Health in 2 Point 00, Episode 103 | ACA Ruling, Sutter Health Settlement, & Bright Health

Today, I’m closing out the year of Health in 2 Point 00 from the ski slopes. In Episode 103, Jess asks me about the ACA ruling that the individual mandate is unconstitutional, whether Sutter Health got what they deserved after the $575 million settlement, health insurer Bright Health raising a huge $635 million round, and a rumor about a $250M Softbank investment coming next week. Wishing you all a very happy 2020! —Matthew Holt

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11 Healthcare Innovation Trends To Watch In 2020

By ANDY MYCHKOVSKY

As we near the end of the year, rather than reflect on fond memories of 2019 (for which I’m grateful for my family, friends, readers, and Twitter followers), I’ve already started thinking about 2020. If you ever wanted to get inside my brain for 5-10 minutes (scary proposition I know) related to healthcare startups and innovation, here are some areas or trends that I will be following in the new decade.

1. Medicare-For-All Will Be Everywhere

As we move closer to the Democratic Presidential caucus, some of the top-polling candidates (Sen. Elizabeth Warren, Sen. Bernie Sanders, Andrew Yang) are endorsing a Medicare-For-All (M4A) platform. If one of those candidates receive the nomination for the 2020 Presidential election, private v. public health insurance will be front and center. It will dominate all major news. I’m watching how the weight of the entire healthcare industry will politically respond to a national Medicare-4-All Presidential debate (both publicly and privately).

2. Updating Physician Anti-Trust Rules To Support Value-Based Care

In October, the U.S. Department of Health and Human Services (HHS) released their long-anticipated proposed rules to update the anti-kickback and physician referral regulations, to help spur greater provider participation in value-based care arrangements. Any changes once finalized would affect the Civil Monetary Penalties Law, the Federal Anti-Kickback Statute, and the Physician Self-Referral Law (“Stark Law”). After comments are received, I’m watching how the healthcare machine helps craft these new regulations that some would say, stifles innovation in provider care delivery.

3. One Medical’s Financials (from S-1)

This is dependent on One Medical, the technology-enabled primary care practice with 70+ locations in nine major U.S. cities, actually going public. However, CNBC reported the company has hired banks including JPMorgan and Morgan Stanley in preparation for an initial public offering (IPO). The company was formerly valued at $1.5 billion during a financing round in 2018 and could file its prospectus by as early as the first quarter of 2020. I’m watching to see how a primary care practice, traditionally low profit margin services business with moderate EBITDA multiples, is able to become financial viable with much smaller panel sizes, but a $199 membership fee, technology services, and higher patient engagement.

4. Softbank’s Vision Fund II

As I said repeatedly on this blog, I want more venture investment into healthcare startups that deliver measurable patient value. Therefore, if Masayoshi Son wants to put his $100+ billion behemoth investment fund (assuming he actually raises it) towards the $3.7 trillion American healthcare system, I’m all for it. Earlier this month, CNBC reported that Honor, the home healthcare startup, could receive up to $150 million in funding. I just hope that he also dabbles in rounds prior to Series C, because those are the companies I care less about helping (as they should already be on their way to becoming profitable). It’s the seed stage to series B that I believe needs further capital and VC competition to help push innovation. I’m watching to see if billions of dollars flow into the industry that most needs it.

5. The Year of Payer M&A

Besides UnitedHealthcare and Aetna/CVS, both too large to purchase, I’ve long wondered if large retailers would ever purchase a for-profit national payers (especially Molina or Centene/Wellcare). For example, Walmart has significant geographic overlap with the health insurance exchange and Medicaid managed care membership of either health plan. If you want to be in healthcare right now, doesn’t hurt to be closest to the premium dollar (unless Medicare-For-All happens…). CVS seems to have done well with the acquisition of Aetna and is pushing for a network of health hubs to deliver care. I’m watching to see if one of the major retailers who have dabbled in healthcare (Walmart, Kroger, Walgreens) actually becomes the actual health insurance company and drives membership into preferred facilities.

