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“Beyond Nicotine”: Tobacco Joins Hands With Pharma.

BY MIKE MAGEE

Connecticut attorney general, William Tong, took a turn in the spotlight this week, representing 33 states and Puerto Rico in announcing that vaping original, Juul, had agreed to pay penalties of $438.5 million to settle lawsuits against the company.

Juul in essence acknowledged that the company’s marketers had targeted young students, used social media to attract underage teens, and had given them free samples. With 45% of the company’s Twitter followers between ages 13 and 17, and an age verification methodology authorities label as “porous”, they were happy to get the nation’s attorney generals out of their hair.

Over the past four years, Juul has lost over 95% of its value. When Altria bought a 35% stake in the company in December, 2018, they paid $12.8 billion. That translates to just $450 million today. What were they thinking? At the time, Juul was fighting to preserve their “flavor pods” – with mango and creme brûlée a favorite among teens. 

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Vaccine Myocarditis Update

BY ANISH KOKA

The European Medicines Agency decided on July 19, 2021 that myocarditis and pericarditis be added to the list of adverse effects of both messenger RNA (mRNA) based vaccines (BNT162b2 [Pfizer-BioNTech] and mrna-1273 [Moderna]) against COVID-19. This advice was based on numerous reports of myocarditis that followed a clinical pattern that strongly suggested a causal link between these particular vaccines and myocarditis/pericarditis. The adverse events that appeared to be predominantly in young men typically occurred within a week after injection, and were clustered after the second dose of the vaccine series. A recent national database from France sheds some light on the approximate rates of mrna vaccine related myocarditis.

Between May 12, 2021 and October 31, 2021 within a population of 32 million persons aged 12-50 years, 21 million first doses of the BNT162b2 (Pfizer) vaccine and 2.86 million first doses of the mrna-1273 (Moderna) vaccine. In the same period, 1612 cases of myocarditis and 1613 cases of pericarditis with myocarditis were recorded in France. Compared to matched control subjects, the risk of myocarditis was markedly increased after 1st and 2nd doses of the vaccine. For the Pfizer vaccine, the odds of myocarditis were 1.8 times the expected background rate for the 1st dose and 8 times the expected background rate for the 2nd dose. The Moderna vaccine, which delivers about three times the dose of the Pfizer vaccine has an even higher risk of myocarditis — a stunning 30 times the expected background rate after the second dose. A prior history of myocarditis was associated with an odds-ratio of 160.

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Putting the “e” in DNA

BY KIM BELLARD

The Wall Street Journal had a great article a couple days ago that tickled my fancy on two fronts: DNA, and the deep ocean.  Both fascinate me. It introduced me to a term I’d not heard before but have now discovered is a thing: “eDNA.”  It’s something I suspect we’ll be hearing more about, and a technique we’ll be using much more, in the years to come.

The article, Finding New Drugs From the Deep Sea via ‘eDNA’, talks about a different approach to discovering potential sources of new medicines: “environmental DNA,” or eDNA.  As the US Geological Survey describes it: “Environmental DNA (eDNA) is nuclear or mitochondrial DNA that is released from an organism into the environment.” You may not want to know this, but “Sources of eDNA include secreted feces, mucous, and gametes; shed skin and hair; and carcasses.”

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We Should Channel People Into Medicare Advantage Plans Where They Won’t Have Amputations or Go Blind (Part 2)

By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last year arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1pt2). We also published his criticism (Part 1Part 2Part 3) of Medpac’s analysis of Medicare Advantage.  Now Medpac is meeting again and George is wondering why they don’t seem to care about diabetic foot amputations. We published part one last week. This is part two– Matthew Holt

We have more amputations and we have more people going blind in our fee for service Medicare program today because we buy care so badly and because we have no quality programs or care linkages for our chronically Ill patients and our low income people in that program.

We have far better care in our Medicare Advantage programs at multiple levels today, and we should be building on that better care for everyone.

The important and invisible truth is that we have major successes in providing better care to Medicare Advantage members across the entire spectrum of that package of care. The sad truth is that MedPac actually keeps those huge differences in care performance by the plans secret from the Congress and from the American public for no discernable or legitimate reason.

We have an epidemic of amputations that are causing almost a fifth of our fee for service diabetes patients who get foot ulcers to lose limbs. The number of patients in both standard Medicare Advantage and in the Medicare Advantage Special Needs Programs who undergo amputations and who have that functional and dysfunctional care failure is a tiny fraction of that number.

MedPac pretends the program does not exist. They did a lengthy study on the overall special needs dual eligible program for Medicare a year ago without mentioning the plans or describing any of the things that the plans to do make care better for those patients.

We know that in fee for service Medicare, 20% percent of diabetes patients routinely get ulcers and 20% of those ulcers to turn into amputations. There are far fewer amputations for Medicare Advantage plan members—and we have failed our overall Medicare population badly by not sharing that information more broadly at open enrollment time.

Medicare Advantage Five Star quality plans that have created a culture of quality improvement at many care sites. Those plans compete fiercely on quality goals and take pride in attaining and celebrating the highest scores.  We started with less than 10% of plans with the highest scores for the first enrollment periods. Now more than 90% of Medicare Advantage members are able to choose between four and five star plans.

The quality measurements that are missing from the set of consumer choices are the ones that relate to the most serious issues for the consumers—and that’s where MedPac should be putting the right set of information on the table to compare the two systems of care. Large amounts of data show that amputations caused by diabetes follow very predictable patterns.  

