Ready for Robots?

By KIM BELLARD

When I was young, robots were Robby the Robot (Forbidden Planet, etc.), the unnamed robot in Lost in Space, or The Jetsons’ Rosey the Robot. Gen X and Millennials might think instead of the more malevolent Terminators (which, of course, are actually cyborgs). But Gen Z is likely to think of the running, jumping, back-flipping Atlas from Boston Dynamics, whose videos have entertained millions.

Alas, last week Boston Dynamics announced it was discontinuing Atlas. “For almost a decade, Atlas has sparked our imagination, inspired the next generations of roboticists and leapt over technical barriers in the field,” the company said. “Now it’s time for our hydraulic Atlas robot to kick back and relax.”

The key part of that announcement was describing Atlas as “hydraulic,” because the very next day Boston Dynamics announced a new, all-electric Atlas: “Our new electric Atlas platform is here. Supported by decades of visionary robotics innovation and years of practical experience, Boston Dynamics is tackling the next commercial frontier.” Moreover, the company brags: “The electric version of Atlas will be stronger, with a broader range of motion than any of our previous generations.”

The introductory video is astounding:

Boston Dynamics says: “Atlas may resemble a human form factor, but we are equipping the robot to move in the most efficient way possible to complete a task, rather than being constrained by a human range of motion. Atlas will move in ways that exceed human capabilities.”

They’re right about that.

CEO Robert Playter told Evan Ackerman of IEEE Spectrum: “We’re going to launch it as a product, targeting industrial applications, logistics, and places that are much more diverse than where you see Stretch—heavy objects with complex geometry, probably in manufacturing type environments.”

He went on to elaborate:

This is our third product [following Spot and Stretch], and one of the things we’ve learned is that it takes way more than some interesting technology to make a product work. You have to have a real use case, and you have to have real productivity around that use case that a customer cares about. Everybody will buy one robot—we learned that with Spot. But they won’t start by buying fleets, and you don’t have a business until you can sell multiple robots to the same customer. And you don’t get there without all this other stuff—the reliability, the service, the integration.

The company will work with Hyundai (which, ICYMI, owns Boston Dynamics). Mr. Playter says Hyundai “is really excited about this venture; they want to transform their manufacturing and they see Atlas as a big part of that, and so we’re going to get on that soon.”

The company also announced Orbit, software “which provides a centralized platform to manage your entire robot fleet, site maps, and digital transformation data.” It declared: “With a robust team of ML experts shaping our products, we are prepared to bring impactful AI to market immediately—we’ve already started with Spot, and it will get even better and faster with Atlas.”

Speaking of AI, perhaps lost in the Atlas buzz, last week Mantee Robotics came out of two years of stealth mode to announce MenteeBot, which the company described as “an end-to-end humanoid robot with sufficient dexterity for a wide spectrum of activities in both households and industrial warehouses.”  By “end-to-end” they mean AI-driven.  

The company expects a household version and a warehouse version, with a prototype expected in 1Q 2025.

And, of course, there are numerous other companies racing to get humanoid (and other) robots into our lives, including Agility Robotics, Figure, NVIDIA, and, in its spare time, Tesla. One way or another, get ready for robots in our lives and workplaces – if they’re not already there.

New research confirms that, even if robots don’t take your job, they make workers less happy.  “Our key finding is that robots harm work meaningfulness and autonomy,” the authors say.  The key to mitigating that is to give workers control over the robots, which, of course, runs contrary to having them be AI-driven. Expect some unhappy workers.  

An interesting perspective comes from Jennifer Pattison Tuohy, writing in The Verge: Maybe I don’t want a Rosey the Robot after all.

“The question,” she says, “is should we be working toward an all-capable, bipedal, human-like bot to take everyday chores off our hands? The more I think about it — and the more robots I have roaming around my home — the more I think the answer is no. We don’t need a robot that understands what we say and can replicate our movements; we need robots that do one job (or maybe two related jobs) and do them well.”

As she points out, “when my self-emptying dishwasher breaks, I can responsibly recycle it and get a new one. When my humanoid robot housekeeper reaches the end of its firmware updates, I’ll have to put it out to pasture.” That, she worries, “brings with it a whole host of complicated challenges around the nature of consciousness and the boundaries of humanity.” 

That sorts of put the “retirement” of the original Atlas in a different perspective, doesn’t it?

If we’re going to have all these robots living with us, we better pay attention to how we socialize them. A new paper argues that it is people who make robots social, not programming.

