Accepting your Future Avatar: Leveraging Digital Twins for Transforming Healthcare

by  SMRITI KIRUBANANDAN

A possibility to do better and be better by observing yourself (your twin) reacting to various feeds and gaining the ability to gain better care and improve research, seems like a super power. The concept of a Digital Twin is the ability to replicate a person, an object or a process derived from extracting various data points from internet of things (IOT) that are attached to the original object. One can view how the digital twin responds to various feeds and give us a deeper understanding on the possibilities and impact for the real person or object. Shifting this concept into healthcare, I am going to take this up a notch and propose, what if a person has an opportunity to accept their future avatar presented to them and it is reflected and implemented immediately?

As per Research and Markets report 

• Up to 89% of all IoT platforms will include digital twins by 2025
• Digital twinning will be a standard IoT feature by 2027
• Nearly 36% of executives across a variety of industries understand the benefits of digital twinning, with about half of them planning to use it in their operations by 2028

Here are some of the ways a Digital Twin would play a role in making healthcare accurate, smart and reliable while greatly improving member experience: 

Delivering the right Frequency of Care 

In the United States, 400,000 hospital patients experience some form of preventable harm each year, accounting for a cost of over $20 billion annually.

Giving the proper care at the right time is vital in improving patient experience and the quality of care, and reducing healthcare costs. By using the digital twin concept, we can replicate the process, understand a person’s reactions to different treatments, and help customize the frequency of care needed. That might include understanding and getting more precise with the medication doses based on the Twin’s reactions or refining a type of surgical procedure based on possible recovery and impact. It might inspire a patient to make the right decisions based on the digital twin at the right time. Accepting their future avatar might give a patient hope and psychological comfort before starting a treatment or procedure and, most importantly, could build trust with their provider.

Accelerating Research for Public Health

With the Emergency use authorization provided to Pfizer by the FDA, we were able to produce 7 billion doses of the Covid-19 vaccine within a year, 71.5% were willing to take the vaccine, but a large proportion were hesitant to do so.

The Covid-19 pandemic showed our strengths and weaknesses.How quickly we can accelerate research and release vaccinations during an emergency and yet how do we manage the long-term impact, efficacy, and benefits of the series of boosters and the many probabilities that come with it. By implementing the Digital Twin concept, we would be able to understand the impact based on people’s pre-existing conditions and lifestyle factors, predict the future success rate, and then recommend if one needs another booster or what extra measures need to be taken to keep patients safe and healthy. This could have eradicated the trust and hesitancy many had while receiving their first dose and which then prevented many from taking the extra boosters. It could also perhaps help create a vaccine that can defend us against the many variants. While there are many layers to the complex nature of our understanding of the Covid-19 virus, Digital Twins might allow us to dive deeper into research and become more accurate in our guidance to the public. The concept of Digital Twin could provide a better level of certainty and hope in this context.

Retrofitting our Healthcare Workforce

There are 940,000 active physicians, 5 million active nurse practitioners for 330 million people in the US. 61% of physicians and approximately 40% of nurses are experiencing burnout. We need our healthcare workforce to be in a better place to deliver optimal care. 

The primary reasons for burnout are too many administrative tasks, less time with patients, long hours, a lack of emotional support, poor infrastructure, and difficulty accessing the correct data to give the proper care at the right time. Now, we imagine implementing the Digital Twin concept in this space.We could then predict a healthcare worker’s stress load based on the data points collected and proactively provide them with the necessary support required–giving them a few days off as an example. 

We could even leverage the Digital Twin to understand a hospital working environment. This might help us predict supply chain concerns, improve processes such as patient appointments and billing based on increase or decrease in demand given the recent pandemic, or improve ICU structures. This might be comparable to retrofitting a building to keep it resilient during an earthquake.

Empowering Holistic Healthcare and Wellness

As the Blue Zones research has shown, making the right diet choices, getting enough sleep, spending time in nature, and spending more time with your community have proven to improve a long-range healthy lifespan. Most of us need to be incentivized to make the right health choices. We are now seeing that healthcare is focussing on fueling the FoodRx movement, which involves providers encouraging members to eat more fruits and vegetables and honestly believe in food as medicine. If we implemented a Digital Twin concept, we could show people a road map of how they would be healthier and at the highest optimal rate based on the steps they need to take to get there. Seeing an avatar with a clear roadmap for achieving that could be a game changer to encourage people to make the right choices and truly take healthcare into their own hands. 

Accepting your Future Avatar 

What if you see your future avatar via the digital win concept to be liberating and exciting? Would you look at your future avatar and accept the version with the click of a button by using a mirror effect? Some of the changes we see get imprinted in our DNA within a few minutes. 

As we are in the field of practicing healthcare, acceptance and surrendering play a key role. Are we ready to accept our better versions, and if so, how soon? 

A Digital Twin allows us to make errors, expand our minds, and create a sense of trust and hope within ourselves and our healthcare ecosystem.

Smriti Kirubanandan MS,MPH,CN is the Founder and Executive Producer of the HLTH Forward Podcast & Heads Marketing for the Life Sciences and Healthcare Group at Tata Consultancy Services, This is her first piece for THCB

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Searching For The Next Search

By KIM BELLARD

I didn’t write about ChatGPT when it was first introduced a month ago because, well, it seemed like everyone else was. I didn’t play with it to see what it could do.  I didn’t want it to write any poems. I didn’t have any AP tests I wanted it to pass. And, for all you know, I’m not using it to write this. But when The New York Times reports that Google sees ChatGPT as a “Code Red” for its search business, that got my attention.