6. Startup Health Plan Enrollment for 2020

I’m rooting for any company trying to disrupt the traditional health insurance industry, because I value competition. Companies like Oscar, Bright Health, Devoted Health, Clover Health, and Alignment Health are all high-flyers in terms of venture funding. However, insurance is fundamentally a risk-pool game where the team with the largest membership should also have the lowest actuarial volatility. Sub-scale plans, especially those that require high marketing and broker administrative fees like in commercial or Medicare Advantage, do not survive without adequate membership. I’m watching to see if these startup plans can attract larger amounts of membership during the 2020 open enrollment process, and how that affects future investment in the space.

7. State Regulators, Doctors, Pharmacists, and Direct-To-Consumer Pharmacy Startups

Companies like Hims, Roman, Curology, Pill Club, Nurx, and Lemonaide have all capitalized on the rocket-ship trend in healthcare, the combination of e-commerce, subscription, and virtual visits. It has been reported that Hims reached $100 million in annual subscription revenue and could reach $250 million in reoccurring revenue by the end of 2020. For healthcare, that is unthinkable since it’s not just health insurance premium revenue. These companies are proving that patients will choose convenience and good marketing over having to go to a doctor in-person for treatment of a specific conditions with generic drug options. The concept of mail-order pharmacy is nothing new, however, this new wave has attracted criticism all across the provider community. I’m watching to see if any states begin to mandate in-person physician office visits before allowing prescription scripts to be ordered and how these well-funded startups will respond.

8. Whatever 23andme And GoodRx Are Up To

In my opinion, two of the most interesting startups to watch in healthcare. In general, I want to see how each diversifies their healthcare revenue and gains member traction across different verticals. How will 23andme expands their business portfolio away from one-off $199 (or $99 on-sale) DNA testing, as one of the front-runners in the genetic data mining world. Seeing competitors like Veritas Genetics struggle with the economics of sequencing the human genome must be taken into account. GoodRx is moving beyond offering savings on prescription drugs, and into GoodRx Care, a program that helps people access virtual visits with physicians. Cost for services start at $20, depending on the condition and I’m excited to see how it performs and if they also launch a DTC pharmacy product. I’m watching each of these companies and leaders because they are two of the better startups in the game.

9. Amazon

Amazon is like Oprah. It only needs one word at everyone agrees its important. In my opinion, no company is better at execution than the Seattle-based book company. And e-commerce company. And digital streaming company. And cloud computing, artificial intelligence leading company. And now, healthcare company. Amazon is the sleeping giant that appears to have awaken. With PillPack’s first deal with BCBS Massachusetts and the creation of Amazon Care, the healthcare service being offered to employees around Seattle, Jeff Bezos has made his first moves. I’m watching to see if they double down on the pharmacy or device distribution marketplace (watch out Cardinal, McKesson, and AmerisourceBergen), or call an audible and expand their healthcare services offering beyond just their employees and families.

10. Alphabet’s Future In Healthcare

I always suspected the the co-founders of Google, Sergey Brin and Larry Page, had a passion for helping improve healthcare. Never talked to them about it, but that was my hunch. Hence why an incredible amount of resources and talent was put into healthcare spin-offs like Calico, Verily, and Google Health. Now that Sundar Pichai has been named CEO of Alphabet and the most the valuable subsidiary, Google, he has a big challenge in responding to constant public challenges around privacy and breaking up “big tech”. I’m watching to see if Sundar takes his foot off healthcare in lieu of these obstacles or if he doubles down on the $3.7 trillion market.

11. Walmart Health Expansion or Marketing

The entire healthcare industry was shocked when Walmart announced their new health clinic in Dallas, GA. They were offering primary care, dental, counseling, labs, x-rays, audiology, and other services for much below “market” rates? Cost of an appointment varies from $59 to $99 without insurance, as well as accepting many of the largest health insurance plans. Is this going to be like the $4 generic drug list or a small pilot and brilliant marketing ploy? I’m watching to see how many more clinics are announced, where they’re located, and whether the economics of supporting a healthcare provider service at historically low rates will be financially viable.

Andy Mychkovsky is a Director at Evolent Health and the Founder of a healthcare startup and innovation blog, Healthcare Pizza. This post originally appeared on Healthcare Pizza here.

