Today on Health in 2 Point 00, Jess helps me celebrate my birthday Kylie Jenner-style. On Episode 140, Jess and I discuss Humana investing $100 million in Heal, Lemonaid raising $33 million in a Series B, CVS Caremark announcing 5 new companies in their digital health platform—4 of which are about weight loss, and perplexing health intelligence company Sema4 raising $121 million in a seed round. —Matthew Holt
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By SYLVIE STACY, MD, MPH
As a physician and writer on the topic medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over 17,000 physicians surveyed in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, 13.5% indicated that they planned to seek a nonclinical job within the subsequent one to three years, which was an increase from less than 10% in a similar survey fielded in 2012.
The causes of this mounting interest in nonclinical work have not been adequately investigated. Speculated reasons tend to be related to burnout, such as increasing demands placed on physicians in clinical practice, loss of autonomy, barriers created by insurance companies, and administrative burdens. However, attributing interest in nonclinical careers to burnout is misguided and unjustified.
Physicians are needed now – more than ever – to take on nonclinical roles in a variety of industries, sectors, and organizational types. By assuming that physicians interested in such roles are simply burned out and by focusing efforts on trying to retain them in clinical practice, we miss an opportunity promote the medical profession and improve the public’s health.
Supporting medical students and physicians in learning about and pursuing nonclinical career options can assist them in being prepared for their job responsibilities and more effectively using their medical training and experience to assist various types of organizations in carrying out missions as they relate to health and health care.
A shifting locus of control from physicians to patients
A major reason for the expanding need for medical doctors outside of patient care settings is a shift in health- and disease-related locus of control from providers to patients. Medical information is increasingly available, comprehensive, accurate, and free of charge. Individuals wishing to learn about their own health can do so, often without the help of a doctor. Similarly, large data sets, new technologies, and analytical techniques are taking on a progressively significant part of patient care and consumer health.
Domains of patient care that were historically the responsibility of doctors are now in the hands of not just patients themselves, but also corporations, regulators, policymakers, and others whose efforts will ultimately impact patient actions and outcomes.
Physicians in nonclinical roles ensure that the most appropriate decisions are made from a clinical and scientific perspective, despite that fact that these decisions are being made outside of a traditional patient encounter. Physicians can, for example, provide clinical expertise in the development of a device, confirm that scientific data are interpreted accurately, and effectively communicate medical information to stakeholders.
Medicine is becoming less of an art and more of a science
In addition to technologies changing the way that individuals maintain their health, they are altering the way that clinicians deliver care. Electronic health records, health care analytics platforms, and artificial intelligence algorithms play a role in guiding physicians’ medical decision-making in every type of care setting.
As the role of technologies in clinical care becomes more widespread, involvement by physicians throughout the full lifecycle of these tools to ensure that they are scientifically accurate, medically sound, usable, reliable, and valuable. Medical professionals, more so than others, can ensure alignment with the needs of both clinicians and patients as a product or service is being developed.
Nonclinical work addresses a need for systems-thinking in the medical profession
There is little emphasis within medical education on building proficiency on an organizational and system-wide level – and even less on a societal level. While it is vital that doctors are competent in handling medical situations involving individual patients, they should further be able to contribute their knowledge and skills outside of a clinical setting.
The medical profession is not lacking in medical expertise. What is lacking is education on how to use this expertise in a broader capacity, including in the type of work that is the focus of many nonclinical roles.
Medical students and residents who are interested in using their medical expertise outside of patient care are quite limited in their training options to be prepared for this. Some may have the opportunity to do a rotation in an area such as quality improvement or clinical informatics. A few may take time off from their program to pursue an internship with a consulting firm or federal government agency, though are likely to be challenged by logistics, funding, and scheduling issues.
The options available to practicing physicians to participate in continuing medical education on nonclinical topics have been increasing, with courses on topics such as leadership skills, health care financing, and addressing burnout. Nonetheless, there is a need for additional education, especially programs that teach physicians how to use their skills and expertise in settings where their training didn’t take them: outside of the hospital and clinic.
Currently, burnout leaves doctors thinking that they want to “leave medicine” when, if fact, they would be fulfilled in a career that utilizes their medical and clinical knowledge to a great extent, just in a different way than they’re used to. Though a career pivot might mean that they stop directly treating patients, it is far from “leaving medicine.” This misconception leaves too many physicians feeling stuck, not realizing that they have viable options to explore. Many don’t realize the extent to which their experience and knowledge will come into play in other types of work settings.
