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A Hamiltonian View of Post-Pandemic America

By MIKE MAGEE

“In countries where there is great private wealth much may be effected by the voluntary contributions of patriotic individuals, but in a community situated like that of the United States, the public purse must supply the deficiency of private resource. In what can it be so useful as in prompting and improving the efforts of industry?”

Those were the words of Alexander Hamilton published on December 5, 1791 in his “Report on the Subject of Manufactures.” He was making the case for an activist federal government with the capacity to support a fledgling nation and its leaders long enough to allow economic independence from foreign competitors.

Today’s “foreign force” of course is not any one nation but rather a microbe, gearing up for a fourth attack on our shores with Delta and Lambda variants. This invader has already wreaked havoc with our economy, knocking off nearly 2% of our GDP, as the nation and the majority of its workers experienced a period of voluntary lockdown.

Our leaders followed Hamilton’s advice and threw the full economic weight of our federal government into a dramatic and direct response. Seeing the threat as akin to a national disaster, money was placed expansively and directly into the waiting hands of our citizens, debtors were temporarily forgiven, foreclosures and evictions were halted, and all but the most essential workers sheltered in place.

Millions of citizens were asked to work remotely or differently (including school children and their teachers) or to not work at all – made possible by the government temporarily serving as their paymaster and keeping them afloat.

As we awake from this economic coma, many of our citizens are reflecting on their previously out-of-balance lives, their hyper-competitiveness, their under-valued or dead-end jobs, and acknowledging their remarkable capacity to survive, and even thrive, in a very different social arrangement.

If our nation is experiencing a trauma-induced existential awakening, it is certainly understandable. America has lost over 600,000 of our own in the past 18 months, more people per capita than almost all comparator nations in Europe and Asia. This has included not just the frail elderly, but also those under 65. In the disastrous wake of this tragedy, 40% of our population reports new pandemic-related anxiety and depression.

A quarter of our citizens avoided needed medical care during this lockdown. For example, screening PAP smears dropped by 80%. And so, Americans’ chronic burden of disease, already twice that of most nations in the world, has expanded once again. There will be an additional price to be paid for that.

The Kaiser Family Foundation’s most recent Health System Dashboard lists COVID-19 as our third leading cause of death, inching out deaths from prescription opioid overdoses. Year-to-date spending on provider health services through 2020 dropped 2%, but pharmaceutical profits, driven by exorbitant pricing, actually increased, bringing health sector declines overall down by -.5% compared to overall GDP declines of -1.8%. The net effect? The percentage of our GDP devoted to health care in the U.S. actually grew during the pandemic – a startling fact since our citizens already pay roughly twice as much per capita as most comparator nations around the world for health care.

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#Healthin2Point00, Episode 221 | Funding for Novacardia, Wellthy, Osso VR, and Form Health

Today on Health in 2 Point 00, the funding reports are out: Rock Health is saying $14.7 billion for the first half of the year, and Startup Health is saying $20.1 billion. Those numbers are pretty much what the numbers were for ALL of 2020. Now onto some deals: on Episode 221, Jess asks me about Novacardia raising $57 million for its cardiology practice management business. Wellthy raises $25 million, bringing its total up to $50 million – this is a caregiving navigation concierge firm aimed at employers. Osso VR raises $27 million in a Series B, less than a year after closing their A, working on virtual reality for practicing surgery. Finally, Form Health raises $12 million in a Series A for its obesity telehealth platform. —Matthew Holt

Does Newly IPO’d Privia Health’s Climbing Stock Price Prove Value-Based Care Can Scale?

By JESSICA DaMASSA, WTF HEALTH

Privia Health ($PRVA) went public a few weeks ago and the stock not only popped when it hit the market, but has continued to rise. When you look at the numbers – and hear about the business model from CEO Shawn Morris – it’s easy to get excited and see why. Privia calls itself a “physician enablement” business, which is the two-word marketing way of saying that they bring together different docs in a region and give them the systems to become part of a value-based care network while also maintaining their private practices. They’re more or less building accountable care organizations (ACOs) in a hub-and-spoke fashion, uniting docs around Privia’s common tech systems, workflow processes, value-based care strategies, and contracting power with commercial and government payers. The model is appealing to docs who want to make the switch to value-based care, but still want the autonomy of their own practices. The value prop has already attracted more than 2,700 providers in 650 different locations netting the biz $817 million in revenue in 2020 – and Shawn says they’ll only expand from here. What’s the growth plan? Value-based care models are often criticized as “un-scalable” – what does Shawn say to combat that? A great, detailed chat that pitches a hopeful end to fee-for-service healthcare and a promising future for a newly public healthcare co.

CONFERENCE UPDATE–Policies|Techies|VCs: What’s Next For Health Care?

