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The Art of Clinical Decision Making: Friday Afternoon Dilemmas

By HANS DUVEFELT

The woman had a bleeding ulcer and required a blood transfusion. The hospital discharge summary said to see me in three days for a repeat CBC. But she had a late Friday appointment and there was no way we would get a result before the end of the day. She also had developed diarrhea on her pantoprazole and had stopped the medication. As if that wasn’t enough, her right lower leg was swollen and painful. She had been bed bound for a couple of days in the hospital and sedentary at home after discharge.

She could still be bleeding and she could have a blood clot. There were no openings for an ultrasound until almost a week later. Normally, with the modern blood thinners, we can just start anticoagulation until the diagnosis of a blood clot can be confirmed or disproven. But you don’t do that when somebody has a bleeding ulcer.

The radiology department solved my dilemma by pointing out that the emergency room can order an ultrasound and the department will call in an on-call technician. So that is where my patient had to go. Her blood count was stable and the ultrasound was negative. So now we just have to hope that lansoprazole, which she had taken in the past, but stopped because she didn’t have heartburn, would be effective.

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THCB Gang Episode 47, Thursday March 18

Joining me , Matthew Holt (@boltyboy), on THCB Gang this week were fierce patient activist Casey Quinlan (@MightyCasey), consumer advocate & CTO of Carium, Lygeia Ricciardi (@Lygeia), THCB regular authors radiologist Saurabh Jha (@roguerad) & cardiologist Anish Koka (@anish_koka), with futurist Jeff Goldsmith on hand to keep us all honest. We started with Casey’s current health journey and Anish’s inability to get vaccines for his clinic — and this moved to a really fun and raucous discussion about whether the public sector can work in health care, whether we need to mandate the vaccine and if America is becoming a failed state! Great stuff!

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

#Healthin2Point00, Episode 192 | Happify, 100Plus, Health Recovery Solutions—& Glen Tullman is back

Today on Health in 2 Point 00, we’re back with more deals as promised for our post St-Patty’s episode. On Episode 192, Jess and I have lots to chat about because Glen Tullman is back—he becomes the CEO of Transcarent, a new company which is going direct to employers and doing navigation and telehealth and centers of excellence. Despite the crowded space (especially after this week’s Doctor on Demand and Grand Rounds merger), Glen says there is huge demand from employers. Catch our interview with him on WTF Health. Next, Happify Health gets $75 million, bringing their total up to $123 million. I had an interview with their President Ofer Leidner on THCB Spotlight yesterday, so tune in there to find out about this mental health company delivering automated, self-service care. Finally, two remote patient monitoring companies get funding – 100Plus gets $25 million in a Series A, and Health Recovery Solutions gets $70 million in a C. How are these different and why is there all this money in RPM now? —Matthew Holt

Glen Tullman’s Return to Digital Health: In-Depth Chat on New CEO Role at Transcarent

By JESSICA DaMASSA, WTF HEALTH

As if one consumer digital health company with an $18.5B exit wasn’t enough, Livongo founder Glen Tullman has decided to give the transformation of healthcare another go – this time as Executive Chairman & CEO of Transcarent. Matthew Holt and I sit down with Glen to hear about the “new kind of experience” that Transcarent is offering self-insured employers and their employees: one focused on providing unbiased information, guidance for accessing high-value healthcare, and an at-risk model that promises to share back the financial benefits associated with better healthcare decision-making.

Could you consider Transcarent an aggregator, a healthcare navigator-PLUS, or is it more like a next-gen health plan that does everything but process claims? Glen talks about how his team was “asked” to jump into providing a better experience for this kind of healthcare service, details what the company needs next, and explains the role of Bridge Health, which merged with Transcarent in October 2020 when the company closed its $44M Series A. Familiar investors, General Catalyst and Glen’s own 7Wire Ventures, have led the funding for Transcarent and we find out if there will be any additional support from the Health Assurance Acquisition Corporation (the SPAC that Glen launched in partnership with General Catalyst’s Hemant Taneja and others) that could potentially provide a vehicle for taking the business public. And, what about Teladoc Health? With a seat on TDOC’s Board, does Transcarent’s commitment to offering “unbiased” direction to the best possible healthcare put Glen into a conflict of interest? This is one catch-up chat you’re not going to want to miss!

#Healthin2Point00, Episode 191 | Doctor on Demand & Grand Rounds merge, plus more staggering deals

Today on Health in 2 Point 00, it’s St. Patrick’s Day and to top off your green beer we’ve got plenty of green money. First up on Episode 191, the news we’ve been waiting for: Doctor on Demand and Grand Rounds merge. No SPAC here, but this is a real harbinger for the future. Strive Health raises $140 million – this is Google money, looking to reinvent chronic kidney disease care. Social determinants of health startup Unite Us raises $150 million, integrating social services into medical records to address the social determinants. Finally Clarify Health raises $115 million working with population health data for drug companies, hospitals, and health plans. —Matthew Holt

Ofer Leidner, Happify Health

by MATTHEW HOLT

Happify Health is a online mental health company that is focused almost exclusively on scaling care by offering self-service tech solutions across the patient journey. After R&D starting in 2012, they’ve been scaling since 2017 and now are working with large employers and big health plans. What they don’t do is have their own therapists or psychiatrists. This is an interesting approach and probably much more scalable than many of their competitors. Today they raised $73m more to build out their solutions. I talked to Happify Health’s President, Ofer Leidner about how far they can go with automated self-service. He thinks it’s a long way.