“If we want to understand what makes a robot social, we have to look at the broader scope of the communities around robots and people’s interactions with each other,” said Malte Jung, co-author and Cornell associate professor. “It’s not just about programming a better character for the robot, making it respond better to human social features, making it look cuter or behaving more naturally.”

Take that in: we’re to the point we need to worry about socializing robots.

AI is infiltrating our lives faster than we realize and in ways we don’t realize the implications of yet, and that’s going to happen with robots too.  Whether we’re ready or not.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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Jeff Gartland, Relatient

Relatient focuses on intelligent scheduling, specifically for the larger specialty groups. They touch over 50m patients and 45,000 providers a year, and are now a significant player in the key part of patient experience–converting a patient looking into an actual appointment with the provider. I spoke with CEO Jeff Gartland at HIMSS in March 2024.–Matthew Holt

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Aasim Saeed, CEO of Amenities

Aasim Saeed is the CEO of Amenities. He’s a doc, ex-McKinsey Consultant and spent a lot of time building a version of his tool for Baylor Scott & White. We had a wide ranging conversation about how health systems treat patients (not well), whether health systems know the value of their customers (no!), and how to bump up “in network” utilization. Amenities is a front door tool that essentially replaces those sh*tty MyChart portals, and eventually will lead to creating a loyalty membership experience. He gave me a tour of the new-ish tool that is live at MemorialCare in southern California, and coming soon to a system near you.–Matthew Holt

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Harnessing Digital Innovation to Unlock Cancer Discoveries

By DOUG MIRSKY & BRIAN GONZALEZ

What if digital innovations could be the key to reducing the burden of cancer? CancerX was founded in 2023 as part of the Cancer Moonshot to achieve this goal. By uniting leading minds across industries such as technology, healthcare, science, and government, we are breaking down silos and leveraging digital innovation in the fight against cancer. With ambitious goals to cut the death rate from cancer by at least 50% and to improve the experience of people who are affected by cancer, digital innovation is critical.

As a public-private partnership co-hosted by Moffitt Cancer Center and the Digital Medicine Society, CancerX has created a unique ecosystem and community of public and private innovators. We are focused on fostering innovation and collaboration to accelerate the pace of digital tools to help patients across their entire cancer journey. We unite experts across industries and the government, leveraging the success of the Department for Health and Human Services’ InnovationX model; a public-private partnership approach that has driven breakthroughs in kidney care, Lyme disease and COVID-19. In collaboration with the Office of the National Coordinator for Health Information Technology (ONC) and the Office of the Assistant Secretary for Health (OASH), CancerX is in sync with the US government in our common Cancer Moonshot goals to boost government-wide engagement with industry muscle. This type of multidisciplinary partnership is necessary to change the landscape of cancer treatment and care.

At the one year anniversary of CancerX, we look back on a very fast pace in building up our three pillars of work, demonstrating the ways that digital innovation is contributing to fighting cancer:

1. Pre-Competitive Evidence Generation – A rolling series of multi-stakeholder initiatives to develop evidence, best practices, toolkits, and value models to drive the success of the mission.
2. Demonstration Projects – These implementation projects pilot novel, mission-aligned approaches to demonstrate their value and sustainability for scale to drive broad adoption.

3. Startup Accelerator – This program provides mentorship, education, and exposure to funding and clinical partnership opportunities to a start-up cohort aligned with the mission.

And we are already deeply underway with efforts across each of the three pillars.

With our inaugural effort, a pre-competitive evidence generation project, we initially set out to identify and demonstrate how health systems might derive the most value from digital solutions as part of their oncology strategies to support patients facing financial distress or access issues. In November, 2023 we released: 

• A Core Competencies guide for health system use in designing a digital strategy to improve patient access and reduce patient cost
• A Financial Navigation guide for support service divisions and nurse navigators to use as a guide for intervening along the patient journey with the use of digital health tools to reduce out-of-pocket cost
• A Solutions Catalog showcasing tools available off the shelf to support the implementation of a digital oncology strategy

The final two workstreams currently underway are focused more narrowly on defining and maximizing the benefit of digitally-enabled patient navigation programs for health systems, as well as the patients and care partners they serve. Resources from these workstreams will be released in the summer of 2024.

In our initial demonstration project, the CancerX community sprinted into action to support the collective efforts of the Center for Medicare and Medicaid Innovation (CMMI), the National Cancer Institute (NCI), the US Food and Drug Administration (FDA) and the Office of the National Coordinator for Health Information Technology (ONC) to advance cancer-related data standards.