By MATTHEW HOLT & JESS DAMASSA

Policies|Techies|VCs: What’s Next For Health Care? is the conference bringing together the CEOs of the next generation of virtual & real-life care delivery, and all the permutations thereof. Today we add to last week's fantastic list of speakers with another 14 great speakers, including one CEO of  a company that has just SPACed onto the public market (Sharecare), and another that is about to (Babylon Health)! You can register here or learn how to sponsor. This week's new additions are:

Trulli

Ali Parsa
Babylon Health

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Julia Hu
Lark

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Niko Skievaski
Redox

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Rushika Fernandopulle
Iora Health

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Andy Coravos
HumanFirst

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Iyah Romm
Cityblock

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Pauline Lapin
CMMI

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Michelle Davey
Wheel

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Blake McKinney
CirrusMD

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Jeff Ruby
Newtopia

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Sami Iniken
Virta

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Deena Shakir
Lux Capital

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Jeff Arnold
Sharecare

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Stephanie Tilenius
Vida

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Cancer Centers Rebounding From COVID-19 Can Grow By Making the Most of New Technologies for Clinical Trials

For community cancer centers that rely on patient reimbursement to stay afloat, a smart data-driven approach to clinical trials provides a foundation for future growth.

Brenda Noggy
Dr. Tandy Tipps

By TANDY TIPPS and BRENDA NOGGY

Covid-19’s tragic, devastating impact on cancer treatment is now well documented. Cancer screenings dropped by almost 90 percent at the peak of the pandemic. Billing for some leading cancer medications dropped 30 percent last summer. Studies found a 60 percent decrease in new clinical trials for cancer drugs and biological therapies.

Cancer centers, like every part of the US health system, have a lot of ground to make up. Those community cancer centers without grants and other institutional advancement funds, experience financial and human resources as major constraints to charting a path to growth. For them, successful programs which generate revenues for expansion or break even help them maintain fiscal health. Often, unfortunately, too often their research programs lose money.

Clinical trials have not been a viable revenue source because of the difficulty in accurately predicting patient enrollment and the challenges of managing trial portfolios, a task that requires streamlined feasibility processes that include querying baseline populations for new trials and potentially eligible patients.

The hard work of patient screening and trial matching requires clinical coordinators, physician investigators and research support staff to spend between three to eight manually scouring databases of electronic medical records and unstructured files to find patients eligible for trials based on increasingly complex inclusion and exclusion criteria. This costly process does not take into consideration the pre-screening efforts in patient matching that may not be reimbursable.

Resources are also needed to implement feasibility processes to accurately predict how many patients might enroll in a trial if they are eligible. Most community-based sites do not have an accurate ability to query their current patient populations by disease cohort or mutation in real time. They often rely on physicians’ memories to estimate patient numbers for trial feasibility questionnaires, which must returned to sponsors quickly, usually before cancer centers have definitive recruitment numbers.

As a result, before COVID, an average of only 5 percent of patients had a chance of participating in trials, 50 percent of clinical trials failed to meet enrollment goals and less than 14 percent were completed on time. Cancer centers still incur the administrative and clinical resources required to maintain the protocols in the first place, however.

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THCB Gang Episode 61 – Thurs July 8

On Thursday’s #THCBGang Matthew Holt (@boltyboy) was joined by regulars, employer health expert Jennifer Benz (@jenbenz); patient safety expert and all around wit Michael Millenson (@MLMillenson); THCB regular writer Kim Bellard (@kimbbellard);  privacy expert and now entrepreneur Deven McGraw  (@HealthPrivacy); and–we were thrilled to have back–fierce patient activist Casey Quinlan (@MightyCasey). Lots of discussion about Casey’s latest patient experience as she continues to undergo the #METSparty.

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

The Art and Soul of Medicine Exist in the Ordinary

By HANS DUVEFELT

The Art of Medicine is Doing the Ordinary Well

Primary care doctors don’t usually operate any sophisticated medical instruments or perform any advanced procedures. But there is still art in what we do. We take care of ordinary ailments in ordinary people and that can be done well or not so well. There is no obvious glamor in it, but when our prescriptions, basic procedures or simple advice help people feel better, we live up to our own and our patients’ hopes and expectations – and some of the time, we even exceed them.

Art is art, regardless of the medium or subject. Weren’t the old Dutch masters’ most appreciated paintings depictions of ordinary people in ordinary circumstances? Not every artist gets to paint the Sistine Chapel.

So many things in our culture are at the two extremes of poorly done and exquisite: fast fashion or haute couture, drive-up burgers or five star restaurants. Fewer things are made with care by craftspeople for individual users. Medicine needs to be more like that in order to bring real healing in many conditions.

In our everyday encounters with our patients, we are often distracted by things other than what they expect or hope to get from us. We have agendas imposed on us for preventive care and public health purposes. It is sometimes hard to do your best if you can’t concentrate on the issue at hand. Art requires focus. It is not a casual endeavor. It requires attention to detail, just as much as a vision of the big idea. It is – or should be – for each of us, in order to do our best, to find the balance between those two aspects of our work.

