#Healthin2Point00, Episode 202 | Virta, Seqster, Kaia, Capsule & Accolade acquires PlushCare

On Health in 2 Point 00, Jess and I talk about TDOC earnings before getting into today’s deals. First, Virta Health scores $133 million in a round led by Tiger Global for its keto diabetes reversal program. Seqster raises $12 million in its Series A, and there are some interesting investors in this one. MSK startup Kaia Health raises $75 million, bringing its total to $123 million. Online pharmacy Capsule raises $300 million, bringing its total to $570 million. Finally Accolade acquires virtual primary care platform PlushCare in a $450 million deal. —Matthew Holt

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#Healthin2Point00, Episode 201 | European Funding Deals – complete with accents!

Today on Health in 2 Point 00, we’re back from our 200th episode celebration! In Episode 201, we have an all-European funding deals episode for you, and I even attempt to answer every story in an accent relevant to the company. First, French insurance company Alan raises €185 million. Scottish company Current Health raises $43 million in a Series B for remote patient monitoring. Thankfully we have an English company in the mix, Proximie raises $38 million, bringing their total to $48 million – they do AR for the OR. Kry, a Swedish telehealth company with 3 million visits, raises $316 million bringing their total to $570M. Finally, German company Caresyntax raises $100 million bringing their total to $177M doing data analytics around surgery. —Matthew Holt

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The Market Forces Behind Vaccine Passports

By SAURABH JHA

Unlike medical meetings, rendering Beethoven’s Ninth Symphony isn’t easy on Zoom, so the local orchestra has been furloughed and their members work for Uber.  The opera house wants to reopen, preferably before we reach the elusive herd immunity threshold. They mandate vaccinations for their artists, not least because the performers can keep their masks off. Should they extend this requirement to their patrons?  

Vaccine passports, proof of immunity against SARS-CoV-2, to work, dine, fly or watch shows, are controversial. Opponents say they blithely disregard decency, are operationally onerous, and hurt liberty. Worryingly, they create a caste system, which wouldn’t be as concerning if based on just immunology. Such a two-tiered system could sadly mirror societal inequities because it’s the poor who may disproportionately be left unvaccinated. Supporters of vaccine passports further the very structural disadvantages they seek to end.

When arguments are too compelling they likely betray an obvious simplicity. Too often arguments against mandates assume they’d be a government fiat. The opponents recline on the country’s inherently liberal streak conjuring visions of rugged individuals fighting unelected bureaucrats. They say with undisguised pride “this isn’t who we are. We’re the US, not New Zealand. We can’t be controlled.”

This narrative is so tightly embedded in right-of-center discourse that it’s now folklore bordering on an Ayn Rand fairy tale. The narrative is nonsense. The state is too incompetent to either govern adeptly or tyrannize efficiently. Case-in-point: CDC’s easily forgeable paper vaccine certificate. If the state were serious about prying on people’s antibodies, it’d have made the immunosurveillance digital.

The obsession with big government should be antiquated. By censoring content, Facebook and Twitter showed that freedom can more efficiently be curtailed by the private sector. Bottom-up censorship is arguably more powerful than top-down censorship because it has buy-in from a segment of the market. It may very well be the private sector which demands vaccine passports, which begs two questions – why and why not?

The scientific arguments against vaccine passports are even more compelling than the deontological arguments. Vaccinations are nearly 100 % effective in stopping infections. The unvaccinated don’t endanger the vaccinated. The unvaccinated endanger only each other and they have a right to accept the mutual risk.

Yet, the opera house may ignore science. For starters, they’d be signaling a safe environment, and even if the safety is excessive, it might be necessary to arrest the inertia of their risk-averse patrons who, having avoided crowds for a year, may need more than science for reassurance. They’d also be signaling a commitment to vaccinations which, despite the hesitancy is some quarters, is now ingrained in public psyche as the path out of the pandemic. A private entity may signal collective virtue for selfish reasons. Adam Smith’s invisible hand works in mysterious ways.     