Specifically, we provided additional support and insights into the ongoing collaboration between the CMMI’s Enhancing Oncology Model (EOM) and the development of ONC’s United States Core Data for Interoperability (USCDI+) – Oncology extension, which aims to support the establishment of domain-specific data element lists as extensions to the existing USCDI.

The CancerX Startup Accelerator is the first-ever innovation accelerator focused on the intersection of digital innovation and cancer. We have brought together champions, innovators, and expert users of oncology digital technology to help boost the development of these promising startups that

have strong potential to solve unmet needs in cancer care.

Out of more than 100 startups, 16 were competitively selected for this first CancerX Startup Accelerator cohort. These startups are focused on one of five aspects of oncology: clinical research, screening and diagnosis, treatment and management, clinical operations, and patient/survivor/caregiver experience. They include:

• The Blue Box
• C the Signs
• Cancer Insights
• Curiva
• EnteroTrack
• GesundAI
• GrayOS
• Lind AI
• Mika Health
• Navya
• Oatmeal Health
• Orbit Genomics
• Realyze Intelligence
• Reimagine Care
• SurvivorPlan
• XanthosHealth

By the end of the cohort, these startups will have received in-person and online mentorship from experienced innovators, insights from subject matter experts, connections with potential investors, and networking with other oncology digital technology startups, giving them a jumpstart on bringing their products and services into the lives of those who are fighting cancer.

Doug Mirsky, PhD is Vice President of the Digital Medicine Society. Brian D. Gonzalez MD is the Associate Center Director of the Moffitt Cancer Center.

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Will Artificial Intelligence (AI) Trigger Universal Health Care in America? What do expert Academics say?

By MIKE MAGEE

In his book, “The Age of Diminished Expectations” (MIT Press/1994), Nobel Prize winner, Paul Krugman, famously wrote, “Productivity isn’t everything, but in the long run it is almost everything.”

A year earlier, psychologist Karl E. Weich from the University of Michigan penned the term “sensemaking” based on his belief that the human mind was in fact the engine of productivity, and functioned like a biological computer which “receives input, processes the information, and delivers an output.”

But comparing the human brain to a computer was not exactly a complement back then. For example, 1n 1994, Krugman’s MIT colleague, economist Erik Brynjolfsson coined the term “Productivity Paradox” stating “An important question that has been debated for almost a decade is whether computers contribute to productivity growth.”

Now three decades later, both Krugman (via MIT to Princeton to CCNY) and Brynjolfsson (via Harvard to MIT to Stanford Institute for Human-Centered AI) remain in the center of the generative AI debate, as they serve together as research associates at the National Bureau of Economic Research (NBER) and attempt to “make sense” of our most recent scientific and technologic breakthroughs.

Not surprisingly, Medical AI (mAI), has been front and center. In November, 2023, Brynjolfsson teamed up with fellow West Coaster, Robert M. Wachter, on a JAMA Opinion piece titled “Will Generative Artificial Intelligence Deliver on Its Promise in Health Care?”

Dr. Wachter, the Chair of Medicine at UC San Francisco, coined his own ground-breaking term in 1996 – “hospitalist.” Considered the father of the field, he has long had an interest in the interface between computers and institutions of health care. 

In his 2014 New York Times bestseller, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” he wrote, “We need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12. Instead, they transform the work, the people who do it, and their relationships with each other and with patients.”

What Brynjolfsson and Wachter share in common is a sense of humility and realism when it comes to the history of systemic underperformance at the intersection of technology and health care.

They begin their 2023 JAMA commentary this way, “History has shown that general purpose technologies often fail to deliver their promised benefits for many years (‘the productivity paradox of information technology’). Health care has several attributes that make the successful deployment of new technologies even more difficult than in other industries; these have challenged prior efforts to implement AI and electronic health records.”

And yet, they are optimistic this time around.

Why? Primarily because of the speed and self-corrective capabilities of generative AI. As they conclude, “genAI is capable of delivering meaningful improvements in health care more rapidly than was the case with previous technologies.”

Still the “productivity paradox” is a steep hill to climb. Historically it is a byproduct of flaws in early version new technology, and status quo resistance embedded in “processes, structure, and culture” of corporate hierarchy. When it comes to preserving both power and profit, change is a threat.

As Brynjolfsson and Wachter put it diplomatically, “Humans, unfortunately, are generally unable to appreciate or implement the profound changes in organizational structure, leadership, workforce, and workflow needed to take full advantage of new technologies…overcoming the productivity paradox requires complementary innovations in the way work is performed, sometimes referred to as ‘reimagining the work.’”