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Revisiting the Concept of Burnout Skills

By HANS DUVEFELT, MD

I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.

Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.

Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.

In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.

Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.

The Harvard Business Review piece listed four pitfalls and described two types of leaders, which in our case would be clinical leaders: Leader A and Leader B.

Dr. B is a walking recipe for burnout and Dr. A may be the one whose job feeds his soul, at least to some degree (you still have to like people and medicine):

These four pitfalls run through the minds and daily realities of primary care doctors constantly, I dare say:

Just do more: The future reimbursement model is said to be based on value, loosely speaking. But clinics’ quarterly cash flow is largely determined by patient volume. Doctors have patient quotas, and any quality related incentives or requirements are typically tacked on top of the productivity targets without much infrastructure or time set aside for figuring out how to reach those targets in any kind of systematic way.

Just do it now: We certainly are operating in a constant state of emergency to at least some degree. Particularly the addition of quality targets is done in a not very proactive fashion, but much more reactive, with short term “fixes” that tend to be disjointed, as if we are all trying to make improvements to a moving vehicle while also trying to keep an eye on the road.

Just do it myself: Oh, yes, we have all heard about every staff member practicing to the top of their license, but everyone seems so busy, so how many times a day do we think “It’ll take me longer to get this done if I delegate it to someone else, I’ll have to tell them I need this done, how to do it and then – will I trust that it actually got done?”

Just do it later: Sometimes now is the right time, and sometimes later is the right time. But who decides?Physicians tend to put what the HBR calls “value add” work on the back burner, because changing how we work requires detaching from the short sighted thinking of getting through the piecework of the day. We don’t take enough time to think about what we’re doing and why.

Burnout happens when you work hard without seeing real alignment between your efforts and your goals and values, if you get right down to it. I have read and written much lengthier definitions, but the graph in this article made me shorten mine.


Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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Young Health Leaders Unite! | Alex Maiersperger & Antwan Williams, Advancement League

BY JESSICA DAMASSA, WTF HEALTH

While the “healthcare ecosystem” sounds like a nice place to begin a career, the day-to-day can often make it feel like the industry is about survival of the fittest — especially for young professionals who are just starting out. Enter The Advancement League, an organization-slash-support-system for young leaders and entrepreneurs. Co-founders Alex Maiersperger and Antwan Williams started the organization as a way to unite bright-eyed, up-and-comers from health systems, health plans, and startups who not only want to build big careers in health, but who also want to apply their youthful optimism, new ideas, and tech to changing the experience of healthcare for the better. How can you get involved? Tune in for all the details about the organization’s events, especially their “big one,” the Young Health Leader’s Summit.

Filmed at HLTH 2019 in Las Vegas, October 2019.

Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew HoltGet a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.

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Reference Manuals May Be Facing Obsolescence

We must ensure their relevance to contemporary patient care

By LONNY REISMAN, MD

It’s 1992 and disruptive technologies of the day are making headlines: AT&T releases the first color videophone; scientists start accessing the World Wide Web; Apple launches the PowerBook Duo.

In healthcare, with less fanfare, a Harvard physician named Dr. Burton “Bud” Rose converts his entire nephrology textbook onto a floppy disk, launching the clinical tool that would ultimately become UpToDate. Instead of flipping through voluminous medical reference texts, such as the Washington Manual, doctors could for the first time input keywords to find the clinical guidance they needed to make better treatment decisions.

The medical community embraced UpToDate’s unique ability to put knowledge at their fingertips. Today more than 1.7 million clinicians around the world use UpToDate to provide evidence-based patient care with confidence. For many, it along with other reference sources has become foundational to providing high quality medical care.

More than just an easy-to-use reference, UpToDate has gone on to improve patient outcomes, according to the Journal of Hospital Medicine.

In the new era of 21st century digital medicine, however, there are opportunities to go further in support of clinicians and patients. Reference tools must be powered by predictive and prescriptive analytics, be personalized to individual patient circumstances, and be integrated into clinician workflow. In some cases, clinicians may be unaware of which questions to ask of a computerized reference manual, or how to incorporate the nuances of an individual patient’s case into the general insights of a reference. Searching for heart failure treatment, for example, may be too broad a query and the resulting recommendations therefore may not provide optimal care for a specific patient’s unique medical circumstances. New digital health solutions that consider patients’ co-illnesses, contraindications, symptomatology, current treatment regimens, and hereditary risks are essential.