Even if the unvaccinated implicitly accept the risk of infecting each other, the opera house might not want to be the author of their viral destiny. If the viral spread is traced to the theater, even if the opera house can’t be sued, they’d get bad publicity. Market forces would encourage the establishment to be more prudent than science demanded.   

Couple weeks after receiving my second dose, I was walking to the grocery store in a state of immunological euphoria. In a flash of defiance to the spike protein, I took off my mask to salute my antibodies. A man walking his dog looking disapprovingly at me crossed the road. I wanted to shout “I have been vaccinated, you judgmental Puritan”. Instead of showing him the Kaplan-Meier curves of the Pfizer vaccine, I put my mask back on. I still wear a mask – to protect myself not from the virus, but the judgmentalism of strangers. The alternative is tattooing “I have been vaccinated” on my forehead, but I’m of a shy disposition.

The vaccinated are now hanging out together. After a year of seeing each other on Zoom, they now have dinner at each other’s houses. The mute option has gone. The masks are off.  They’re comfortable because they know they’re vaccinated. An unsaid vaccine honor system already exists. We don’t call it “vaccine passport.” We call it “mutual agreement.”

To understand how businesses might behave, we must understand their clientele and also their costs of obtaining information. All entities try reducing information costs. Discerning between different tiers of risk is costly for both an upscale French eatery and a hole-in-the-wall Schezuan restaurant. The former may enforce vaccine passports so that their affluent patrons feel relaxed sipping Côtes du Rhône wine. For the latter, requiring vaccine passports may drive away their, less affluent, customers.

As more of the more affluent get vaccinated, their urge to normalize will increase. However, this urge won’t rise smoothly. It’ll be preceded by extreme fear, as they’ll feel like they’re walking on landmines. In that inflexion between extreme fear and frontier spirit – which could last days or months – they may demand that the places they frequent mandate vaccine passports.  Upscale restaurants may oblige. Airlines, though not budget airlines, may also oblige. Vaccine passports will segment the more affluent segments of the market.   

Two underappreciated forces in affluent nations are fear and virtuosity, both plentiful here.  The corollary to feeling good about yourself for being vaccinated is wanting to distinguish yourself from the “reprobates” who aren’t. Compliance with masks can be signaled. Compliance with vaccinations, notwithstanding the vaccine selfies posted on Twitter, is more difficult conveying. Vaccine passports unmask our invisible immunology.

Of course, there are legitimate reasons not to be vaccinated. But markets aren’t good at discerning intent – the information costs are prohibitive. Markets may be more nuanced than central diktats but are still not nuanced enough for the heterogeneity of risk and preferences in society. This means we can’t assume that the unvaccinated have entered “I’ll let you infect me if you let me infect you” covenant.

As getting vaccinated gets easier, and more get vaccinated, the already low efficacy of vaccine passports will be even lower. But the zeal for vaccine passports will increase, precisely because getting vaccinated got easier. It’s easier for hotels to turn guests away at 60 % than 25 % occupancy. Why are passports mandatory for international travel, with no exception? Partly because they just are, and partly because anyone can get one.

The incredibly efficacious COVID-19 vaccines made masks redundant. Vaccine passports are the heir apparent to “throw your masks off”. They’ll exist because the vaccinated and unvaccinated are in different risk tiers. And the vaccinated will want their lives to be easier because they’ve been vaccinated.  

Since the start of the pandemic, we’ve tried making restrictions more risk based. We’ve quarantined international travelers, restricted travel from viral hotspots, such as India. The maxim of the operationally challenging “test, trace, and isolate” is keeping people who test positive away from people who test negative. It’s an odd deontology which concludes that it’s ok segregating society on the basis of “has virus” but not “does not have virus”, particularly as the latter is now more within one’s control – one couldn’t as easily have chosen not to be infected as one can now choose to get vaccinated.