Roblox and Healthcare’s Metaverse

By KIM BELLARD

As neither a gamer nor the parent of a gamer, I’ve been proud that I’ve stayed even mildly in touch with the cultural phenomenon that gaming is.  I’ve written about, for example, the Metaverse, Fortnight, and e-sports.  Still, I somehow managed to be completely oblivious to the existence of Roblox, until they went public this week and was valued at $45b, larger than Electronic Arts (which I had heard of). 

Once again, I think there are lessons for healthcare.

P.J. McNealy, CEO of Digital World Research, described Roblox to NPR as: “Minecraft meets Nintendo, which meets Lego and mobile phones enable a whole bunch of it.”  Whatever the metaphor, Roblox is booming.  It was valued at $4b a year ago, but the pandemic was very, very good for it. 

Half of America children use Roblox.  Two thirds of its users are 16 and younger, and most of them were spending lots of time at home last year.  It is now estimated to have 37 million unique daily users, spending some 30 billion hours on the site last year.  It is available in 180 countries, in 11 languages.

What makes Roblox particularly unique is that it is not a game developer; it is a platform where users develop the “experiences”.  Roblox describes its mission thusly:

Roblox’s mission is to bring the world together through play.  We enable anyone to imagine, create, and have fun with friends as they explore millions of immersive 3D experiences, all built by a global community of developers.

It claims 8 million developers have created 20 million experiences — and that it paid over $300 million to them.  The games are free but users can buy and spend an in-game virtual currency (Robux), which can be exchanged for actual money (Roblox shares 30% of the revenue with developers).  At least one developer made over $1 million in a single year; over 1200 made at least $10,000, with over 300 making over $100,000. 

Mr.  McNealy believes the IPO will allow Roblox significant expansion:

This money will either give them an opportunity to build more content for the for the platform or to go to adjacent platforms like music or partnering with Spotify or movie service.  That’s where this is going to go.

CEO and co-founder David Baszucki isn’t content with the younger market, wondering: “So how do we make it possible for Roblox to connect with everyone in the world?”  Alex Hicks, cofounder of Roblox studio Red Manta, sees such potential, telling Polygon: “Lots of kids already know what Roblox is, but they’re just scratching the surface with the older audience.” 

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The Art of Asking: What Else is Going on?

By HANS DUVEFELT

Walter Brown’s blood sugars were out of control. Ellen Meek had put on 15 lbs. Diane Meserve’s blood pressure was suddenly 30 points higher than ever before.

In Walter’s case, he turned out to have an acute thyroiditis that caused many other symptoms that came to light during our standard Review of Systems.

Ellen, it turned out, was pretty sure her husband was having an affair with one of his coworkers. And, since this wasn’t the first time, she was secretly working on a plan to move out and file for divorce. She admitted she’d always had a tendency to stress eat.

Diane’s daughter had just announced that she was pregnant by a man she wasn’t sure wanted to be around in the long run.

How do we know whether a patient’s subjective symptoms, laboratory values or even their vital signs are caused by their known medical conditions, a new disease or their state of mind?

We are often tempted to proceed down familiar tracks and tackle seemingly straightforward problems with medications: More insulin would take care of Walter’s blood sugar. Ellen could use a couple of months of phentermine. Diane needed a higher dose of lisinopril or perhaps some hydrochlorothiazide.

As Sherlock Holmes said, “there is nothing more deceptive than an obvious fact”.

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#Healthin2Point00, Episode 190 | Forward Health, Cedar, & Babylon

Today on Health in 2 Point 00, primary care appears to have jumped the shark because there is a deal in this episode in which the investors on the round are probably Jess’s favorite group of investors ever. Forward Health raises $225 million in a Series D – there’s Softbank money in this round as well as The Weeknd – but why didn’t they just go public? Patient billing company Cedar raises $200 million, bringing their valuation up to $3.2 billion, although I’m not too impressed by the concept. Finally, Babylon is making inroads into the U.S. from the U.K., buying a California-based provider group. —Matthew Holt

Inside Owlet’s SPAC IPO: From Smart Sock Baby Monitor to Data-Driven Pediatric Healthcare Co

By JESSICA DaMASSA, WTF HEALTH

Oh Baby! Connected digital nursery startup, Owlet Baby Care, just announced their SPAC IPO and intention to take their infant smart sock from baby monitor to FDA-approved medical device. I talk with Owlet’s co-founder & CEO, Kurt Workman, to find out why the baby health tech company (which has raised $48M in venture funding) has decided to take the business public in order to pursue its plans for growth as a pediatric healthcare company caring for baby “from conception to kindergarten.” Kurt gets into the details behind the work Owlet’s team is doing now to get their device FDA-approved in two different ways, and how they’re using Livongo Health’s remote monitoring/data analytics/telehealth model as a precedent for pursuing health insurance reimbursement. There may be lots of market skepticism out there about wearables – particularly socks, and especially with infants – but this deep-dive into Owlet’s vision for data-driven parenting provides a pretty compelling vision for both better and more cost-effective baby care, and the bonus of a better night’s sleep for new parents. Owlet’s calling it an $81 BILLION DOLLAR addressable market, and Kurt believes that it stands alone in terms how its bringing together full-stack connected technology and a consumerized healthcare experience to bridge the gap from hospital to home.

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