DEMO: Medstar Health’s digital front door – featuring b.well Connected Health

Medstar Health, a big hospital system in the Washington DC area, has been using a selection of digital health tools like Bluestream Health’s telehealth system for a while. Now they are showing to the world their implementation of b.well Connected Health‘s patient interface which as you’ll see is being used to create a digital first experience for their patients, enabling booking of virtual and physical appointments. I spoke with John Lock, Chief Digital Transformation Officer at MedStar Health & Kristen Valdes, CEO of b.well Connected Health, while Cathryna Nieves, AVP, Digital Transformation at MedStar Health gave a full demo of the experience. I don’t often head into the belly of the beast, but it’s very interesting to see how big incumbents like Medstar are working with tech vendors to react to the billions being spent by venture capitalists to create denovo virtual first health services–Matthew Holt

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How to Talk to Clinicians: Forget Workflows, Just Tell Us How Things Work

BY HANS DUVEFELT

Workflows are all the rage with EMR people. But doctors, NPs and PAs are smart. Nothing burns us out as fast or as completely as being told how to do things instead of why. We are not circus animals.

Let me explain:

If we had no professional education at all, we would have clinical workflows memorized instead of clinical knowledge. For example, two weeks after starting an ACE inhibitor like lisinopril, order a basic metabolic profile. That sounds pretty straightforward, but if you add up all the possible clinical workflows we would need if we didn’t know medicine at all, that would be a huge burden – a massive amount of seemingly random and senseless rules.

But, of course, the clinical knowledge we acquired in our training is that ACE inhibitors can act like a stress test for patients with undiagnosed renal artery stenosis and a BMP drawn soon after starting such medications ensures we aren’t causing kidney damage with our prescription.

Such clinical knowledge makes us not only order the blood test, it guarantees that we will always remember to do it because it makes sense. It is like memorizing a beautiful poem instead of a long string of random letters.

Especially since computer workflows are often counterintuitive to clinicians, it helps us to know why they require us to seemingly do the wrong thing. As I have written before, EMRs are workarounds because today’s computer programs can’t replicate how the clinical mind works. Some of us might even take a certain pride in becoming expert at using a less than brilliant tool when we have the admission of our IT people that it is the EMR that is stupid and not us.

Seriously, we deal with worse challenges than that every day, just trust our intelligence and let us know when and why our computers can’t yet do what every reasonable clinician would expect them to.

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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Pithiatism Redux

BY MARTIN SAMUELS

Those of us in medicine have all seen the famous painting of the Tuesday afternoon lessons at the Salpȇtrière in Paris in the 19^th century. In Pierre Aristide André Brouillet’s painting, one can clearly see the great professor, Jean-Martin Charcot, holding forth while the patient, Blanche Whitman, is being supported by a tall young man, Joseph Jules Francois Felix Babinski, the Chef de Clinique (the chief resident) and allegedly the favorite to succeed Charcot. He never did as he was failed repeatedly on the exam necessary to become a faculty member at the university by a jealous, xenophobic, anti-immigrant rival, Charles Bouchard. Babinski was born in France and served in the army twice, but his name was Polish as his parents had emigrated to France to escape bias in Poland (sound familiar?).  Ironically almost no one remembers Bouchard (his only contribution being the Charcot-Bouchard aneurysm which may be the cause of some intracerebral hemorrhages), but there is no doctor on earth who does not know Babinski’s name. This is one of many reasons why Babinski is my neurological hero.  

