back to this earlier conversation around whether it’s tech giants or other companies,” he adds, “it is a race to the speed of the organization. How quickly we learn and how quickly we make the decisions. Bottom line, that’s it.”

There’s plenty more great insights and trend predictions where these came from, plus the juicy details behind how G4A itself has pivoted this year. Check out the full interview now.

Economics Lessons from the Subcontinent: India’s Coronary Stent Policy

By ANISH KOKA MD

It is commonly believed that deliberate, careful price regulation by enlightened technocrats trumps the haphazard and chaotic regulation of prices imposed by the free market—especially when the market is subject to greed and corruption.

A most interesting case study challenging that belief comes courtesy of the largest Democracy in the world: India.

In 2017, an arm of the Indian Government, the National Pharmaceutical Pricing Authority (NPPA) took action to control the price of coronary stents in India by capping their retail price.  The problem that stimulated this action was their exorbitant price that made them unaffordable to many Indians.

The retail prices of US made drug-eluting stents ranged from Rs 80,000 – 150,000 (~$1000 – ~$2000), while the price of Indian made drug-eluting stents ranged from Rs 45,000 – 90,000 (~$600 – ~$1200).  Considering that a good job for 90% of the Indian labor force pays about Rs 180,000 per year, these prices put most coronary stents out of the reach of a vast swath of the populace.

What regulators knew, however, was that the price point at which coronary stents were being imported into India was a fraction of the price being charged to Indians.  The up-charge had everything to do with what happened after the stent was brought onto Indian soil: The Indian subsidiary of the US stent manufacturer would sell its product to a domestic distributor that would then employ all means necessary to ensure their stent was chosen by cardiologists to be implanted.

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For American Indians, Health is a Human and Legal Right

Sam Aptekar
Phuoc Le

By PHUOC LE, MD and SAM APTEKAR

Most will be surprised to learn that American Indians and Alaska Natives represent the only populations in the United States with a legal birthright to health care.[1] Even though Article 25 of the UN’s Universal Declaration of Human Rights declares, “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including…medical care and necessary social services,” U.S. federal policy only guarantees this human right to enrolled tribal members. The source of this juridical entitlement is what the United States Supreme Court has defined as the federal trust responsibility.

Between 1787 and 1871, the United States signed nearly 400 treaties with Indian tribes, in which, for the exchange of millions of acres of tribal land, the U.S. government promised in perpetuity to respect their sovereignty and provide benefits, including housing, education, and healthcare. Argued in March 1983, United States v. Mitchell is the most recent Supreme Court case establishing this principle as a matter of law. This week marks the 36-year-anniversary of that seminal case, providing us the opportunity to discuss the federal government’s failure to adequately fund the healthcare institutions that serve American Indians and Alaska Natives despite its legal responsibility to do so.

Supreme Court Justice Thurgood Marshall penned the majority opinion of United States v. Mitchell.

The current life expectancy for American Indians and Alaska Natives is 73 years, 5.5 years less than that of the general population. American Indians die at higher rates from heart disease, cancer, diabetes, stroke, and kidney disease. When we consider why Native communities suffer from preventable and treatable diseases at disproportionate frequencies, we must first evaluate the inequity in Congressional funding for Indian Health Services (IHS), the national agency within the Department of Health and Human Services that is responsible for providing comprehensive healthcare to the country’s enrolled American Indians and Alaska Natives.