How far and how fast could mAI push health care transformation in America? Three factors that favor rapid transformation this time around are improved readiness, ease of use, and opportunity for out-performance.

Readiness comes in the form of knowledge gained from the mistakes and corrective steps associated with EHR over the past two decades. A scaffolding infrastructure already exists, along with a level of adoption by physicians and nurses and patients, and the institutions where they congregate.

Ease of use is primarily a function of mAI being localized to software rather than requiring expensive, regulatory laden hardware devices. The new tools are “remarkably easy to use,” “require relatively little expertise,” and are “dispassionate and self-correcting” in near real-time when they err.

Opportunity to out-perform in a system that is remarkably inefficient, inequitable, often inaccessible and ineffective, has been obvious for some time. Minorities, women, infants, rural populations, the uninsured and under-insured, and the poor and disabled are all glaringly under-served.

Unlike the power elite of America’s Medical Industrial Complex, mAI is open-minded and not inherently resistant to change.

Multimodal, large language, self learning mAI is limited by only one thing – data. And we are literally the source of that data. Access to us – each of us and all of us – is what is missing.

What would you, as one of the 333 million U.S. citizens in the U.S., expect to offer in return for universal health insurance and reliable access to high quality basic health care services?

Would you be willing to provide full and complete de-identified access to all of your vital signs, lab results, diagnoses, external and internal images, treatment schedules, follow-up exams, clinical notes, and genomics?

Here’s what mAI might conclude in response to our collective data:

1. It is far less expensive to pay for universal coverage than pay for the emergent care of the uninsured.
2. Prior algorithms have been riddled with bias and inequity.
3. Unacceptable variance in outcomes, especially for women and infants, plague some geographic regions of the nation.
4. The manning table for non-clinical healthcare workers is unnecessarily large, and could easily be cut in half by simplifying and automating customer service interfaces and billing standards.
5. Direct to Consumer marketing of pharmaceuticals and medical devices is wasteful, confusing, and no longer necessary or beneficial.
6. Most health prevention and maintenance may now be personalized, community-based, and home-centered.
7. Abundant new discoveries, and their value to society, will largely be able to be validated as worthy of investment (or not) in real time.
8. Fraudulent and ineffective practices and therapies, and opaque profit sharing and kickbacks, are now able to be exposed and addressed.
9. Medical education will now be continuous and require increasingly curious and nimble leaders comfortable with machine learning techniques.
10. U.S. performance by multiple measures, against other developed nations, will be visible in real time to all.

The collective impact on the nation’s economy will be positive and measurable. As Paul Krugman wrote thirty years ago, “A country’s ability to improve its standard of living over time depends almost entirely on its ability to raise its output per worker.”

As it turns out, health data for health coverage makes “good sense” and would be a pretty good bargain for all Americans.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex (Grove/2020).

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And Now For Something Completely Different

By KIM BELLARD

The most interesting story I read in the past week doesn’t come from the more usual worlds of health and/or technology, but from sports. It’s not even really news, since it was announced last fall; it’s just that it wasn’t until last week that a U.S. publication (The New York Times) reported on it. In a nutshell, a Paris football (a.k.a. soccer) club is not charging its fans admission during the current season.

Since last week I wrote about medical debt in the U.S. healthcare system, you might guess where this is going. The club is Paris FC. Last November it announced:

For the first time in history, Paris FC is offering free tickets for all home matches at the Stade Charléty, starting from the 11 November until the end of the 2023-2024 season from its Bastia reception, in a bid to offer a new and innovative vision of football by welcoming as many people as possible.

The policy includes the men’s second division team and the woman’s first division team. The NYT article clarifies that fans supporting the visiting team might be charged a “nominal” fee, and that hospitality suites still pay market rates.

Pierre Ferracci, Chairman of Paris FC, said: “We are proud to support this ambitious and pioneering project, which goes beyond the simple framework of sport in terms of the values it conveys. We want to bring people together around our club and our teams, while committing ourselves with strength and conviction. In a context of difficult purchasing power, we are confident that a club can be an ideal tool for bringing together people of goodwill and engage with societal issues.”

Fabrice Herrault, Paris FC’s general manager told NYT: “It was a kind of marketing strategy. We have to be different to stand out in Greater Paris. It was a good opportunity to talk about Paris F.C.” The club estimates it might cost them $1 million.

It seems to be working. The NYT reports:

Months later, most metrics suggest the gambit has worked. Crowds are up by more than a third. Games held at times appealing for school-age children have been the best attended, indicating that the club is succeeding in attracting a younger demographic.