A Clinical Lesson at the Salpêtrière, Pierre Aristide Andé Brouillet

Charcot was a master of the clinical-pathological method whereby he was able to recognize and describe such disorders as amyotrophic lateral sclerosis and multiple sclerosis. In the twilight of his career, Charcot became obsessed with what at the time was called hysteria. He applied his tried-and-true clinical-pathological methods searching for the lesion in the nervous system causing the array of disorders that fell under the rubric of hysteria. These included both attacks of neurological symptoms (eg paralysis, blindness, seizures, loss of sensation, gait disorders, and coma) and a way of life characterized by bouts of illness, fatigue, and weakness (neurasthenia). The Salpȇtrière was an old hospital converted from a gun powder factory (hence the name saltpeter) that was more than a hospital. It was a safe haven for homeless women.  Thus Charcot, trapped by acquisition bias, believed that hysteria was a disease of women (hence the reference to the uterus that was first suggested by the Greek school of ) and that it could be treated by various manipulations of the uterus and ovaries and also hypnosis. Charcot died having never found the lesion in the nervous system responsible for this illness. After Charcot’s death, Babinski revealed his longstanding skepticism of the concept of hysteria.  He suspected that the dramatic “shows” that were performed at the famous Tuesday afternoon sessions actually reflected a usually unconscious folie a deux between the patient and the professor. By participating in these demonstrations some patients, Charcot’s muses, such as Blanche Whitman, became famous and were the recipients of better living conditions in the Salpȇtrière. It was a Catch 22.  One had to be crazy to get better. Whether these muses were “consciously” cooperating with Charcot, for both of their benefits, is undeterminable as it begs the question of will, which is a conundrum that interferes with the proper care of patients. It is always best to start by believing the patient. Willful deceit (i.e. malingering) does, of course, exist, but it is best practice to only resort to that explanation when all other possibilities are excluded. It almost never helps to think that a patient is a copy of the Baron von Munchausen or his pop-culture of The Music Man, the charming sociopath.  

Thus Babinski suggested the term pithiatism, which according to my colleague, Marinos Sotiropoulos, was created by combining the Greek words “pitho-” (persuasion, as in Peitho, the mythical Goddess of persuasion) and “-iatos” (curable, an adjective with the same roots as iatros, meaning doctor).

In fact, together with his colleague, Jules Froment, Babinski wrote an entire monograph on the subject, published in 1918 in which they argued that the term was meant to convey that these disorders were caused by suggestion and cured by persuasion by the doctor. “Hysteria is a pathological state manifested by disorders which it is possible to reproduce exactly by suggestion…and can be made to disappear by the influence of persuasion (counter-suggestion) alone.” In the preface by the eminent British Neurologist, E. Farquhar Buzzard, it was suggested that the principles were correct but the term pithiatism might “not be destined for general adoption….there is no doubt that there has been much confusion as to the meaning of hysteria in the mind of the public as well as in that of the medical profession. Perhaps a new name may be associated with a clearer understanding and may escape the obloquy attaching to its predecessor.” That was a prescient suggestion, and now is the time.

After Babinski, the term hysteria was replaced with conversion disorder and dissociative states, based on the influence of another acolyte of Charcot, Sigmund Freud.  His concept was that conversion was a form of “body language” whereby a patient acts out an unconscious conflict (converts it), which may also be revealed in surrealistic dreams which could be interpreted to reveal underlying psychological stress. Recall that surrealism was actually born at the Pitié Hospital where Babinski worked as one of his residents was Andre Bréton who wrote that watching Babinski examine a patient was the ecstatic experience that led Breton to leave neurology and found the surrealist movement.  This period was followed by the rise of “biological psychiatry” and, with it, the anti-Freud movement which moved “alienism” (the old name for psychiatry) into neuropsychiatry, where the field currently resides. Another irony is that modern functional neuroimaging has produced a new form of Charcot’s clinical-pathological method and the search for the lesion of hysteria goes on today, probably with the same result.  

With these changes, a new name for hysteria was coined to help deal with the misogynistic implication of this being a manifestation of “weakness” in females. Babinski violently disagreed with this concept because of his experience in the then all-male military where identical symptoms were rampant. Hysteria was clearly an equal opportunity syndrome, but what to call it to avoid the stigma that psychogenic illness had come to cause? Hence, a “functional” disorder was born. Though innocent-sounding the term is neither accurate nor helpful.  Many disorders are functional (e.g. migraine, epilepsy, vasospasm, irritable bowel syndrome) but have no relationship to the disorders from which “hysterical” patients are subject. It also contains no implications for treatment. It is just a euphemism.  

