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Kamala will Win The Popular Vote And No One Is Pointing Out That Absolute Certainty In The Popular Media 

By GEORGE HALVORSON

I have been railing against the Electoral College (and the Senate) as anti-democratic forever, and no one much cares. Turns out George Halvorson noticed–Matthew Holt

We all need to remember that Joe Biden got 11,110,258 California votes in the last election and we need to know and remember that Donald Trump got 6,006,409 votes in that state.    

Kamala Harris is on the same track as Biden in every survey and that means she will beat Trump by at least five million votes in that state and she will win the national vote total by at least that many votes because the other vote counts are basically tied and have many fewer voters than California.  

The vote differences in other states like Arizona and Georgia are a few thousands votes but only California and New York have million vote differences and she is clearly winning by millions of votes in each of those states.  

That means that Trump is guaranteed to lose the popular vote total again by millions of votes. 

It’s not clear yet if they can somehow create an electoral college win from those vote totals but it is very clear and absolutely guaranteed for him to be millions of votes behind to start that process.   

Large numbers of Americans will be extremely angry and upset if he loses the popular vote by almost ten million votes and somehow manages to get into the White House with that huge loss and pretends that he actually earned that victory with real votes. He will obviously be the biggest loser on the popular vote  because there’s no way to make up the California and New York numbers.   

That loss is absolutely guaranteed because those two states are doing for Harris exactly what they did for Biden and they are both even less supportive of Trump than they were against Biden. 

The people who see him lose by ten million or more votes and then somehow claim and win the White House will probably protest that result with very visible descriptions of their unhappiness and anger and his ability to lead credibly in the face of that anger will probably be badly damaged and clearly labeled with brand damaging and clear description of what happened.  

It would probably be better for the country if the electoral college results followed the actual popular vote.  

Election night is going to be interesting.  

The huge popular vote win will be visible very early because both California and New York numbers are so inevitable and so overwhelmingly against him that we won’t have to wonder or guess about those numbers at any point in the process. 

The news media should be ready for that massive popular vote difference because we know now that those numbers are absolutely going to happen.

George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14

The Clinical Enterprise is the Beating Heart of Health Systems

By JEFF GOLDSMITH

As health systems struggle to emerge from the post-COVID financial crisis, the importance of the clinical enterprise to these systems has dramatically increased.  Healthcare organizations are getting larger, as failing enterprises are absorbed into growing systems. 

Yet clinicians of all stripes but particularly physicians feel a deepening sense of alienation from the expanding care systems in which they work.   In many “wanna-be” health systems, the clinical “enterprise”  is a loosely connected roll-up of independent practices held together by RVU-based compensation plans and a common corporate logo on the door. 

A roll-up is not a credible foundation for a system, but merely a holding action.  If you have lost your clinicians, you do not have a franchise!    

In an age when clinician burnout and moral injury threaten the well-being of care givers, how care systems foster caregivers’ commitment to their enterprise has become the central strategic challenge.  When one looks at the leading enterprises in healthcare- from the Mayo Clinic to Johns Hopkins Medicine – they have one thing in common.  They are not only led by clinicians, but the clinicians there work together both to maintain high clinical standards and develop and propagate clinical innovation.  

This commitment has a direct financial consequence for health systems.  In an environment where an increase percentage of health care revenues are “risk” revenues, having affirmative control over the cost of delivering care is the key to the organization having a future. Ultimately, that control comes not from clever compensation schemes, but from how clinicians behave in working together to manage their patients. 

To be clear, the clinical enterprise does not mean that all clinicians are salaried employees.  In some organizations like Kaiser Permanente, for example, clinicians are employees of the Permanente Medical Groups, a closed panel entity which provides most of Kaiser’s clinical care.   

But in many organizations, clinicians may be independent practitioners or members of affiliated medical groups, but are still actively involved in the governance of the clinical enterprise.  In academic institutions, not all members of the clinical enterprise are full time faculty.  And not all of them have MDs after their names, but are advance practice nurses and other clinicians with post-graduate degrees.  