The idea is not entirely de novo; last spring Fortuna Düsseldorf, a German second division football club, announced it would offer free admission for at least three matches this season, with the intent that eventually all home matches. “We open up football for all. We will have free entry for league games in this stadium,” Alexander Jobst, the club’s chief executive, said at the time. “We call it ‘Fortuna for all’ which can and will lead us to a successful future.”

In a NYT interview last spring, Mr. Jobst added: “We think it is completely new. We were trying to think about how we could do the soccer business completely different from before.”

I’m always a sucker for efforts to think about a business completely different than before.

Fortuna has now had two of its three free matches, and Mr. Jobst told NYT last week: “Our average attendance has gone from 27,000 to 33,000. Our merchandise sales are up by 50 percent. Our sponsorship revenue is up 50 percent. We have reached a record number of club members.”

Sure sounds like a success.

Keep in mind that for most professional sports, ticket and concession revenues are gravy; the real money is from TV deals, as well as sponsorships. The NFL, for example, only gets 17% of its revenue from fans, the NBA 26%, and MLB 31%, while MLS and NHL need over 40% (not such good TV deals!). Fortuna, in case you’re interested, only gets 20% of its revenue from tickets, even though it is only in the second division.

Meanwhile, Paris FC only gets 4% of its budget from ticket sales. “We’re not taking a big risk, and we won’t lose out,” Mr. Feracci told Le Monde. “The balance will be positive, thanks to new sponsorship income and the arrival of new shareholders who have shown themselves to be keen on our vision.

Spectators matter, not just as a revenue source. We all remember American professional sports during the early days of the pandemic. The NBA finished its 2019-2020 season in a bubble, with players, staff, and media quarantined, playing in empty arenas. Most of the NFL and MLB games that year were also without fans. Players and television viewers hated the experience; it just didn’t seem real without actual fans in attendance.

“Since the pandemic, there has been a growing awareness of the role of spectators in the ‘production’ of sporting events,” Luc Arrondel, a professor at the Paris School of Economics, told NYT. “The presence of supporters in the stadium increases the desirability of the television product, and therefore, possibly, the value of television rights,” 

Professor Arrondel has even made the case in a paper (“Faut-il payer les supporters?”) that it might actually make sense for professional teams to pay the most ardent fans to attend in-person.

Yes, all that is thinking about the business completely differently.

=========

Meanwhile, there’s the U.S. healthcare system, which treats its “fans” – i.e., patients – as revenue from whom every dollar should be squeezed. E.g., ever pay a facility fee for a doctor’s visit, or pay the inflated U.S. prices for prescription drugs? It’s not surprising that we end up with all that medical debt. As I wrote last week: “why are so many charges so high, why aren’t people better protected against them, and why don’t more Americans have enough resources to pay their bills, especially unpredictable ones like from health care services?”

So here’s a thought” out-of-pocket spending is “only” 11% of national health expenditures. What if we just abolished it? Healthcare’s version of not making fans pay to attend football matches.

Now you might say – that’s crazy, how would the health care system make up that 10%? I’d say two things: first, we all know that there’s 10% of savings to be had in our bloated system; what better to use them for than this?  Second, and more importantly, we need to admit that the current business model in the U.S. healthcare system does not work.

It’s time to think of ways to do the business of healthcare “completely different than before.”

Not making patients pay out-of-pocket might not be the “right” way to do that, although we could do worse, but, in any event, we better think of something completely different before the system crashes.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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If data is the new oil, there’s going to be war over it

By MATTHEW HOLT

I am dipping into two rumbling controversies that probably only data nerds and chronic care management nerds care about, but as ever they reveal quite a bit about who has power and how the truth can get obfuscated in American health care. 

This piece is about the data nerds but hopefully will help non-nerds understand why this matters. (You’ll have to wait for the one about diabetes & chronic care).

Think about data as a precious resource that drives economies, and then you’ll understand why there’s conflict.

A little history. Back in 1996 a law was passed that was supposed to make it easy to move your health insurance from employer to employer. It was called HIPAA (the first 3 letters stand for Health Insurance Portability–you didn’t know that, did you!). And no it didn’t help make insurance portable.

The “Accountability” (the 1st A, the second one stands for “Act”) part was basically a bunch of admin simplification standards for electronic forms insurers had been asking for. A bunch of privacy legislation got jammed in there too. One part of the “privacy” idea was that you, the patient, were supposed to be able to get a copy of your health data when you asked. As Regina Holliday pointed out in her art and story (73 cents), decades later you couldn’t.