Moving toward improvements in medical education and protecting the medical workforce
The issues described above can be addressed from multiple angles and on different levels, in light of the fact that opportunities for physicians outside of clinical care are growing in number, breadth, and interest to doctors.
Undergraduate medical education must foster and invest in learning environments that prepare physicians to be both clinicians and medical experts. Medical schools and residency programs, where possible, should support and encourage trainees to rotate in nonclinical settings and capacities. Continuing medical education providers should make an effort to include topics in their content that enable physicians to utilize their medical knowledge outside of clinical setting.
If they are trained sufficiently, physicians who experience burnout or frustrations in patient care can transition smoothly to a rewarding nonclinical role. Once there, they can make just as much (or more) of a positive impact on our population’s health than they did while directly treating patients.
Sylvie Stacy, MD, MPH is a preventive medicine specialist and blogs about career fulfillment for medical professionals at Look for Zebras. She recently published the book 50 Nonclinical Careers for Physicians.
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Today on THCB Spotlights, Matthew sits down with Paul Johnson, the CEO of Lemonaid. Lemonaid just closed a $33 million Series B led by Olive Tree Ventures, expanding their direct-to-consumer online services which provide primary care visits as well as pharmacy and medication delivery to your home and launching into more chronic areas of care, such as hypertension, high cholesterol, asthma and type 2 diabetes. Why did they wind up with an Israel-focused lead investor in Olive Tree as a San Francisco-based company? Where is Lemonaid in terms of growth and revenue? And how is Lemonaid differentiating itself against some of the other chronic care management and telehealth companies? Find out how the company aims to provide care for patients holistically and be the first point of contact for patients in seeking healthcare.
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Health tech deals are just back to back this week! On Episode 139 of Health In 2 Point 00, Jess asks me about Withings getting $60M in a new round to develop their connected devices & apps products, Neurovalens raising €5.5M to grow their headset technology that helps with obesity, insomnia, diabetes, & more, Pocket Health raising $6.5M to build out their image sharing platform within in EHRs, and Sidecar Health raises $20M for their price transparency direct pay option. I also talks about Livongo’s new DPP program which provides users with diet tips & coaching sessions to offset diabetes in high-risk populations —Matthew Holt
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By JESSICA DaMASSA, WTF HEALTH
A startup PBM? Partnered up with Walmart to bring “everyday low prices” to prescription drug pricing? Is this too good to be true? A.J. Loiacono, founder & CEO at Capital Rx, gives us a quick primer on “Pharmacy Benefit Managers” (PBMs) and why they’ve become known for the element of mystery they bring to prescription drug pricing. With three big PBMs (CVS’s Caremark, Express Scripts, and UnitedHealth’s OptumRx) controlling three quarters of the total market, it’s no surprise that VC-backed challenger companies in this space are rare. So, how does A.J. believe Capital Rx will shake things up? Learning about this new kind of tech-enabled, customer-focused PBM not only inspires hope for a clear future of prescription drug price transparency, but also makes one wonder about the new vision for American healthcare unfolding at Walmart.
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By MICHEL ACCAD, MD
With cases of COVID-19 either disappeared or rapidly diminishing from places like Wuhan, Italy, New York, and Sweden, many voices are speculating that herd immunity may have been reached in those areas and that it may be at hand in the remaining parts of the world that are still struggling with the pandemic. Lockdowns should end—or may not have been needed to begin with, they conclude. Adding plausibility to their speculation is the discovery of biological evidence suggesting that prior exposure to other coronaviruses may confer some degree of immunity against SARS-CoV2, an immunity not apparent on the basis of antibody seroprevalence studies.
Opposing those viewpoints are those who dismiss the recent immunological claims and insist that rates of infections are far below those expected to confer immunity on a community. They believe that the main reason for the declining numbers are the behavioral changes that have occurred either under force of government edict or, in the case of Sweden, more voluntarily. What’s more, they remind us that the Spanish flu pandemic of 1918-1919 occurred in 3 distinct waves. In the summer of 1918 influenza seemed overcome until a second wave hit in the fall. Herd immunity could not possibly have accounted for the end of the first wave.