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Health in 2 Point 00, Episode 75 | Rounds & IPOs, Health Datapalooza, & the Facebook Controversy

Today on Health in 2 Point 00, Jess and I are at 10th annual Health Datapalooza in Washington D.C.! Jess talks to me about Xealth’s $11 million round to develop out its company, and Change Healthcare is applying for a $100 million IPO. The big takeaways from Health Datapalooza are that many people and companies have integrated data into their systems, but they haven’t been able to gain many actionable insights from it. Also, if you haven’t heard of the complaint Andrea Downing, Fred Trotter, and David Harlow wrote to the FTC concerning the privacy and data that can be downloaded from Facebook’s groups, you better check it out. It details out the concern that Facebook is not protecting the data of patients as anyone can download sensitive data from the groups and use it — Matthew Holt

All for One, One For All

By MIKE MAGEE MD

Within the ever-widening array of Democratic contenders for the Presidency, the “Medicare-for-all” debate continues to simmer. It was only six weeks ago that Kamala Harris’s vocal support drew fire from not one, but two billionaire political rivals. Michael Bloomberg, looking for support in New Hampshire declared, “I think we could never afford that. We are talking about trillions of dollars… [that] would bankrupt us for a long time.” Fellow billionaire candidate Howard Schultz added, “That’s not correct. That’s not American.”

Remarkably, neither man made the connection between large-scale health reform’s potential savings (pegged to save 15% of our $4 trillion annual spend according to health economists) and the thoughtful application of these newly captured resources to all U.S. citizens without discrimination. Bloomberg’s own 2017 Health System Efficiency Ratings listed the U.S. 50th out of 55, trailed only by Jordan, Columbia, Azerbaijan, Brazil, Russia. Yet he seemed unable to connect addressing waste with future affordability.

Schultz was similarly short sighted. While acknowledging that the manmade opioid epidemic, mental health crises, and income inequality are “systemic problems” and at levels “the likes of which we have not had in a long time”, he failed to connect the cause (a remarkable dysfunctional and inequitable health care system) with these effects.

As I outline in “Code Blue: Inside the Medical Industrial Complex” (Grove Atlantic/ June 4, 2019), today’s greatest risk to continued progress and movement toward universal coverage and rational health planning is sloppy nomenclature.  To avoid talking past each other, we need to define the terms of this debate while agreeing on common end points.

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Radiology in India

By SAURABH JHA, MD

What are the challenges of bringing advanced imaging services to India? What motivates an entrepreneur to start build an MRI service? How does the entrepreneur go about building the service? In this episode, I discuss radiology in India with Dr. Harsh Mahajan, Dr. Vidur Mahajan and Dr. Vasantha Venugopal. Dr. Harsh Mahajan is the founder of Mahajan Imaging, a leading radiology practice in New Delhi, and now a pioneer in radiology research in India.

Listen to our conversation on Radiology Firing Line Podcast here.

Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

Teladoc, CVS, Utilization Rates, & Apple in ‘THE YEAR of Telehealth’

By JESSICA DA MASSA, WTF Health

According to Toby Cosgrove, 2019 is “THE YEAR of telehealth.” The former CEO of Cleveland Clinic, who is currently an executive advisor to Google Cloud’s healthcare and life sciences team, proclaimed it as such to CNBC, saying that this year is “THE YEAR” telehealth becomes ubiquitous.

That’s a pretty bold statement – particularly as utilization rates for virtual visits continue to fall short of expectations – so we double-checked this prognostication with Teladoc’s CEO, Jason Gorevic.

Does he think 2019 is going to be telehealth’s turning point?

Well, although he’d rather call the space ‘virtual care’ instead of ‘telehealth’ (maybe this will be the difference maker?), he confesses he’s pretty much on board with Cosgrove’s assertion that more consumers than ever will visit virtual exam rooms this year.

But, why?

How does 2019 become “THE YEAR” of virtual care? Is this going to be an industry-wide boon, or is Teladoc just banking on its partnership with CVS and their new family member, Aetna?

Tune in to hear Jason get real about what’s impacting utilization rates, how things are going to change this year, AND whether or not he’s worried about competing with Apple, Google, and Amazon for screen time. (Hint: He’s not.)

Last Couple of Months in Oncology with Dr. Bishal Gyawali: March 2019

By BISHAL GYAWALI MD, PhD

Hey, I’m back!