Meanwhile, over the last 30 years America’s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a chart of 91 health systems with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don’t need me to remind you that many of those systems are guilty with extreme prejudice of monopolistic price gouging, screwing over their clinicians, suing poor people, managing huge hedge funds, and paying dozens of executives like they’re playing for the soon to be ex-Oakland A’s. A few got LA Dodgers’ style money. More than 15 years since Regina picked up her paintbrush to complain about her husband Fred’s treatment and the lack of access to his records, suffice it to say that many big health systems don’t engender much in the way of trust. 

Meanwhile almost all of those systems, which already get 55-65% of their revenue from the taxpayer, received additional huge public subsidies to install electronic medical records which both pissed off their physicians and made several EMR vendors rich. One vendor, Epic Systems, became so wealthy that it has an office complex modeled after a theme park, including an 11,000 seat underground theater that looks like something from a 70’s sci-fi movie. Epic has also been criticized for monopolistic practices and related behavior, in particular limiting what its ex-employees could do and what its users could publicly complain about. Fortune’s Seth Joseph has been hammering away at them, to little avail as its software now manages 45%+ of all encounters with that number still increasing. (Northwell, Intermountain & UPMC are three huge health systems that recently tossed previous vendors to get on Epic).

Meanwhile some regulations did get passed about what was required from those who got those huge public subsidies and they have actually had some effect. The money from the 2009 HITECH act was spent mostly in the 2011-14 period and by the mid teens most hospitals and doctors had EMRs. There was a lot of talk about data exchange between providers but not much action. However, there were three major national networks set up, one mostly working with Epic and its clients called Carequality. Epic meanwhile had pretty successfully set up a client to client exchange called Care Everywhere (remember that).

Then, mostly driven by Joe Biden when he was VP, in 2016 Congress passed the 21st Century Cures Act which among many other things basically said that providers had to make data available in a modern format (i.e. via API). ONC, the bit of HHS that manages this stuff, eventually came up with some regulations and by the early 2020’s data access became real across a series of national networks. However, the access was restricted to data needed for “treatment” even though the law promised several other reasons to get health data.

As you might guess, a bunch of things then happened. First a series of VC-backed tech companies got created that basically extract data from hospital APIs in part via those national networks. These are commonly called “on-ramp” companies. Second, a bunch of companies started trying to use that data for a number of purposes, most ostensibly to deliver services to patients and play with their data outside those 91 big hospital systems.

Which brings us to the last couple of weeks. It became publicly known among the health data nerd crowd that one of the onramp companies, Particle Health, had been cut off from the Carequality Network and thus couldn’t provide its clients with data.

The supposed reason was that they were getting data without a “treatment” reason.

Now if you really want to understand all this in detail, go read Brendan Keeler’s excellent piece “Epic v Particle”. Basically Particle cried foul and unusually both Michael Marchant, a UC Davis Health employee & the Chair of the big health systems on the ”Care Everywhere Committee” (remember that from earlier?) and then Epic itself responded. Particle’s founder Troy Bannister in a linkedin post and an official release from Particle said that they had not received notice or any evidence of what they’d done wrong. Michael said they had. I started quoting the Dire Stairs line “two men say they’re Jesus, one of them must be wrong.” (FD. Troy was briefly an intern at Health 2.0 long, long ago).

Then Epic publicly released a letter to its clients explaining that, contrary to what Troy & Particle said, it had been discussing this with Particle for months and had had several meetings before and after it cut them off. So unless Particle’s legal counsel was parsing its words very very carefully, they knew Epic and its clients were unhappy, and it was unlikely Troy was Jesus. Michael might still be, of course.

In the letter Epic named 4 companies who were using Particle’s data in a way it didn’t like– Reveleer and MDPortals (who are one not two companies as they merged in 2023 before this issue started), Novellia and Integritort. 

So what do they do with the data. Reveleer says that “leveraging our AI-enabled platform with NLP and MDPortals’ sophisticated interoperability allows us to deliver providers a pre-encounter clinical summary of patients within their EHR workflow at the point of care.” Sounds like treatment to me. But Reveleer also does analysis for health plans. You can see why hospitals might not like them.