It’s time to return to Babinski’s term, pithiatism. It is not judgmental and simply describes the key features of the illness and its treatment: caused by suggestion and cured by persuasion. The suggestion may come from within the patient or from society (via the news or social media). It explains the long history of epidemic illnesses caused by stress, defined by Ivan Pavlov as a life-threatening stressor with no chance of escape or control. Social media have amplified the effect of external stressors (e.g. storms, fires, murders, floods, disease) but the principles remain the same as those seen in the Pitié-Salpȇtrière and during wars. The disorder may, indeed, be more common in women in civil society simply because women are more likely to be placed in stressful circumstances with little chance of escape or control. Babinski’s experience in the army proves that men are just as susceptible if the environment is toxic enough.  

In the office, I spend a great deal of time using persuasion to help my patients; a form of modern hypnosis or Mesmerism (focused attention) to relieve suffering using the power of the reflex hammer, the tuning fork, and persuasion by the aged doctor.  

Dr. Martin A. Samuels, 2nd from left

Recommended Reading:

Babinski JFF, Froment J. Hysteria or Pithiatism and Reflex Nervous Disorders in the Neurology of War.  University of London Press. London. 1918.

Philippon P, Poirier J. Joseph Babinski. Oxford University Press. Oxford and New York. 2009

Hustvedt A. Medical Muses. W.W. Norton & Company. New York and London. 2011.

Martin Samuels is a professor of neurology at Brigham and Women’s Hospital.

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Seqster: The Salesforce of Healthcare?

By JESSICA DaMASSA, WTF HEALTH

It’s not difficult to get Seqster’s CEO Ardy Arianpour fired up, but to get to the details about his business and what he refers to as its “f-ing incredible tech stack,” takes a little doing. Is Seqster a health data analytics company like Clarify Health or Komodo Health, or more of a longitudinal patient health record startup like bWell or Picnic Health?

According to Ardy, these companies would actually make great Seqster clients, and that his tech would serve as the ideal, white-labeled operating system upon which they could engage with patients, collect their data, and examine it alongside EMR data, pharmacy data, social determinants of health data, and even genomic data. While those aforementioned health tech startups might be able to do many of these services themselves, the life sciences companies, health systems, health plans, digital health startups, and non-profit patient registries Seqster does count as clients are using its platform for everything from running decentralized clinical trials to providing patients with a longitudinal single-source medical record.

Ardy breaks down the “operating system” approach Seqster is taking, and how he sees his platform becoming as the “Salesforce of healthcare.” Beyond the specific examples that really bring this concept to life, we talk about what’s ahead for the business, which has raised $23 million in total funding and, interestingly, counts both Takeda Digital Ventures and 23andMe’s CEO and Founder, Anne Wojcicki on its cap table.

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Get Ready for (Healthcare) Microgrids

BY KIM BELLARD

We depend on it.  Indeed, our daily lives are unimaginable without it.  The trouble is, it’s become unreliable.  Lives have been lost because it wasn’t performing when it needed to be.  It’s built around large facilities that are often decades old.  Parts of it don’t communicate/coordinate well with others.  Its workforce is aging and burnt out.  There is no person or agency charged with ensuring its resiliency. It badly needs to be rethought for the 21^st century. 

Oh, you thought I was talking about our nation’s power grid?  I was talking about our healthcare system.  

The parallels are striking, and concerning.  They’re huge industries, based on early 20^th century approaches, and beset by 21st-century challenges to which they may not be easily adaptable.  If we don’t manage their evolution to the 21^st century right, we’re dead.  Literally.  

The power outages in Texas last year caught everyone’s attention.  Texas prides itself on being an energy producer, but its power industry was caught flat-footed by “unexpected” winter weather that many had, in fact, predicted.  People went for days or even weeks without power.  

Oh, that’s Texas, people elsewhere might say. They hate regulations, they love low prices, their power grid isn’t (for the most part) connected to other grids, so the failures were not really surprising. Maybe, but it’s not just Texas.  The Wall Street Journal reported:

Large, sustained outages have occurred with increasing frequency in the U.S. over the past two decades, according to a Wall Street Journal review of federal data. In 2000, there were fewer than two dozen major disruptions, the data shows. In 2020, the number surpassed 180.

In fact, the article says, “Utility customers on average experienced just over eight hours of power interruptions in 2020, more than double the amount in 2013.”  Our power plants and transmission lines are aging badly, we have a phobia of nuclear that is also starting to apply to coal as well, climate change is throwing more extreme weather at us, and many of the renewable options (solar, wind, geothermal) are not quite ready for prime time yet.  