The alarmists may have a point. However, recent history offers a more instructive example.
Until early 2015, epidemiologists considered Mongolia to be exemplary in how it kept measles under control. In the mid-1990s, the country instituted a robust vaccination program with low incidences of outbreaks, even by the standards of developed countries. In the early 2000s, it adopted a 2-step MMR immunization schedule and, after 2005, its vaccination rates were upwards of 95%. From 2011 through 2014, not a single case of the virus was recorded, leading the WHO to declare measles “eradicated” from Mongolia in November 2014.
On March 18, 2015, however, a measles case occurred in the capital Ulaanbaatar, featuring a viral genotype similar to that of an outbreak in neighboring China. Within days, numerous other cases arose, marking the beginning of a multifocal epidemic across the country. A first wave of infections lasted until July and another one, begun in the fall of 2015, lasted until the spring of 2016. Taken together the outbreaks caused nearly 54,000 cases of measles and 140 deaths despite implementation of a program of supplemental immunizations instituted in the middle of 2015. Most of those affected were children less than 1 year of age who had not yet received any immunization, but 6% of the victims had received one or even 2 shots.
What does this unfortunate event tell us about herd immunity? A review paper titled “Herd Immunity: A Rough Guide,” written by Fine, Eames, and Heymann and published in 2011, gives important insights on the topic.
Herd immunity holds that if a sufficient number of people are immune to a contagious disease, then this immunity protects those who would otherwise be susceptible to it. The idea was first proposed in the 1930s when epidemiologists noted that the occurrence or disappearance of epidemics of common respiratory viruses, such as measles, mumps, or chickenpox, correlated with the presence or absence of a critical mass of immune individuals within a community.
The widespread introduction of vaccines in the 20th century confirmed many examples of herd immunity, which occurs when an immune individual interferes with the chain of transmission of the contagious agent. Vaccination campaigns spurred the development of theoretical models to estimate “thresholds” of herd immunity based on estimates of transmissibility factor, or the famous R0. It is from such models a herd immunity threshold (HIT) estimates are derived and a HIT range of 50-80% has been proposed for COVID-19. In other words, models predict that 50-80% of the population must be infected and develop immunity to COVID-19 before the phenomenon of herd immunity can take effect.
Fine et al. describe in some detail the highly complex social and biological factors that bear on the modeling of herd immunity, and they warn against placing too much confidence in HIT estimates. Despite growth in understanding and despite refinement in theoretical models, they believe that we ought to remain circumspect when considering the question of thresholds in practical terms:
Managers [of vaccination programs] must be wary of target thresholds for vaccination, insofar as thresholds are based on assumptions that greatly simplify the complexity of actual populations. In most circumstances, the sensible public health practice is to aim for 100% coverage, with all the doses recommended, recognizing that 100% is never achievable, hoping to reach whatever is the ‘‘real’’ herd immunity threshold in the population concerned (emphasis mine).
The measles outbreak in Mongolia vindicates their cautionary advice. One might have felt justified into thinking that Mongolia possessed herd immunity on the eve of March 18, 2015 only to realize the next day that it didn’t.
On reflection, the reason for the difficulty is simple. To be immune is a “negative” concept. It cannot be positively established by empirical observation. It is only the opposite that can be demonstrated, i.e., that a person is infected. Of course, when knowledge about a particular infection is solid and biological markers of immunity are robust, the presumption of immunity can be made with more confidence, but it remains a presumption.
Where does that leave us as far as COVID-19 lockdowns are concerned?
Those who oppose lockdowns should be glad to see that Sweden and many other places may soon be “COVID-free.” But invoking herd immunity as an explanation, persuasive as the biology may be, could be premature. Arguments against lockdowns should look elsewhere for their grounding.
Conversely, opponents of lockdowns cannot be so sure that herd immunity has not occurred in some places. Our understanding of the immunology and transmissibility of SARS-Cov2 is sufficiently sparse to allow very wide confidence intervals around any point estimate of herd immunity thresholds. The optimists could very well be right.
One last point. At the end of their article, Fine et al. point out that most vaccination programs aim not to eradicate infectious disease but to reduce disease to a level that is “tolerable.” In a sense, then, our societal attitudes towards disease and death bear importantly on whether we perceive that herd immunity has been reached.