Novellia is a PHR company, presumably using “treatment” to enable consumers to access their data to manage their own care. This was EXACTLY what Joe Biden wanted the 21st  Century Cures Act to give patients the right to do and what Epic CEO Judy Faulkner told him he shouldn’t want (depending exactly who you believe about that conversation). But it’s probably not a particular “treatment” under HIPAA, because who believes patients can treat themselves or need to know about their own data anyway? (I’ll just lock you all in a room with Dave deBronkart, Susannah Fox and Regina Holliday if you want the real answer). This is apparently the line where ONC folded in its ruling to the vested interests that providers (and their EMR vendors) didn’t have to provide data to patient requests.

Finally, Integritort does sound like it’s looking for records so it (or its law firm customers) can sue someone for bad treatment (or as it turns out defend them for it). Is that “treatment” under the HIPAA definition?  Almost certainly not. On the other hand, do the providers cutting them off have a vested interest in making sure no outside expert can review what they’ve been up to? I think we all know the answer to that question. 

But anyway it looks like Particle switched off Integritort’s access to Carequality on March 22nd before Particle was entirely switched off by Carequality sometime around April 1.

What is not answered in the letter is why, if Carequality can identify who these records are going to, it needed to switch all Particle’s access off. Additionally, you would think that Particle’s path of least resistance would be to cut off the named clients Epic/Carequality was concerned about and try to sort through things while keeping its system running–which it seems it did with Integritort. Whatever happened, instead of this negotiation continuing behind the scenes, we all got to witness a major power play–with clearly Epic & its big customers winning for now.

I think most people who are interested in getting access to data for patients are all agreed on the need for new “paths” which were already defined in the regulations but not implemented, and also presumably for agreed standards (with associated liability) of “know your customer laws” for the onramps like Particle to make sure that the clients using them are doing the right things vis a vis confirming patient identity et al. 

Slight digression: I am confused about why identity proofing is such a big deal. In recent weeks I have had to prove my identity for the IRS, for a credit union, and for the TSA. Not to mention for lots of other websites. There are companies like IDme, Clear and many others that do exactly this. I don’t see anything so specific about health care that is different from credit cards, bank accounts, airport safety, etc. Why can those agencies/organizations access all that data online but for some reason it’s a bridge too far for health care?

However you can see where the fault lines are being drawn. There are a lot of organizations, many backed by rich VCs or huge quasi-tech corporations, that think they can do a much better job of caring for Americans than the current incumbents do. (Whether they can or not is another matter, but remember we are spending 18% of GDP when everyone else spends 10-12%). Those organizations, which include huge health plans, tech cos, retail clinics, startup virtual care clinics, and a whole lot more, need data. Not everything they or the intermediaries they do will fit the “treatment” definition the current holders of that data want to use. On the other hand, the current incumbents and their vendors are extremely uninterested in any changes to their business model.

Data may be the new oil but, like oil, data needs refining to power economies and power health care services. We spent much of the last century fighting about access to oil, and we’re going to spend a lot of this one fighting about data. Health care will be no exception.

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Tim O’Connell, CEO, emtelligent

Tim O’Connell discusses emtelligent’s capability to take unstructured clinical data and using NLP, match it to clinical ontologies and figure out what disease patients have, and enable payers and providers to do something about it–rather than payment coding which is what NLP has usually been used for. I spoke to him at HIMSS in March where he was launching emtelligent own new large language model (LLM). Anyone with a health data set is a potential client, but Tim thinks we can use all this data and his company’s technology to radically improve our understanding of clinical care, and improve it–Matthew Holt

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Health Care’s Debt Problem

By KIM BELLARD

Among the many things that infuriate me about the U.S. healthcare system, health systems sending their patients to collections – or even suing them – is pretty high on the list (especially when they are “non-profit” and./or faith-based organizations, which we should expect to behave better).

There’s no doubt medical debt in the U.S. is a huge problem. Studies have found that more than 100 million people have medical debt, many of whom don’t think they’ll ever be able to pay it off. Kaiser Family Foundation estimates Americans owe some $220b in medical debt, with 3 million people owing more than $10,000. It’s oft cited that medical debts are the leading cause of bankruptcy, although it’s quite not clear that is actually true.

So you’d think that helping pay off that debt would be a good thing. But it turns out, it’s not that simple.

A new study from the National Bureau of Economic Research (NBER) by Raymond Kluender, et. alia, found that, whoops, paying off people’s medical debt didn’t improve their credit score or financial distress, made them less likely to pay future medical bills, and didn’t improve their mental health.

“We were disappointed,” said Professor Kluender told Sarah Kliff in The New York Times. “We don’t want to sugarcoat it.”