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Pete Hudson, Alta Partners & Transcarent Investor (Part 2)

Pete Hudson is one of the OGs of digital health. As an emergency room doc he was fed up with his friends bothering him with their medical problems and he created a tool called iTriage, which helped patients figure out what condition they had, and where to go to deal with it. This was fifteen years ago and we’re now starting to see the evolution of that. Pete is now a venture capitalist and an investor in Transcarent–the sponsor of a new video series on THCB. This is part 2 of our conversation (part 1 is here) and we dive much more into AI and what Transcarent’s Wayfinding tool and other AI like it could do to change health care and the patient experience–Matthew Holt

Chris Darland, Peerbridge Health

Chris Darland is CEO of Peerbridge Health, which is the maker of a “3 lead to 12 lead” EKG patch that can give a better view of overall cardiac health than what’s on the market now–which tend to specialize in AFIB. Chris thinks that the Peerbridge Cor product will lead to a new world where for a much lower price we can have much better data on many more people who are at potential risk for heart disease and much more. I talked with him to discover what’s coming and what the impact might be on the overall health care system. Will we have fewer bypasses and stents? Maybe…Matthew Holt

Pete Hudson, Alta Partners & Transcarent Investor (Part 1)

Pete Hudson is one of the OGs of digital health. As an emergency room doc he was fed up with his friends bothering him with their medical problems and he created a tool called iTriage, which helped patients figure out what condition they had, and where to go to deal with it. This was fifteen years ago and we’re now starting to see the evolution of that. Pete is now a venture capitalist and an investor in Transcarent–the sponsor of a new video series on THCB. We had a long conversation about the evolution of digital health, what went right, what opportunities got missed, and what to expect next. This is part one of our conversation, and allows two guys who were there close to the start of this world to survey what’s happened since–Matthew Holt

Can Someone Actually Be Responsible?

By MATTHEW HOLT

I was having a fight on Twitter this week and it hit me. America 2024 is Japan 1989. 

The topic of the fight was right-wing VC Peter Thiel. In 2001 he put a ton of Paypal stock allegedly worth less than $2,000 into a Roth IRA. The Roth IRA was designed so that working stiffs could put post tax cash into an IRA, grow it slowly and take out money tax-free. (For traditional IRAs you put in pre-tax money and get taxed when you take it out). You may have read the story in ProPublica. Magically Thiel earned less that year than the max allowable income limit (around $100K) to contribute to a Roth IRA, and magically that stock was within weeks worth much more and then, later, hundreds of millions more. Since then Thiel has invested those Paypal returns in Facebook, Palantir and much more, and that Roth IRA has billions of dollars in it that can never be taxed.

My twitter adversary was saying that Thiel obeyed the law. I doubt it, but that’s not really the point. When the Roth was introduced it wasn’t meant to be a loophole that Silicon Valley types could use to hide billions from tax. But neither my twitter “friend” nor Peter Thiel want to take responsibility or pay their fair share.

Japan in 1989 was wealthy and successful and heading off a speculative cliff which it’s since taken 3 decades to dig out of. There were numerous academics pointing this out, but the most interesting analysis was The Enigma of Japanese Power written by a Dutch journalist named Karel van Wolferen. Here’s a summary from wikipedia with my emphasis added

Van Wolferen creates an image of a state where a complicated political-corporate relationship retards progress, and where the citizens forgo the social rights enjoyed in other developed countries out of a collective fear of foreign domination….Japanese power is described as being held by a loose group of unaccountable elites who operate behind the scenes. Because this power is loosely held, those who wield it escape responsibility for the consequences when things go wrong as there is no one who can be held accountable.