No mandate should be judged on its own. It must be judged only in the context of other, more restrictive, mandates.  Weak restrictions create more freedom by displacing stronger restrictions. Presently, Americans require negative COVID-19 test before boarding flights back to the US. Whatever the merits of this restriction, it can make people fear being stranded in another country. Between having a blood test 48 hours before your flight and hoping it’s negative, and showing proof of vaccination, which would you choose? If you’re a frequent flyer would you choose a one-time certificate or a blood test every time you fly?

Across the political spectrum logical consistency has taken a flogging in this pandemic. For instance, consider the Great Barrington Declaration (GBD), which has widespread support amongst conservatives. GBD’s risk-based restriction, “focused protection”, uses the steep age gradient of COVID-19 mortality. Focused protection means we protect the elderly with vigor but not fret about the youth partying. How is keeping unvaccinated granny away from parties in crowded bars, pre-vaccine, categorically different from keeping unvaccinated granny away from the unvaccinated youth in an opera house?  

The scientists will scoff at my conflation. Not all risk heterogeneity is the same. And risk is diminishing – unvaccinated granny is safer now. Vaccinations have flattened the age-mortality-gradient.  My point is that vaccine passports are no more unique in the genre of risk-based restrictions than a Labrador is uniquely canine.

Will vaccine passports reduce faith in vaccinations? It’s certainly plausible that those who don’t want to be vaccinated will resent compulsion. But those at the margins may more likely get vaccinated if vaccinations makes their lives easier.

When individual preferences clash with groups preferences markets segment, which is why we have budget airlines. Vaccine passports may also be a consequence of such tension. They’re not the key to reopening the economy. Rather, they may be the result of their phased re-opening.  Removing the mask mandate will neuter vaccine passports. Vaccine passports will be redundant if the country normalizes today. But many places won’t normalize overnight, or at the same time, and as we creep towards normalization, businesses may use vaccine passports to create sanctuaries of pseudo-normal life, particularly for their employees.

Technocrats think about net benefits of policy, of effect sizes, of uncertainty. Markets aren’t concerned by the algebra of regression equations but governed by the concerns of the time. Perception of risk often lags actual risk. Perception is shaped by multiple entities, such as media, institutions, and television doctors. The closer we reach the end of the pandemic the more impatient markets will become to end the pandemic.

As we’ve been told, markets know best 😉

Saurabh Jha is a long-time contributor to THCB. He can be reached on Twitter @RogueRad

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THCB Gang Episode 52, Thursday April 29, 1pm PT – 4pm ET

Thursday’s #THCBGang will be another with a special guest. Matthew Holt (@boltyboy) will be joined by regulars, employer health expert Jennifer Benz (@jenbenz); patient safety expert and all around wit Michael Millenson (@MLMillenson); WTF Health host & Health IT girl Jessica DaMassa (@jessdamassa); & Consumer advocate & CTO of Carium Health, Lygeia Ricciardi (@Lygeia).

Our special guest is Shantanu Nundy @DrNundy who is Chief Medical Officer of Accolade and more importantly author of new book Care After Covid. We’ll be digging into the question what the post-covid health care system looks like, while discussing why I’m grumpy Accolade just paid $450m for Plushcare!

As ever you can watch live at 1pm PT/4pm ET or if you’d rather listen, the audio is preserved as a weekly podcast available on our iTunes  & Spotify channels.

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The “Health Tech Responds to COVID-19” Showcase Webinar!

By ELIZABETH BROWN

Catalyst @ Health 2.0 is excited to be hosting the Health Tech Responds to COVID-19 Showcase Webinar, sponsored by the Robert Wood Johnson Foundation! A little under a year ago, Catalyst, with the support of the Robert Wood Johnson Foundation, launched the “Health Tech Responds to COVID-19” platform to maximize the health tech community’s response to the pandemic. The platform features an “Always on” Rapid Response Open Calls (RROCs); a blog/informational website to showcase innovators and experts in this space, and the development of a comprehensive database that allows the public to search and filter for innovative solutions – SourceDB for COVID-19.