So, get a generator.  In fact, many people are.  That’s fine, if you have the money (often $10,000+), can get the fuel and can keep the generator in working order, and will only need them for limited amounts of time.  That’s a lot of “ifs.” 

That’s where microgrids come in.

According to Microgrid Knowledge, 

A microgrid is a self-sufficient energy system that serves a discrete geographic footprint, such as a college campus, factory, hospital complex, business center, military installation, or neighborhood. Microgrids can operate independently from the grid using power generated on-site; they can also be used for backup power. Microgrids are designed to operate consistently in both “blue sky” and emergency situations supported by a range of energy resources, such as renewable energy, energy storage, combined heat, and power or generators.

Their definition somewhat snidely concludes: “It’s easy to know which buildings have microgrids. They are the ones lit up during grid outages while surrounding buildings remain in the dark.”

A Chicago neighborhood is about to become “the country’s first neighborhood-scale microgrid” – one that proponents believe “could serve as a model for utilities and communities across the country.”  The US Army plans to have microgrids on all of its 130 bases worldwide by 2035.  Many universities, hospitals, airports, and business parks have already developed microgrids.  They are an idea whose time has come.

Healthcare needs to literally join in.  If there’s a hospital, nursing home, pharmacy, dialysis center, or other health care facility that hasn’t already become part of a microgrid, it’s time.  Those 1960’s-era backup generators are not going to cut it.

Healthcare needs to figuratively join the microgrid movement.  Think of hospitals as the traditional power plants, the loci of the healthcare system.  Everything revolves around them, especially as they’ve bought physician practices, developed more outpatient facilities, and consolidated.  They control how healthcare is practiced and at what cost in their community/region. They power the system.

That’s worked for us, in our dysfunctional U.S. healthcare way, but the cracks are showing. We don’t like how much we’re paying, we’re not seeing that monopolies/oligopolies are getting us higher quality care, and in the pandemic, hospitals did not prove to be enough.  Their staff – which had already been stressed by staffing issues/EHRs/other problems — were overwhelmed, and started leaving.  Patients stacked up in hallways, there wasn’t enough of some critical equipment/supplies, dead bodies had to be held in refrigerated trucks.  

We’re effectively seeing healthcare’s versions of brownouts, or even blackouts.  If there is one thing our healthcare system is not, it is resilient.

A healthcare microgrid would more effectively keep people out of hospitals.  It would rely less on physicians, especially specialists.  It would be community-based.  It would be available 24/7, and be able to flex capacity as needed.  It would be “smart,” and incorporate as many 21^st century technologies as possible, such as home monitoring.  Unlike actual microgrids (but more like most power grids) and unlike current medical practice, it would freely cross city/state/regional lines.

Telemedicine is an example of what should be included in microgrids.  The pandemic taught us the value of telehealth, but lots of existing rules had to be waived for that to happen.  Those rules are being reimposed, just as many of us are going back to seeing physicians in person. Some hospitals are bold enough to impose facility fees for telehealth visits. Those are all signs that telehealth is not part of a microgrid; it’s being coopted by the power plants – er, hospitals.

Similarly, are we really taking advantage of nurse practitioners or physician assistants can do?  Why do we even think of nurse practitioners as “nurses” or PAs just as assisting physicians?  Do we give pharmacists as much authority as their training would allow for?  

And, of course, when are we going to get AI that can be our first line of medical advice, and perhaps more?

These are microgrid questions. They’re not questions we should only be considered during times of extreme crisis, as the current pandemic; they are questions we should be answering for the next crisis.    

The analogy is not perfect. I don’t know exactly what a healthcare microgrid would look like.  But, just as I know traditional power grids are not going to be enough for our energy needs, our traditional healthcare system is not going to be enough for our healthcare needs. We need something more resilient and more localized.  We need healthcare microgrids.

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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What Would Newt Do? Making Value-Based Care Victorious

By MICHAEL MILLENSON

Health care’s much-trumpeted transition “from volume to value” care remains more tepid than transformational, according to a new study. Looking at 22 health systems nationwide, RAND researchers found that compensation continues to be “dominated by volume-based incentives designed to maximize health systems revenue.”