In Thiel’s case a collective network of tax accountants, junk philosophers, and purchased politicians like JD Vance ensure that no one has to be accountable. Ultimately Thiel doesn’t feel responsible for paying what he owes. Of course the exposure of Trump’s tax cheating shows that he doesn’t either. And many people find this OK.

Meanwhile I got into it a little with Jeff Goldsmith on last week’s THCB Gang about why hospitals are still paid per transaction when it would be much better for them to be paid some kind of global budget for the services they provide and for doctors to be paid a salary to exercise their best judgment rather than be tempted into providing care just because they get paid for it. Both COVID and the recent Change Healthcare outage put health care providers in a terrible situation financially because they depend on being paid fee-for-service via claims for individual transactions. Did the leadership of America’s hospitals and doctors come out asking for a change to the system? No, they just got a government hand out and begged for a return to standard operating procedure. No one can rationally look at how we pay for health care in America and say “give us more of the same” but there’s no leadership to change it at all.

Talking about lack of leadership, Amber Thurman died in Piedmont Henry Hospital because no-one on the medical team was prepared to give her the D&C that she desperately needed. They were scared of going to jail under Georgia’s draconian anti-abortion law. There are many, many guilty parties here.

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THCB Gang Episode 140, Thursday October 3

OK we are really back.! Following last weeks special with the Women Healthcare Leaders for Progress, the “regular” THCBGang is coming back for the Fall, mostly but not always at the 1pm PT 4pm ET timeslot on Thursdays.

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday October 3 at 1pm PST 4pm EST are futurist Jeff Goldsmith: delivery & platform expert Vince Kuraitis (@VinceKuraitis); author & ponderer of odd juxtapositions Kim Bellard (@kimbbellard);

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

The Silicon Curtain Descends on SB 1047

By MIKE MAGEE

Whether you’re talking health, environment, technology or politics, the common denominator these days appears to be information.  And the injection of AI, not surprisingly, has managed to reinforce our worst fears about information overload and misinformation. As the “godfather of AI”, Geoffrey Hinton, confessed as he left Google after a decade of leading their AI effort, “It is hard to see how you can prevent the bad actors from using AI for bad things.”

Hinton is a 75-year-old British expatriate who has been around the world. In 1972 he began to work with neural networks that are today the foundation of AI. Back then he was a graduate student at the University of Edinburgh. Mathematics and computer science were his life. but they co-existed alongside a well evolved social conscience, which caused him to abandon a 1980’s post at Carnegie Mellon rather that accept Pentagon funding with a possible endpoint that included “robotic soldiers.” 

Four years later in 2013, he was comfortably resettled at the University of Toronto where he managed to create a computer neural network able to teach itself image identification by analyzing data over and over again. That caught Google’s eye and made Hinton $44 million dollars richer overnight. It also won Hinton the Turing Award, the “Nobel Prize of Computing” in 2018. But on May 1 2023, he unceremoniously quit over a range of safety concerns.

He didn’t go quietly. At the time, Hinton took the lead in signing on to a public statement by scientists that read, “We believe that the most powerful AI models may soon pose severe risks, such as expanded access to biological weapons and cyberattacks on critical infrastructure.” This was part of an effort to encourage Governor Newsom of California to sign SB 1047 which the California Legislature passed to codify regulations that the industry had already pledged to pursue voluntarily. They failed, but more on that in a moment.

At the time of his resignation from Google, Hinton didn’t mix words. In an interview with the BBC, he described the generative AI as “quite scary…This is just a kind of worst-case scenario, kind of a nightmare scenario.”

Hinton has a knack for explaining complex mathematical and computer concepts in simple terms.

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Red Alert about Red Buttons

By KIM BELLARD

In a week where, say, the iconic brand Tupperware declared bankruptcy and University of Michigan researchers unveiled a squid-inspired screen that doesn’t use electronics, the most startling stories have been about, of all things, pagers and walkie-talkies.