With RWJF’s support, Catalyst has opened up the platform to the larger digital health ecosystem and sought organizations interested in sourcing novel technologies, both COVID-19-specific and those with a broader scope. In this video, we hear from some of our Rapid Response Open Call hosts and participants as well as some special guests like John Brownstein discussing VaccineFinder and Jacob Reider talking about the problems of how to manage the vaccine process among the underserved. This is a great discussion of past, present, and future opportunities that have emerged with the global pandemic.

Elizabeth Brown is a Program Manager at Catalyst @ Health 2.0

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Sharecare’s SPAC IPO: A Second Success for WebMD Founder Jeff Arnold?

By JESSICA DaMASSA, WTF HEALTH

Sharecare, the population-health-slash-care-navigator of the stars (literally, celebrity doc Dr. Oz is a co-founder, and Oprah’s Harpo Productions, Sony Pictures Television, and Discovery Communications are partners) is about to hit the public market via a $4-Billion SPAC IPO with Falcon Capital. Jeff Arnold, co-founder, CEO, and Chairman drops in to talk about how he plans to make Sharecare even more successful than the first healthcare business he founded-and-exited, WebMD.

The Sharecare ecosystem is sprawling. The company’s been around for more than a decade, acquired about a dozen digital health point solutions and health tech businesses, and built a population health analytics platform that’s interwoven consumer, employer, provider, and health plan data for years. Now, the business is even getting into providing Health Security verifications for hotels, restaurants, and the like to prove that their facilities meet guidelines for health and hygiene protocols, cleaning standards, physical distancing and other health requirements implemented in the Covid-19 era.

So, how does Jeff anticipate meeting shareholder expectations for growth? The investor deck touts a future of recurring revenue driving sustainable 20% year-over-year growth; Jeff talks through each of Sharecare’s verticals in detail so we can learn how.

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Healthcare’s Million Dollar Blocks

By KIM BELLARD

Since I first heard about them, I have been fascinated, and dismayed, by the concept of “million dollar blocks.”  For those of you unfamiliar with the term, it doesn’t refer to, say, Beverly Hills,  Chicago’s Gold Coast, or Manhattan’s Hudson Yards — areas where the wealthy congregate.  No, it refers to city blocks for which society spends over a million dollars annually to incarcerate residents of that block.

I, of course, have to think about the healthcare parallels.

The concept dates back many years, credited to Eric Cadora, now at Justice Mapping, and Laura Kurgan, a professor of architecture at Columbia University, where she is the Director of the Center for Spatial Research (CSR).  The power of the concept is to use data visualization to illustrate the problem. 

Here, for example, is CSR’s map of Brooklyn for prison spending:

CSR describes the findings as follows:

The maps suggest that the criminal justice system has become the predominant government institution in these communities and that public investment in this system has resulted in significant costs to other elements of our civic infrastructure — education, housing, health, and family. Prisons and jails form the distant exostructure of many American cities today.

Think about that: “criminal justice is the predominant government institution in these communities.”  Something is wrong with that picture – not theirs, but, rather, the picture of our society that it presents.

Mr. Cadora told NPR in 2012:

No one had ever actually sat down and gotten the home street address of everyone going into prison and jail, as well as all the background information about their age and their employment status, etc. And when you have all that data, it tells you a lot about what’s going on on the block.

In all honesty, what we mapped was not a big surprise to people. But when you actually gather the real data … on maps, [it becomes] immediately understandable to people who didn’t see it — like legislators, city council people, researchers.

No, not a big surprise, not to most people.  We know we spend lots of money on criminal justice; we just don’t always realize how we spend it.  We’ve long had the dubious distinction of locking up more people – in total and per capita – than any other country. 

But if, as they say, a picture is worth a thousand words, then perhaps data visualization is worth a million dollars.  Even hardened criminal justice advocates have to blanche at how spending is so often concentrated in certain blocks, and should wonder if perhaps there are better ways to use that money for them.