Roughly 33% of Medicare patients will have diabetes. 20% of diabetics will have ulcers. That number goes up to 30% for some patient groups—but you can count of at least 20% overall to have ulcers.  We know that the overarching pattern in fee for service Medicare is for 20% of those ulcers to end up needing and getting amputations.

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Medicare Advantage Saves Lives, Limbs, Sight, And Major Amounts of Money – (Part 1)

BY GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last year arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1pt2). We also published his criticism (Part 1Part 2. Part 3) of Medpac’s analysis of Medicare Advantage.  Now Medpac is meeting again and George is wondering why they don’t seem to care about diabetic foot amputations. We are publishing part one today with part two coming soon – Matthew Holt

We need to look honestly at some sad and grim realities about American Health Care and about the role that fee for service Medicare plays for too many people in our country today. 

Fee for service Medicare has the highest level of amputations and one of the highest levels of diabetic blindness of any country in the western world because it buys care so badly and so ineptly and then too often underperforms in multiple ways on the delivery of that care. 

Fee for Service Medicare only buys care and pays for care by the piece. It’s caregivers, both as a group and as individuals, actually can often make more money by performing, inadequate, unsuccessful and, far too often, even bad care, because bad care can result in more care being needed, purchased and paid for.

Many of the failures of care for the patients with the medical conditions that cause them to spend far too much time in the hospital, and in various other care settings, should not be happening—and we know that to be true because large numbers of the care failures are not happening to the patients who are enrolled in Medicare Advantage plans.   

Medicare Advantage plans all have basic care plans and approaches  for their patients that are linked to care related care processes of care—and a very high percentage of those processes do not exist for far too many of our fee for service Medicare enrollees  

The sad and unfortunate reality is that fee for service Medicare has no quality standards, no quality expectations, and that it is, in aggregate, a very expensive way to buy care because bad care often costs more money at several levels than appropriate care.  

Those accusations are easy to prove and they are easy to demonstrate.  

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Deep-Dive Into Availity’s Acquisition of Diameter Health

by JESSICA DAMASSA

“There’s $4-$4.5 trillion dollars of annual spend in the healthcare system. A trillion of that is administrative. And, some big chunk — some BIG number that you measure in the 100’s of billions of dollars – is waste. So, the TAM for what Availity and Diameter Health are going to do together is huge.” Russ Thomas, Availity’s CEO, is clearly excited about his company’s recent acquisition of Diameter Health and we ask him – and Diameter’s President & COO Mary Lantin – why this is such a big deal.

In the end, what this comes down to is making more sense of all the data that flows between providers and payers to automate where possible, find insights to improve business processes and workflows, and, ultimately, cut out that notorious “admin expense” that adds to healthcare cost without creating any value.

For twenty years, Availity’s been in the business of “translating” data from providers into a language health plans can understand, so payors could refine their own business processes and automate pre-auths, pay claims, etc. Diameter, on the other hand, deals in the world of clinical data and “upcycles” it into concepts and “digestible bites” that a health plan can use to automate an administrative workflow process with a provider and – get this – build a longitudinal health record that now Availity’s robust supply of claims and health plan data can fully flesh out.

How excited are Russ and Mary about the idea of this comprehensive, longitudinal, fully-integrated clinical-plus-claims patient record? Much more excited than even I anticipated! Tune in for all the details on the merger and this BIG vision for scaling up the fight against healthcare’s massive spend on administrative waste.

THCB Gang Episode 103, Thursday September 1

Joining Matthew Holt (@boltyboy) on #THCBGang on Sept 1st were THCB regular writer and ponderer of odd juxtapositions Kim Bellard (@kimbbellard); the double trouble of vaunted futurists Ian Morrison (@seccurve) & Jeff Goldsmith, and Consumer advocate & CEO of AdaRose, Lygeia Ricciardi (@Lygeia). Great conversation going from the personal (Jeff’s Covid August & Ian’s tour round the wilds of Canada) to the policy and political.

If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt

What Could Possibly Go Wrong? Outbreaks of Injustice Linked by Two Different Dobbs.

BY MIKE MAGEE

Under the definition for the noun, epidemic, there are two main (and distinctly different) definitions. I know this fact because it was the beginning point of my preparations earlier this summer for a Fall course on “The History of Epidemics in America” at the Presidents College at the University of Hartford. 

The entry reads:

Epidemic noun

ep·​i·​dem·​ic | \ ˌe-pə-ˈde-mik  \

Definition of epidemic (Entry 2 of 2)

1: an outbreak of disease that spreads quickly and affects many individuals at the same time an outbreak of epidemic disease

2: an outbreak or product of sudden rapid spread, growth, or development; an epidemic of bankruptcies

In my course, sessions 1, 2, and 4 will be devoted to the first (and classical, microbe-centric) definition. But my third session will focus on “manmade” epidemics which fall under definition two.

I thought long and hard about this choice. The deciding factor was reading New York Times best selling author, Adam Cohen’s book, “Imbeciles.” It details the shameful story of “The Supreme Court, American Eugenics, and the Sterilization of Carrie Buck.”

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It’s Time for No

BY KIM BELLARD

We all – well, most of us – try to be agreeable.  It’s usually a better social lubricant to say “yes” than “no.”  It’s widely considered to be better for your career to be the one who always says “yes” instead of being the troublesome worker who often says “no.”  “Yes, dear” is a safer marital strategy than “no” or “not again.”  But, like most conventional wisdoms, these deserve to be challenged. 

I’ve read several articles recently where “no” is the suggested strategy, and I think there’s something there.  Especially for healthcare.  

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