Additionally, the pace of change in medical science continues to accelerate, and with it, the proliferation of life-saving treatments and diagnosis. When I enrolled in med school in the 1970s, medical knowledge was doubling every seven years; now it’s closer to every two months. That makes it virtually impossible for clinicians to truly be informed regarding the latest studies and guidelines – therefore making it ever more challenging to effectively query medical reference materials.

This heightened pace of evidentiary change has exacerbated the historically slow diffusion of new medical knowledge into general practice, to the detriment of patients. As a member of the American College of Cardiology’s Science and Quality Committee, I spend countless hours each year reviewing the guidelines for cardiac care, knowing full well that it will be years before these new evidentiary approaches become adopted into mainstream practice.

We need 21st century solutions to support increasingly complex medical care. Just as we made the leap from paper to floppy disks to apps, we must now take advantage of recent developments in clinical AI to make another leap: this time to a dynamic and proactive approach to applying medical guidelines to individual patients.

Here’s how clinicians can bring the reference manual truly “UpToDate” for our modern medical times:

1. Personalize for Every Patient

Historically, clinical decision support tools have been used for universal, population level alerts or gaps in care based on simplistic quality measures that apply to all patients…smoking cessation, healthy diets, and exercise. With the advances in AI, nuanced medical guidelines can now follow each patient.

For example, clinical AI tools now exist that can interrogate a variety of patient data – such as electronic health records (EHRs), insurance claims, and patient-generated data – and drill down into clinical, genomic, social and behavioral factors to align patient care with the individualized guideline-directed treatment. This individualized approach ensures each patient receives optimal diagnostic and therapeutic care that is designed to improve outcomes.

2. Dynamically  and Proactively Deliver within Clinical Workflow

Today, most clinicians live their daily lives toggling between their EHR, reference apps like UpToDate and a myriad of other portals. Have a question about the best treatment for your patient with atrial fibrillation and a high bleeding risk? Open a reference app and you will find a multitude of articles to read which may not provide all pertinent information. For example, you may not know to search for “non-pharmacologic treatment” to find information on Left Atrial Appendage Closure (LAAC) device alternatives for a particular patient who is unsuitable for long-term oral anticoagulation. A clinician cannot know to query what they don’t know exists as an alternative for a patient.

Clinical AI tools can proactively deliver these patient-specific recommendations based on the latest medical guidelines directly within a clinician’s workflow, thereby eliminating the need to go searching for the optimal treatment for patients with complex medical needs.

 3. Apply the Guidelines for On-Demand Care

Clinical decision support tools have largely been limited to use at the point of visit, but traditionally offer little insight into recommended patient care outside the four walls of an office visit. Today’s technology can continually analyze new patient data, identify rising health risks,  and promote opportunities to provide optimal care. When lab results, new medications, EHR orders, or third-party data from wearable devices indicate an alteration in patient health status that warrants consideration of a guideline-directed diagnostic or treatment intervention, new guidance can be proactively sent to the clinician and patient – driving purposeful virtual or in-person engagement.

Digitized reference materials have come a long way, but clinicians and health systems today must evolve these capabilities to continually and efficiently apply the medical guidelines – the bedrock of medicine – for the patients they serve.

Dr. Lonny Reisman is the founder and CEO of HealthReveal, and former chief medical officer of Aetna

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Fertility Predicting Wearable Expanding into Birth Control, Menopause | Lea Von Bidder, Ava Science

BY JESSICA DAMASSA, WTF HEALTH

Ava Science is a FemTech company best-known for their fertility-predicting wearable device that collects biometric data from a woman’s wrist in order to track ovulation. The device predicts fertility with 89% accuracy (according to published clinical trial data) and is among one of the most well-funded FemTech startups out there, having raised a cumulative $47M. So what’s next? Lea von Bidder, Ava’s CEO, explains the data-driven vision for the company, which is currently one of the few medical device wearables that is approved for collecting digital biomarkers. The startup is eager to capitalize on that first-mover advantage in the women’s health space, and is looking at other ways to use their data. Lea talks through her plans for exploring a full-range of women’s health applications, from non-hormonal birth control to new products that might appeal to women during pregnancy or menopause.