CSR has a variety of projects in addition to their criminal justice work, including some focused on healthcare.  Earlier this year, for example, they created an interactive vaccine allocation map to help guide decisions about allocating then-scarce COVID-19 vaccines, and late last year their New Politics of Care project used an interactive map to highlight existing areas of health care needs.  They proposed a New Deal for Public Health, with a million new community health workers deployed around the country based on the identified needs.  

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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Health in 2 Point 00 — The 200th Episode Special!

Believe it or not, Jessica DaMassa and I have been banging out digital health tech & funding news for 200 episodes of this oh-so-cute little show. To celebrate, after several takeover episodes when Jess replaced me with a number of special guests, this time four of the digital health & health care digerati replaced Jess to ask me some oh so serious questions. It’s a special edition with guest appearances from Glen Tullman, Eugene Borukhovic, Lisa Suennen & Ian Morrison, as well as plenty of BS from us two regulars! — Matthew Holt

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Please Sign Below: Fraudsters Phishing for Physician Signatures

By HANS DUVEFELT

Almost every day I catch a suspicious fax needing my signature. Often it is an out of state vendor who wants my permission to provide a back brace for a diabetic patient, a continuous blood glucose monitor for a non-diabetic or a compounded (custom made) ointment of some sort that makes no sense from what I know of that patient’s history.

Often, I get a fax appearing to be from Walgreens, just asking me to sign and certify that so-and-so is under my care. Those faxes have Walgreen’s logo, my patient’s correct address and my own DEA and NPI numbers already printed. The problem is that 90% of my patients don’t use Walgreens 20 miles north or south of my clinic, but the local Rexall pharmacy. Once, I called the phone number on the fax and it just rang and rang.

I am convinced that his is just an illicit way to collect physician signatures, so the scammers won’t even have to get my signature on one form at a time. This way it’s like they’ve got their own rubber stamp to use again and again.

I suspect these scams are successful often enough to be quite profitable. I know this because I sometimes sign these forms almost automatically before I catch myself and toss them in the shred box under my desk.

One of the many dirty little secrets in medicine is that doctors get so many papers to sign that there is actually no way we could read them all before scribbling our signature if we still want to see patients, meet clinic revenue projections and match our own productivity quotas.

I used to joke that the only kind of paper in my clinic I didn’t have to sign was the toilet paper. In spite of our computers, we get more papers than ever before to sign. This is probably because everybody else, like the home health agencies, use their computers to generate more and more pages that require our signature.

The really disturbing thing about these scams is that these vendors are billing Medicare for things harried or otherwise inattentive doctors unwittingly “order”. The fact that they can bill Medicare means that they are somehow credentialed to do so.

It must therefore be way too easy to qualify for a place at the Medicare money trough.

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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Inside Cano Health’s SPAC IPO & Tailoring Medicare Advantage Primary Care for the Latino Market

By JESSICA DaMASSA, WTF HEALTH

Healthcare SPAC-trackers interested in placing bets on value-based primary care for the lucrative Medicare Advantage market will love hearing Cano Health’s CEO Marlow Hernandez dive into the details behind his company’s $4.4B valuation and 7,000% three-year growth rate. Cano Health’s clinics provide “primary care plus” for 100,000 seniors, targeting the particular needs of underserved Latino senior markets in Florida, Texas, Nevada, and Puerto Rico. With $1.4B in revenue, Cano’s business looks similar to publicly-traded Oak Street Health – which boasts a market cap of $14B.

Hoping to replicate what they’ve started in Florida (where Cano Health boasts a long-standing relationship serving Humana’s Medicare Advantage members) the company is building partnerships with major national MA plan providers like UnitedHealthcare, Anthem, Centene and Devoted and scaling up its network of more than 550 primary care physicians. A surprising component of the business plan? Cano Health’s health tech stack! Marlow explains how the care delivery co developed its own practice management software for care navigation, billing, and back-office admin and is already licensing it to more than 1,000 independently owned medical centers.

Tune in for more on the scale-up and scale-out plans for Cano Health before it starts trading at $CANO. The planned merger with Jaws Acquisition Corp (the SPAC led by Barry Sternlicht of Starwood Capital fame) is “imminent.”

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