Although confusing payment schemes bear part of the blame, there are deeper problems that appeared in sharp relief when I chanced upon a long-ago PowerPoint from a prominent political strategist and early advocate of “data-driven reimbursement.” 

I refer, of course, to Newt Gingrich. His recommendations from 2007 about designing transformational change in health care provide a perspective that remains useful today in addressing what is ultimately a political problem. Frankly, value-based care (VBC) advocates perform dismally.

Going Along the Gingrich Roadmap

Back in 2004, Gingrich and I both served on a commission seeking to improve the quality of long-term care. This was during a period when a neutered Newt, out of power, was undergoing a political makeover by championing bipartisan health reform ideas such as electronic health records (EHRs) and evidence-based care. He even shared an award from NCQA with then-New York Sen. Hillary Clinton. 

What Gingrich also shared, often, were his thoughts about what was necessary to drive the kind of sweeping alteration of the status quo represented by his leading Republicans to their first House majority in decades. Reviewing that roadmap, it’s not surprising that VBC advocates remain far from their destination.

The journey starts off in the right direction, with VBC advocates following Gingrich’s advice to “focus on large changes.” Trying to upend the way physicians have been paid since Hippocrates made his first house call certainly qualifies. But ambition has to be articulated as part of an organizing and attractive vision.

In 1997, in a book called Demanding Medical Excellence, I summarized the urgency of what we now call value-based care this way: 

Tens of thousands of patients have died or been injured years after year because readily available information was not used – and is not being used today – to guide their care….(The health care delivery system) must be restructured according to evidence-based medical practice, regular assessment of the quality of care, and accountability.

In a similar vein, Gingrich in 2007 emphasized “a clear and compelling vision for quality” that would appeal to patients and medical professionals by promising safe care (no preventable deaths or injuries); consistent clinical excellence (appropriate and effective evidence-based care); and clinicians and staff partnering with patients.

Language That’s Bureaucratic, Not Bold

In contrast, the coalition sponsoring last month’s Health Care Value Week positioned transformation as a series of “models” addressing a bureaucratic checklist of health care “challenges.” The same type of language is used by the Centers for Medicare & Medicaid Services.

Even what the policy community believes are catchy labels may resonate very differently with ordinary people. “Value” care sounds like the medical equivalent of a meal at Taco Bell. (Also, if your child falls sick, do you want “best care” or “best value for the money”?) “Accountable” care has overtones of treatment decisions made by CPAs. And a “medical home” is where Mom says she’d rather die than go to.

What is glaringly absent is a clear vision of a health care system where sick people are not injured, killed or suffer economically in ways we know how to avoid; where there is an explicit emphasis on maintaining health; and where clinicians and health care organizations are enabled and rewarded for achieving these goals.

Unfortunately, “health maintenance organization” was already taken.

The Case That Could Be Made

The reluctance to present straightforward arguments for VBC is particularly frustrating in light of recent studies in JAMA Health Forum and JAMA Open that highlight current system failures. 

For instance, when an organization exits a VBC program such as a Medicare accountable care organization, provider behavior changes along with payment. There were fewer preventive services and “lower quality of care,” a University of Michigan-led team concluded.

In a similar finding of current incentives’ impact, Johns Hopkins researchers singled out “investor ownership” of hospitals as an important factor in the overuse of 17 different (!) “low-value” medical services. This, at a time when the Wall Street Journal has chronicled the growing ownership of hospitals by private equity firms.

But perhaps the greatest effect on individual patients from the lack of feedback or accountability mechanisms was shown in a study led by Harvard researchers that analyzed the records of nearly 9,000 physicians treating commercially insured patients. The results, although part of a long-known pattern, are still startling.

Pregnant? Your odds of getting preventive care as simple as prenatal screening from your obstetrician vary from a low of 31 percent to a high of 94 percent. Heart disease? The chances your cardiologist gives you needed statins to vary from 31 percent up to 71 percent. (Results were adjusted for the patient’s clinical profile.)

But the most jarring variations related not to what wasn’t done, but to what shouldn’t have been done, but was; i.e., care without value. For instance, among patients with newly diagnosed osteoarthritis of the knee or the hip, the top-ranked quintile of orthopedic surgeons, following professional guidelines, performed an arthroscopy just two to three percent of the time. The bottom quintile of surgeons used the arthroscope 31 to 66 percent of the time.