But in an age when health has been declared a common good and medicine has become irredeemably politicized, any case and any death can be deemed “intolerable” or weaponized for political aims. That, more than anything else, may be what makes herd immunity particularly elusive.
Michel Accad is a cardiologist based in San Francisco and host of the podcast, The Accad & Koka Report. This post originally appeared on his blog, Alert and Oriented here.
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Episode 20 of “The THCB Gang” will be live-streamed on Thursday, July 30th! Tune in below.
Joining Matthew Holt are some of our regulars: writer Kim Bellard (@kimbbellard), MD & hospital system exec Rajesh Aggarwal (@docaggarwal), radiologist Saurabh Jha (@RougeRad), and guest Jennifer Benz, communications leader at Segal Benz (@jenbenz). A few more might pop in as well! We will be discussing how health tech funding is exponentiating, policy shifts in November, and more updates from the field. Watch it below!
If you’d rather listen, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan
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SPONSORED POST
By CATALYST @ HEALTH 2.0
The novel coronavirus (COVID-19) has underscored the need for efficient and innovative emergency response. Major health organizations, such as the American Hospital Association, have provided resources that can be utilized for organizational preparedness, caring for patients, and enabling the workforce during the pandemic.
As COVID-19 brought to light the lack of emergency response preparedness in the health care system, the Robert Wood Johnson Foundation (RWJF) and Catalyst saw an opportunity to highlight digital health’s potential to support health care stakeholders and the general public. RWJF and Catalyst partnered to launch two Innovation Challenges on Emergency Response for the General Public and Emergency Response for the Health Care System.
The Emergency Response Innovation Challenges asked innovators to develop a health technology tool to support the needs of individuals as well as health care systems affected by a large-scale health crisis, such as a pandemic or natural disaster. The Challenges saw a record number of applications— nearly 125 applications were submitted to the General Public Challenge and over 130 applications were submitted to the Health Care System Challenge.
An expert panel of judges across the health tech, venture capital, design, and emergency response industries evaluated the entries and selected five semi-finalists from each challenge to advance to the next round. Congratulations to:
Emergency Response for the General Public Semi-Finalists:
Emergency Response for the Health Care System Semi-Finalists:
The semi-finalists for the Challenges will be awarded $1,000 each to further develop their application or tool. After Phase II, three finalists from each Challenge will be chosen to compete at a virtual pitch hosted by Catalyst @ Health 2.0. They will demo their technology virtually to an audience of investors, provider organizations, health plans, tech companies, foundations, government officials and members of the media. Judges will select the first, second, and third place winners live after a series of short demos from the finalists. The winners will be awarded $25,000 for first place, $15,000 for second place, and $5,000 for third place.
For further updates on the semi-finalists of the RWJF Emergency Response for the General Public and Emergency Response for the Health Care System Challenge and other programs, subscribe to the Catalyst @ Health 2.0 Newsletter, and follow Catalyst on Twitter @catalyst_h20.
Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.
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There is still health tech funding going on in late July? Wow! On Episode 138 of Health in 2 Point 00, Jess asks me about Ro getting $200M from General Catalyst to expand their telehealth platform, Indigo Diabetes raising 38M Euros to develop its CGM Sensor, Angle Health landing $4M to create a health plan for startups, and Sidecar Health closing a $20M for their point-of-service payments! — Matthew Holt
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By KIM BELLARD
I was driving home the other day, noticed all the above-ground telephone/power lines, and thought to myself: this is not the 21st century I thought I’d be living in.
When I was growing up, the 21st century was the distant future, the stuff of science fiction. We’d have flying cars, personal robots, interstellar travel, artificial food, and, of course, tricorders. There’d be computers, although not PCs. Still, we’d have been baffled by smartphones, GPS, or the Internet. We’d have been even more flummoxed by women in the workforce or #BlackLivesMatter.
We’re living in the future, but we’re also hanging on to the past, and that applies especially to healthcare. We all poke fun at the persistence of the fax, but I’d also point out that currently our best advice for dealing with the COVID-19 pandemic is pretty much what it was for the 1918 Spanish Flu pandemic: masks and distancing (and we’re facing similar resistance). One would have hoped the 21st century would have found us better equipped.
So I was heartened to read an op-ed in The Washington Post by ReginaDugan, PhD. Dr. Dugan calls for a “Health Age,” akin to how Sputnik set off the Space Age. The pandemic, she says, “is the kind of event that alters the course of history so much that we measure time by it: before the pandemic — and after.”