The researchers worked with R.I.P. Medical Debt, a non-profit that buys up medical debt “at pennies on the dollar,” to identify people with such debt, and then compared people whom R.I.P. Medical Debt had helped versus those it had not. One set of people had hospital debts that were at the point of being sold to a collection agency, and another had debts that had already been sent to collection. And, perhaps to highlight how little we understand our healthcare system, they asked experts in medical debt what their expectations for the experiment were.

Much to everyone’s surprise, having debt paid off made no difference between control and debt-relief groups. I.e.,

• “We find no average effects of medical debt relief on the financial outcomes in credit bureau data in either of our experiments.
• We similarly estimate economically small and statistically insignificant effects on other measures of financial distress, credit access, and credit utilization.
• We find that debt relief causes a statistically significant and economically meaningful reduction in payment of existing medical bills.
• We estimate statistically insignificant average effects of medical debt relief on measures of mental and physical health, healthcare utilization, and financial wellness, with “opposite-signed” point estimates for the mental health outcomes relative to our prior.”

In short: 

Our findings contrast with evidence on the effects of non-medical debt relief and evidence on the benefits of upstream relief of medical bills through hospital financial assistance programs. Our results are similarly at odds with views of the experts we surveyed, pronouncements by policymakers funding medical debt relief, and self-reported assessments of recipients of medical debt relief. 

Amy Finkelstein, a health economist at the MIT and a co-director of J-PAL North America, a nonprofit group that provided some funding for the study, told Ms. Kliff: “The idea that maybe we could get rid of medical debt, and it wouldn’t cost that much money but it would make a big difference, was appealing. What we learned, unfortunately, is that it doesn’t look like it has much of an impact.”

If only it was that easy.

To be clear, there were three key statistically significant effects:

• “small improvements in credit access for the subset of persons whose medical debt would have otherwise been reported to the credit bureaus,
• modest reduction in payments of future medical bills, and
• worsened mental health outcomes, concentrated among those who had the largest amount of debt relieved and those who received phone calls to raise awareness and salience of the intervention.”

The authors admitted they had not expected the mental health results and had no good explanation, but their “preferred interpretation is that recipients of the cash payments viewed the transfers as insufficient to close the gap between their resources and needs, raising the salience of their financial distress and harming their mental health.”

As Neale Mahoney, an economist at Stanford and a co-author of the study, told Ms. Kliff: “Many of these people have lots of other financial issues. Removing one red flag just doesn’t make them suddenly turn into a good risk, from a lending perspective.”

The authors concluded:

Nonetheless, our results are sobering; they demonstrate no improvements in financial well-being or mental health from medical debt relief, reduced repayment of medical bills, and, if anything, a perverse worsening of mental health. Moreover, other than modest impacts on credit access for those whose medical debt is reported, we are unable to identify ways to target relief to subpopulations who stand to experience meaningful benefits.

On the other hand, Allison Sesso, R.I.P. Medical Debt’s executive director, told Ms. Kliff that study was at odds with what the group had regularly heard from those it had helped. “We’re hearing back from people who are thrilled,” she said.

As statisticians would say, anecdotes are not data.

————-

Removing medical debt seems like a can’t-lose idea. A number of states and local governments have passed programs to pay off medical debt (most working with R.I.P. Medical Debt) and a number of others are considering it.

Last fall the Consumer Financial Protection Bureau initiated rulemaking that would remove medical bills from credit reports. It has also, according to NPR, “penalized medical debt collectors, issued stern warnings to health care providers and lenders that target patients, and published reams of reports on how the health care system is undermining the financial security of Americans.”

Director Chopra admits: “Of course, there are broader things that we would probably want to fix about our health care system, but this is having a direct financial impact on so many Americans.”

If nothing else, the new study should remind us that our health system is best at putting band-aids on problems rather than solving them. The problems we should be addressing include: why are so many charges so high, why aren’t people better protected against them, and why don’t more Americans have enough resources to pay their bills, especially unpredictable ones like from health care services?

I’m glad R.I.P. Medical Debt is doing what it is doing, but let’s not kid ourselves that it is solving the problem.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

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David Lareau, CEO, Medicomp

Medicomp provides a medical database within an EMR and which delivers all the diagnoses and other information directly to the clinician. It represents the note to the physician as a SMART on FHIR app so that they can quickly find the information they need within their workflow. I had a quick catch up with CEO Dave Lareau, and asked him not only what Medicomp does but how all that generative AI has started to change this. He thinks that the output of LLMs and ambient AI will actually make a greater demand for their tools–from a company that’s coming up on its 50th birthday! (Well 46th….)–Matthew Holt

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