As for patient safety, a separate study found that professional guidelines meant to reduce surgical infections are not being followed over a third of the time. This severe lapse is exposing thousands of Americans to possible “life-changing” consequences such as prolonged hospitalization, sepsis or even death, according to the study’s lead researcher. 

A Willingness to Subvert the Status Quo?

Sixty years ago, science historian Thomas Kuhn wrote a groundbreaking book about what it takes to change an established paradigm. Kuhn demonstrated that logical appeals to evidence don’t work, even with scientists. Instead, paradigm change only occurs when defenders of the old ways can “no longer evade anomalies that subvert the existing tradition.”

Bringing accountability to a medical culture that prizes autonomy, whether done through systemic professional feedback, financial incentives or both requires a genuine paradigm shift. Unfortunately, attacking the status quo of misplaced incentives, ingrained habits and an absence of good information systems is much trickier than proclaiming, “Paper kills,” Gingrich’s pitch for EHRs. There are no easy villains – greedy insurers, rapacious drug companies, high-priced hospitals, or a lack of “consumerism” – to blame.

Moreover, as Eric Patashnik, a Brown University professor and co-author of a book on the politics of evidence-based medicine, told the Washington Post, the public assumes doctors already do the right thing. “The political constituency for evidence-based medicine is weak.”

Certainly, a coalition of provider groups (and others dependent upon their goodwill) is never going to attempt to whip up public support by vividly describing a current-state system riven with crazy-quilt practice variation and tolerating persistently unsafe care. The wiser course is to describe “better quality” with touching anecdotes about home visits by nurses.

There’s another important problem, not spoken about publicly, but epitomized by the RAND study mentioned earlier on compensation. Consider Gingrich’s admonition that a vision of transformational change “must be functionally accurate – you must ‘walk your talk.’” Now, look at the organizations sponsoring Health Care Value Week. How many of them or their parent organizations still depend heavily on revenue maximization from high volume and high prices? 

Democracy’s Deus Ex Machina is Government

Do these factors mean that the move from “from volume to value,” first promised in the Affordable Care Act in 2010, is only slightly more likely than New Newt (v. 2022) reuniting with Hillary? Allow me to suggest a slightly sunnier scenario.

Gingrich’s pro-computerization push worked not only because he was going “with the tide of societal change,” as his strategy outline put it, but also because many others supported the same goal. Even that larger effort ultimately succeeded, however, only after the economic crisis of 2008 prompted federal intervention. With the HITECH Act, the government authorized billions of dollars in payments to physicians and hospitals to subsidize the switch to EHRs.

VBC, however abysmal its advocates’ communication efforts, nonetheless commands strong and broad-based support due both to self-interest (to prevent possibly more radical solutions) and genuine selflessness (it’s the right thing to do). As a result, I believe that the federal government, with private sector support, will via subsidies or mandates do for VBC what was done for EHRs when the opportunity arises. One can only hope that hard lessons learned from the EHR experience will inform the VBC one.

At the Value Health Week summit, Dr. Farzad Mostashari, Aledade’s founder and the former head of the Office of the National Coordinator for Health Information Technology, pointed the way forward. Said Mostashari: “There needs to be a sense of inevitability.”

Michael L. Millenson is president of Health Quality Advisors LLC,
an author and a visiting scholar at the Kellogg School of Management.
He can be reached at mm@healthqualityadvisors.com

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#HealthTechDeals Episode 11: MindMaze, Memora Health, Ro, PriorAuthNow, and Equip

On this episode of Health Tech Deals, Ian Morrison is pinch-hitting for Jessica DaMassa! Ian and I have worked together 25+ years ago, and he’s been sitting in Silicon Valley looking at the American health care system for a long long time. Some deals – MindMaze raises $105M; Memora Health raises $40M; Ro raises $150M; PriorAuthNow raises $25M; Equip raises $58M. Ian also shares his opinions on the American health system and the digital health space.