In a Health Age, she predicts:
We could choose to build a future where no one must wait on an organ donor list. Where the mechanistic underpinnings of mental health are understood and treatable. Where clinical trials happen in months, not years. Where our health span coincides with our life span and we are healthy to our last breath.
Dr. Dugan has no doubt we can build a Health Age; “The question, instead, is whether we will.”
Dr. Dugan head up Wellcome Leap, a non-profit spin-off from Wellcome, a UK-based Trust that spends billions of dollars to help people “explore great ideas,” particularly related to health. Wellcome Leap was originally funded in 2018, but only this past May installed Dr. Dugan as CEO, with the charge to “undertake bold, unconventional programmes and fund them at scale.” Dr. Dugan is a former Director of Darpa, so she knows something about funding unconventional ideas.
Leap Board Chair Jay Flatley promised: “Leap will pursue the most challenging projects that would not otherwise be attempted or funded. The unique operating model provides the potential to make impactful, rapid advances on the future of health.”
Now, when I said earlier that our current approach to the pandemic is scarily similar to the response to the 1918 pandemic, that wasn’t being quite fair. We have better testing (although not nearly good enough), more therapeutic options (although none with great results yet), all kinds of personal protective equipment (although still in short supply), and better data (although shamefully inconsistent and delayed). We’re developing vaccines at a record pace, using truly 21st century approaches like mRNA or bioprinting.
The problem is, we knew a pandemic could come, we knew the things that would need to be done to deal with it, and yet we — and the “we” applies globally — fumbled the actions at every step. We imposed lockdowns, but usually too late, and then reopened them too soon.
Our healthcare organizations keep getting overwhelmed with COVID-19 cases, yet, cut off from their non-pandemic revenue sources, are drowning in losses. Due to layoffs, millions have lost their health insurance. People are avoiding care, even for essential needs like heart attacks or premature births.
Our power lines are showing. The the hurricane that is the pandemic is knocking them down at will. We might have some Health Age technologies available but not a Health Age mentality about how, when, and where to use them.
Dr. Dugan thinks she knows what we should be doing:
To build a Health Age, however, we will need to do more. We will need an international coalition of like-minded leaders to shape a unified global effort; we will need to invest at Space Age levels, publicly and privately, to fund research and development. And critically, we’ll need to supplement those approaches with bold, risk-tolerant efforts — something akin to a DARPA, but for global health.
Unfortunately, none of that sounds like anything our current environment supports. The U.S. is vowing to leave the World Health Organization and is buying up the worlds’s supply of Remdesivir, one of the few even moderately effective treatment options. An “international coalition of like-minded leaders” seems hard to come by. Plus, only half of Americans say they’d take a vaccine even when it is here.
If COVID-19 is our Sputnik moment, we’re reacting to it as we did Sputnik, setting off insular Space Races that competed rather than cooperated, focused narrowly on “winning” instead of discovering. We will, indeed, spend trillions on our pandemic responses, but most will be short-term, short-sighted programs that apply band-aids instead of establishing sustainable platforms and approaches. We’re reacting to the present, not reimagining the future.
Darpa’s mission is “to make pivotal investments in breakthrough technologies for national security,” and it “explicitly reaches for transformational change instead of incremental advances.” Her background at Darpa make Dr. Dugan uniquely qualified to bring this attitude to Leap, and to apply it to healthcare.
The hard part is remembering that it is not about winning the current war, or even the next one, but about preparing for the wars we’re not even thinking about yet.
Most of our population are children of the 20th century. Our healthcare system in 2020 may have some snazzier tools, techniques, and technologies than it did in the 20th century, but it is mostly still pretty familiar to us from then. If we truly want a Health Age, we should aspire to develop things that would look familiar to someone from the 22nd century, not the 20th.
Every time I read about the latest finding about our microbiome I think about how little we still know about what drives our health, just as our growing attention to social determinants of health reminds me how we need to drastically rethink what the focus of our “healthcare system” should be.
Not more effective vaccines but the things that make vaccines obsolete. Not better surgical techniques but the things that make surgery unnecessary. Not just better health care but better health that requires less health care. If we’re going to dream, let’s dream big.
That’s the kind of Leap we need.
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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