Filmed at HLTH 2019 in Las Vegas, October 2019.

Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew HoltGet a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.

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Will Your Health Plan Tell You That It Can Save Your Life?

By MICHAEL MILLENSON

At kitchen tables everywhere, ordinary Americans have been grappling with the arcane language of deductibles and co-pays as they’ve struggled to select a health insurance plan during “open enrollment” season.

Unfortunately, critical information that could literally spell the difference between life and death is conspicuously absent from the glossy brochures and eye-catching websites.

Which plan will arrange a consultation with top-tier oncologists if I’m diagnosed with a complex cancer? Which might alert my doctor that I urgently need heart bypass surgery? And which plan will tell me important information such as doctor-specific breast cancer screening rates?

According to Matt Eyles, president and chief executive officer of America’s Health Insurance Plans (AHIP), insurers over the last decade have made a “dramatic shift” to focus more on consumers.  That shift, however, has yet to include giving members the kind of detailed information available to corporate human resources managers and benefits consultants (one of my past jobs).

What’s at stake could be seen at a recent AHIP-sponsored meeting in Chicago on consumerism. Rajeev Ronaki, chief digital officer for Anthem, Inc., explained how the giant insurer is using artificial intelligence to predict a long list of medical conditions, including the need for heart bypass surgery. Information on individual patients is passed on to clinicians.

“The future of care delivery will see physicians, scientists and consumers alike empowered with the most accurate clinical information in real time,” Ronaki declared.

That may be the future, but it’s not the present for the one in eight Americans that Anthem serves today in its various plans, most affiliated with Blue Cross and Blue Shield. Anthem members have to rely on the limited information available in a new mobile app with the gender-vague name of “Sydney” that’s blandly touted as “smart” and “personal.”

As for obtaining a sophisticated cancer consult, an oncologist working with 2nd.MD, which contracts with the top 20 cancer centers in America for virtual consults, related how a man who was diagnosed with advanced cancer had a grim diagnosis offering perhaps a few months to live. But after the consultant, Dr. Charles Balch, directed him to an advanced cancer center, the man showed “an almost complete response” to immunotherapy, Balch said.

Do you know if your health plan offers that kind of service? Who would even think to ask before enrolling?

Meanwhile, as a consultant I’ve seen the detailed information about individual hospitals and doctors that’s available to some insurers. While a few plans do a good job of sharing meaningful data, most settle for limited information posted in a dusty corner of their website. 

Given health insurers’ negative image – in one national poll, just 16 percent of respondents believed insurers put people over profits –why don’t health plans highlight these kinds of valuable services? Here’s where consumerism confronts unpleasant realities.

Take cancer consults. While a world-class second opinion may save money in the long run, if everyone who thinks they’re a cancer risk joins your plan, that “adverse selection” among the enrolled population could boost medical expenses. 

When it comes to publicizing the use of algorithms to predict illness, the adverse selection problem is complicated by the additional issue of public trust. Even though early intervention can save money, will members believe that a company that gained national notoriety for denying claims for emergency room visits – as Anthem did – has their best interests at heart when it comes to their heart? Other plans have similar trust issues.

And speaking of trust, can members trust that their health plan will risk the ire of doctors and hospitals by publicizing usable data showing that some perform much better than others? 

The way to overcome these issues, I believe, is for powerful national employer groups such as the Federal Employees Health Benefit Program to demand detailed disclosures by health plans to consumers. That puts all plans on an equal footing. Plans should answer carefully defined questions in three areas: What will you do to keep me well? What information will you give me about doctors and hospitals? And what resources do you offer in case of serious illness?

It’s important that insurers’ pay members’ bills without bogus bureaucratic barriers. But it’s even more important to give prospective plan members full and complete information about services that might one day save their life.

Michael L. Millenson is president of Health Quality Advisors LLC and adjunct associate professor of medicine at Northwestern University Feinberg School of Medicine. This article originally appeared on Forbes here.

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