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THCB Gang Episode 83, Thursday Feb 17th, 1pm PT 4pm ET

Joining Matthew Holt (@boltyboy) on #THCBGang at 1pm PT 4pm ET Thursday for an hour of topical and sometime combative conversation on what’s happening in health care and beyond will be: futurist Ian Morrison (@seccurve); Queen of all employer benefits Jennifer Benz (@Jenbenz);  fierce patient activist Casey Quinlan (@MightyCasey); and & patient safety expert and all around wit Michael Millenson (@MLMillenson)

The video will be below. If you’d rather listen to the episode, the audio is preserved from Friday as a weekly podcast available on our iTunes & Spotify channels

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BREAKING: MindMaze Lands Fresh $105M for Digital Neuro-Therapeutics

By JESSICA DaMASSA, WTF HEALTH

You may know the term “digital therapeutics,” but how about the specialized category of “digital neuro-therapeutics”? MindMaze, which has developed a platform approach to creating prescription digital therapeutics for neurological diseases like stroke, Alzheimer’s, and Parkinson’s has just landed $105 million in fresh funding from Concord Health Partners to further advance development of this unique category of pDTx’s.

CEO Tej Tadi, CFO Kevin Gallagher, and Chief Medical Director John Krakauer get us smart on the neuroscience behind MindMaze, their device-plus-gaming interventions, and how they are gaining reimbursement for their brain health and recovery therapies. Each therapeutic is a bit different – MindPod Dolphin, for example, helps patients rehab upper limb motor skills by way of a dolphin-themed gaming experience that incorporates sensors and an anti-gravity vest. The team says there are 10 clinical trials underway across seven indications, with the goal to bring at least three new prescription digital therapeutics to market by next year.

How will this new funding – and a partnership with the American Hospital Association – aid US market expansion for Swiss-based MindMaze? We explore the company’s growth plans, talk about market readiness for digital therapeutics, and even find out the backstory behind how Leonardo DiCaprio ended up on their cap table.

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What the Pandemic Taught Us About Value-based Care

By RICHARD ISSACS

You’ll recall that we ran a long piece (pt 1, pt 2) about Medicare Advantage from former Kaiser Permanente CEO George Halvorson earlier this year. Here’s a somewhat related piece from the current head of the Permanente Medical Group about what actually happened there and elsewhere during the pandemic–Matthew Holt

The COVID-19 pandemic has provided important lessons regarding the structure and delivery of health care in the United States, and one of the most significant takeaways has been the need to shift to value-based models of care.

The urgency for this transformation was clear from the pandemic’s earliest days, as shelter-in-place orders caused patient visits to brick-and-mortar facilities to plummet. That decline dealt a financial blow to many fee-for-service health care providers, who are paid per patient visit, treatment or test performed — regardless of the patient’s health outcome.

Prepaid, value-based health care systems, on the other hand, have demonstrated that they are better equipped to respond to a continually evolving health care landscape. Because they are integrated, with a focus on seamless care coordination, and they are accountable for both the quality of care and cost, these systems can leverage technologies in different ways to rapidly adapt to major disruptions and other market dynamics. Priorities are in the right place: the patient’s best interests. Value is generated by delivering the right level of care, in the right setting, at the right time.

Because value-based care focuses on avoiding chronic disease and helping patients recover from illnesses and injuries more quickly, it has the promise to significantly reduce overall costs in the United States, where nearly 18% of gross domestic product was spent on health care before the pandemic — significantly more than comparable countries. That figure rose to nearly 20% in 2020 during the pandemic.

While providers may need to spend more time on implementing new, prevention-based services and technologies, they will spend less time on managing chronic diseases. And thanks to the preventive approach of value-based health care organizations, society benefits because less money is spent managing chronic diseases, costly hospitalizations and medical emergencies.

Value-based organizations drive additional societal benefits. They understand that building trust with patients requires cultural competency — tailoring services to an individual’s cultural and language preferences. During the pandemic, building trust was especially important with underserved communities, where mistrust of health care systems is prevalent.

Previous long-term investments in telehealth and remote patient monitoring technologies served value-based organizations well during the early days of the pandemic, when 80% of care delivery occurred via telemedicine. Supported by a relaxation of regulations to help the broader health care system deal with COVID-19 patient surges, doctors delivered more telehealth services via video and telephone appointments; hospitals shifted more care into the home with telemedicine and coordinated care teams; and health care organizations deployed more resources to deliver culturally responsive care.