Well, you might not have noticed that my blogs were missing for the last three months but anyways, its good to be back. I was having a little time off blogs and social media as I was transitioning in my career but now I am back. Sometimes, it is very difficult to manage time for things that you must do versus things you enjoy doing, especially when these two don’t intersect. For me, these last few months the things I had to do were all bureaucratic while I couldn’t find the time for things I enjoy doing like writing these blogs. But now that we are back, let’s recap what has happened in the oncology world in the year 2019 so far. I can’t cover all of them, but will try to summarise the major events in oncology.

Hundred Foxes’ Howl versus One LION’s Roar

In my country, there is a saying that goes somewhat like the roar of one lion will scare hundreds of howling foxes away. In medicine, I guess, it translates as one good RCT trumps the results from hundreds of observational studies. For patients with advanced ovarian cancer, primary surgery to achieve complete resection is the most important treatment and prognostic factor.  However, what to do with the lymph nodes is a question that has troubled the oncology community for a long time. Logically, it makes sense to remove the lymph nodes too because they are the sanctuary sites for cancer cells. However, lymph node dissection carries high morbidity. Although multiple observational studies suggested a survival benefit with lymph node dissection, the LION trial, now published in the NEJM, shows that for women with macroscopic complete resection of primary tumour, lymph node dissection increases morbidity (postoperative complications) and post-operative mortality rates but doesn’t improve survival. I am glad that this trial was carried out and these results will now save many women with ovarian cancer worldwide from unnecessary harmful procedures, but I am also sad that we didn’t answer this question until now and thus, many patients suffered unnecessarily. I hope this LION’s roar scares us from jumping to conclusions based on logic or observational data alone and without RCT evidence in future. Another lesson here is the importance of public funds in supporting RCTs like these.

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You Lose a Child, You Lose Your Job

By LEO LOPEZ III, MD

I’m a physician, born in McAllen, Texas. In June 2018, I returned home to demand that immigrant children who had been torn from their families as a result of the Trump Administration’s zero-tolerance policy, be safely and immediately reunited. I demonstrated at a federal detention center in McAllen at the Free the Children Protest. I marched alongside other concerned citizens, and we confronted a bus carrying the children.

With my palms pressed against the bus, I demanded that the government free them. I could not have imagined that just a few months later, I’d demand that the government find them. 

Back then, the Office and Refugee and Resettlement had just certified that over 2,600 children had been separated from their families. 

The Office of Inspector General (OIG) of the Department of Health and Human Services recently released an updated account. They actually weren’t sure how many children were separated. Turns out they didn’t count them. According to the report, HHS doesn’t know exactly if, when, or how they’ll find the lost children.

I grew up right there, along the south-Texas border, and I know that cattle are better accounted for than these infants and children.

So whose fault is it? In my opinion, the blame falls on Health and Human Services Secretary Alex Azar and Homeland Security Secretary Kristjen Nielsen, both of whom are ultimately responsible for executing the President’s policy agenda through their respective departments. The Department of Homeland Security (DHS) systematically separated families. The Department of Health and Human Services failed to identify the children who were separated. 

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Health in 2 Point 00, Episode 74 | European Money, Postpartum Care, & Social Determinants of Health

Today on Health in 2 Point 00, Jess and I are standing on a roof answering health tech questions from the Digital Health Commercialization Panel event in San Francisco. In this episode, Jess asks me about all the money that is being raised or spent in the health tech worlds of Europe and the US. DoctoLib, a company that is like ZocDoc in the US, raised 150 million Euro, which is probably the largest raise for a European company involved in health tech. Meanwhile, in the US, Teledoc also stretches its way into Europe, buying MédecinDirect, which is a telehealth company in France. We also see health tech companies in the employer health space taking home large piles of cash. Cleo, which is a platform entirely run by women serving women’s’ health postpartum, raises 27 million. UniteUs, which is a company focused on improving people’s social determinants of health, raises 30 million, but I still worry about this type of initiative and want to see if there is a market for this type of care and if hospitals are willing to pay for it– Matthew Holt

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