The Soul of Medicine is Connecting as Humans

We are not technicians. We treat the whole person, because most things in primary care are diseases that affect more than just one organ. We now also, again (historically), accept that diseases of the body may have their root causes in what we call the soul. In order to know and treat another person, we must show our own. Only if we do that will we learn enough to be of any real help to the patient who hopes to trust us enough to take our advice. We must create connection.

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Make Mine Bioresorbable

By KIM BELLARD

I learned a new word this week: bioresorbable.  It means pretty much what you might infer — materials that can be broken down and absorbed into the body, i.e., biodegradable.  It is not, as it turns out, a new concept for health care – physicians have been using bioresorbable stitches and even stents for several years.  But there are some new developments that further illustrate the potential of bioresorbable materials. 

It’s enough to make Green New Deal supporters smile.

Bioresorbable stents and stitches are all well and good – who wants to be stuck with them or, worse yet, to need them removed? – but they are essentially passive tools.  Not so with pacemakers, which have to monitor and respond.  Medicine has made great progress in making pacemakers ever smaller and longer lasting, but now we have a bioresorabable pacemaker. 

Researchers from Northwestern University and The George Washington University just published their success with “fully implantable and bioresorbable cardiac pacemakers without leads or batteries.”  What their title might lack in pithy is more than offset by the scope of what they’ve done.  Fully implantable!  No leads!  No batteries!  And bioresorbable! 

Most pacemakers are, of course, designed to be permanent, but there are situations where they are implanted on a temporary basis, such as after a heart attack or drug overdose.  Dr. Rishi Arora, co-leader of the study, noted: “The current standard of care involves inserting a wire, which stays in place for three to seven days. These have potential to become infected or dislodged.” 

Dr. Arora went on to explain:

Instead of using wires that can get infected and dislodged, we can implant this leadless biocompatible pacemaker. The circuitry is implanted directly on the surface of the heart, and we can activate it remotely. Over a period of weeks, this new type of pacemaker ‘dissolves’ or degrades on its own, thereby avoiding the need for physical removal of the pacemaker electrodes. This is potentially a major victory for post-operative patients.

The device is only 15 millimeters long, 250 microns thick and weighs less than a gram, yet still manages to deliver electric pulses to the heart as needed.  It is powered and controlled using near field communications (NFC); “You know when you try to charge a phone wirelessly? It’s exactly the same principle,” GW’s Igor Efimov, a co-leader of the study, told StatNews

It dissolves over a period of days or weeks, based on the specific composition and thickness of the materials.

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The Science of Clinical Intuition

By HANS DUVEFELT

In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and I got down to some serious reading. These two remarkable thinkers have described very eloquently how clinical intuition actually works and describe it as an advanced, instantaneous form of pattern recognition.

Clinical Intuition (should we start calling this CI, as opposed to the other, electronic form of pattern recognition, AI – Artificial Intelligence?) begins with clinical patient experience but is cultivated through reflection, writing and dialogue with other physicians. And as Petersson and I have both written, there isn’t enough of the latter in medicine today. Both of us do as much reflecting and writing as we can, but we both know that more collegial interchange can make all of us better clinicians. Greenhalgh writes:

The educational research literature suggests that we can improve our intuitive powers through systematic critical reflection about intuitive judgements–for example, through creative writing and dialogue with professional colleagues. It is time to revive and celebrate clinical storytelling as a method for professional education and development. The stage is surely set for a new, improved–and, indeed, evidence-based–‘Balint’group.
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC1314297/

Bortolotti, the philosopher, makes the case that experts are more intuitive than novices, a skill that only comes with experience, and have developed advanced pattern recognition abilities that allow them to make decisions faster than possible when only using analysis and reasoning. Her article is quote-heavy. She writes:

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Matthew’s health care tidbits

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this week’s health care tidbits, a little bit of light was shone on two of the dirty tricks health insurers play. First San Diego is suing Molina, Centene (owner of Healthnet) & Kaiser for misleading patients about which providers are in their networks. Apparently Healthnet & Kaiser’s directories were 35% inaccurate and Molina 80%! Now this may be incompetence, but it is not only false advertising, it’s also a way of weeding out high cost patients who may leave when they can’t find a specialist that will take them–and of course avoiding a high cost patient is a nice earner for health plans.

The next trick is double billing. In this lawsuit unearthed by Bob Herman of Axios, Aetna which was being paid to manage an employer’s health network subbed out PT care to an Optum network. Optum then also charged an admin fee. Meaning the provider got less and the patient had to pay more. So while Aetna and United Healthgroup may appear to be fierce competitors, they’re happy to cooperate when it comes to ripping off their clients.

More bad behavior by health plans and I didn’t even mention them cheating on Medicare Advantage RAFs! But the CEO of Chenmed did.

If we are going to let health insurers profit from handling employer and taxpayer business, we should see those arrangements in the clear light of day. Time for some heavy handed Federal regulation, methinks.

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