While the percentage of in-person visits has increased again, patients clearly appreciate the ease and convenience of receiving care via telehealth at home, or wherever and whenever they need it. Many physicians have said they got to know patients better through video visits, because patients are more open to discussing health conditions from the comfort of home. A recent report by McKinsey & Company shows that telehealth utilization is 38 times higher than before the pandemic.

Even before the pandemic, Permanente Medical Groups had explored ways to deliver acute care at home. Both the Northwest Permanente medical group and The Permanente Medical Group in Northern California launched advanced-care-at-home programs that leverage physician-led command centers, community care teams, the organization’s comprehensive electronic health records and remote monitoring to ensure hospital-grade, person-centered care for patients with complex conditions such as sepsis, pneumonia, and coronavirus.

When unprecedented surges led to hospital beds overflowing with COVID-19 patients, value-based health care systems harnessed the power of remote patient monitoring to improve capacity. Building on those efforts, Kaiser Permanente with Mayo Clinic last year announced an unprecedented collaboration to invest about $100 million in a technology company, Medically Home Group, to advance a new health care delivery model that enables more patients to receive acute-level care and recovery services at home. This is part of a movement involving several coalitions of health care systems working to move acute care into the home.

As with telehealth video and phone visits, delivering hospital-level care at home provides another opportunity for health care organizations to gain more visibility into social factors that affect patient health outcomes, such as medication adherence, diet, or food insecurity. The importance of addressing social determinants of health became especially evident during the pandemic as data revealed the disproportionate mortality rate from COVID-19 in Black and Latino communities. Likewise, while value-based health care organizations for years have made non-English-language assistance available to patients, the high death toll in underserved communities underscored the need for even more effective, culturally appropriate communication.

To make sure their messages resonated, these organizations partnered with community leaders who could provide the information and reassurances needed to advance vaccine acceptance. Similar programs included responsive pop-up “vaccine clinics on wheels” that went directly to parks and schools, neighborhood barber shops and beauty salons, and places of worship in underserved urban and rural communities. These efforts offer a window into what the future of value-based care will look like both inside and outside of traditional care settings.

New skills, training and research will be needed by physicians and care teams who will increasingly reflect the diversity of patients and communities served. For example, robust data will be needed to better understand the disparities associated with COVID-19, or for any medical condition. While the U.S. Department of Health and Human Services toward the end of 2020 released guidance that requires labs to include race and ethnicity — along with age, sex and ZIP code — when reporting COVID-19 test results, this data wasn’t required prior to August 2021. To get a better picture of how any disease affects a community, it’s best to collect detailed data from the start.

The health care industry can look to Medicare Advantage, the federal government’s health program that measures and rewards quality coverage and care, as a model for effective, coordinated, managed care. Because Medicare pays a fixed amount per enrollee to providers offering Medicare Advantage plans, care organizations have a powerful incentive to keep patients healthy. The program utilizes the Centers for Medicaid & Medicaid Services Star Ratings system to measure and publicly report plan performance, providing patients with transparency and choice when shopping for quality coverage. In 2022, 89% of all Medicare Advantage enrollees were in plans rated 4 stars or higher.

In addition to improving care quality and patient satisfaction, Medicare Advantage promotes value-based care by reducing health care costs and improving health outcomes for a diverse population of seniors and individuals with disabilities. The program costs U.S. taxpayers 9.5% less per enrollee than traditional Medicare. Medicare Advantage enrollees are 13.4% more likely to be screened for breast cancer compared to those in traditional Medicare, and Medicare Advantage has a 57% lower rate of avoidable hospitalizations for patients with major complex conditions when compared to fee-for-service Medicare.

The pandemic demonstrated the success of value-based models, which take accountability for patient outcomes, and which continue to make necessary, long-term investments to improve care delivery, reduce disparities and focus on population health. Now is the time for a wider range of health care organizations to mobilize by aligning incentives to build a system of care that is more responsive, coordinated, equitable and sustainable.

Richard S. Isaacs, MD, FACS is CEO and executive director of The Permanente Medical Group

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