Now, most of us don’t think much about either pagers or walkie-talkies these days, and when we do, we definitely don’t think about them exploding. But that’s what happened in Lebanon this week, in ones carried by members of Hezbollah. Scores of people were killed and thousands injured, many of them innocent bystanders. The suspicion, not officially confirmed, is that Israel engineered the explosions.

I don’t want to get into a discussion about the Middle East quagmire, and I condemn the killing of innocent civilians on either side, but what I can’t get my mind around is the tradecraft of the whole thing. This was not a casual weekend cyberattack by some guys sitting in their basements; this was a years-in-the-making, deeply embedded, carefully planned move.

A former Israeli intelligence official told WaPo that, first, intelligence agencies had to determine “what Hezbollah needs, what are its gaps, which shell companies it works with, where they are, who are the contacts,” then “you need to create an infrastructure of companies, in which one sells to another who sells to another.”  It’s not clear, for example, if Israel someone planted the devices during the manufacturing process or during the shipping, or, indeed, if its shell companies actually were the manufacturer or shipping company. 

Either way, this is some James Bond kind of shit.

The Washington Post reports that this is what Israeli officials call a “red-button” capability, “meaning a potentially devastating penetration of an adversary that can remain dormant for months if not years before being activated.” One has to wonder what other red buttons are out there.

Many have attributed the attacks to Israel’s Unit 8200, which is roughly equivalent to the NSA.  An article in Reuters described the unit as “famous for a work culture that emphasizes out-of-the-box thinking to tackle issues previously not encountered or imagined.”  Making pagers explode upon command certainly falls in that category.

If you’re thinking, well, I don’t carry either a pager or a walkie-talkie, and, in any event, I’m not a member of Hezbollah, don’t be so quick to think you are off the hook. If you use a device that is connected to the internet – be it a phone, a TV, a car, even a toaster – you might want to be wondering if it comes with a red button. And who might be in control of that button.

Just today, for example, the Biden Administration proposed a ban on Chinese software used in cars.

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A Baby Step Backwards

Bringing the Tools of Accountable Care to Maternity Care is a Great Idea – But This Sure Ain’t It

By VICTORIA ADEWALE & J.D. KLEINKE

How desperate are we to find some kind of good news about the sorry state of maternity care in America? To find out, look no further than the current cover of no less venerable a health policy journal than Health Affairs.

With the headline “Medicaid ACO Improves Maternity Care” jumping off the cover of its September issue, we were expecting great things from the article “Massachusetts Medicaid ACO Program May Have Improved Care Quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, et al.). The headline certainly promises some rare good news for all of us working to fix the national embarrassment that is maternity care in the US in general, and the maternal mortality crisis in particular.

But alas, the article itself is one more reminder that process improvements are not outcomes improvements. It is also a classic case of earnest researchers’ tendency to torture retrospective data — because it happens to be available for study — into something that might be useful. While it would be easy to dismiss out of hand the listless findings of this study of data-convenience, the danger here is they may well provide yet more ammunition for skeptical payers not to pay for more care that numerous studies have shown patients desperately need.

The authors make a valiant effort with an elegant study design to glean what they can from the “natural experiment” of analyzing pre- and post-natal care delivered to pregnant patients before and after the implementation of Accountable Care Organizations in Massachusetts. But as another old saw goes: when you have a hammer, everything looks like a nail; and patient enrollment in a primary care ACO, as with this dataset, hardly counts as an independent variable with much power to predict the care utilization and outcomes of maternity care for covered enrollees.

It is well established in the literature – not to mention an accepted truism among providers and patients – that when most women become pregnant, the bulk of their care shifts from the primary care setting to obstetrician/gynecologists (OB/GYNs) and certified nurse-midwives (CNMs). Many researchers and clinicians believe that much of this shift occurs even before a confirmed pregnancy, as a consequence of fertility challenges and pregnancy planning.

The authors did find that pregnant patients newly enrolled in ACOs had a small increase in the number of pre- and post-natal visits.

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