A few months ago I wrote about how Google saw TikTok as an existential threat to its business, estimating that 40% of young people used it for searches. It was a different kind of search, mind you, with video results instead of links, but that’s what made it scary – because it didn’t just incrementally improve “traditional” search, as Google had done to Lycos or Altavista, it potentially changed what “search” was.    

TikTok may well still do that (although it is facing existential issues of its own), but ChatGPT could pose an even greater threat. Why get a bunch of search results that you still have to investigate when you could just ask ChatGPT to tell you exactly what you want to know?

Look, I like Google as much as anyone, but the prospect that its massive dominance of the search engine market could, in the near future, suddenly come to an end gives me hope for healthcare.  If Google isn’t safe in search, no company is safe in any industry, healthcare included.

“No company is invincible; all are vulnerable,” said Margaret O’Mara, a professor at the University of Washington told NYT. “For companies that have become extraordinarily successful doing one market-defining thing, it is hard to have a second act with something entirely different.” One Google executive described how Google responded to ChatGPT as “make or break” for the company.

————-

The problem with ChatGPT for search is two-fold. The first is that, while it will give you a plausible sounding answer to almost anything you ask it, as Emily Peck of Axios noted, “ChatGPT has no idea whether anything it says is true.” 

At least with traditional search results, you can see results from several sources and evaluate their credibility. With ChatGPT all that happens behind the scenes. ChatGPT doesn’t care whether what it is telling you is true or not; it’s just interested in providing you a response. That hopefully is something that will improve as ChatGPT “learns” to distinguish true from potentially true to unlikely to probably false and to demonstrably false. Over time, it could probably do that as well as (most) users do. 

The second problem is even more dangerous, for Google: it doesn’t fit with the digital advertising model that delivers most of Google’s massive revenues. “Google has a business model issue,” AI expert Amr Awadallah, told NYT. “If Google gives you the perfect answer to each query, you won’t click on any ads.”

And this threat is happening at a time when Google’s share of digital dollars is already declining.

————–

Forrester Research analyst Rowan Curran sees ChatGPT as a major turning point for AI, telling Venture Beat: “The only thing that I’ve been able to compare it to is the release of the iPhone.”  There were smartphones before the iPhone, just as there were AI chatbots before ChatGPT, but the iPhone raised expectations dramatically. Mr. Curran feels ChatGPT is having a similar effect:

I think what is really unique here is we have a technology that is useful today, that is advancing very quickly, and that we are all learning about in real time — in terms of both how to use it and how to prevent it being used in negative ways.

Sridhar Ramaswamy, co-founder and CEO of ad-free search platform Neeva, is similarly excited, telling NYT: “Last year, I was despondent that it was so hard to dislodge the iron grip of Google. But technological moments like this create an opportunity for more competition.”

In addition to Neeva and Dr. Awadallah’s Ventura, there’s AI-driven search engine You.com, “the AI search engine you control.” As with ChatGPT, users take their chances on the accuracy of results; the site warns: “This product is in beta and its accuracy may be limited,” and  “You.com is not liable for content generated.” 

It’s not as though Google has been ignoring AI. Google helped develop what led to ChatGPT, and has a chatbot technology of its own – LaMDA (Language Model for Dialogue Applications) that is so powerful that some feared it was, in fact, sentient. In addition, Google has a host of AI-based products and tools it is working on. Given its market dominance and reputation, though, it has to be careful how it introduces any innovations.

The very nature of what we expect “search” to be is changing. Results might be a text conversation” with a chatbot. It might be curated videos. It might be Dalle-E 2 or Stable Diffusion creating explanatory images, or it might be your favorite expert explaining it to you in a deepfake video. That’s technology evolving.

The business model problem is far deeper. If search has been, essentially, a way to serve up targeted ads, then a chatbot or other model that doesn’t easily accommodate ads is a problem for companies that have relied on them. And companies that don’t rely on ads to generate revenue have to come up with other revenue sources, in an online world where users expect most things to be “free.”

————–

Healthcare has similar issues with AI. As with search, the first is that it is going to enable new ways of delivering information and even care. Initially it won’t do so with as much accuracy as humans, but it will learn quickly and at some point it will rival – or even exceed – human experts. Healthcare can dig in its heels and stick to the human-driven model, but the AI-driven changes are coming.

Again, as with search, the business model challenge is even greater. The healthcare business model is both exceeding expensive and insanely complicated. It isn’t built at all on what is best for people’s care, much less their health. AI will enable models that are far cheaper, far faster, and potentially much simpler. Healthcare will fight to maintain its sources of revenue, but the revolution is coming.

If I were Epic, the Cleveland Clinic, United Healthcare, Big Pharma, or any of healthcare’s other dominant entities, I’d be watching how Google responds to ChatGPT. 

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The Constitution, Health, and Culture in America

By MIKE MAGEE

“The Right to Health Care and the U.S. Constitution.” On the surface, it sounds like a straightforward topic – a simple presentation. But a gentle scratch at the surface reveals a controversy that literally dates back 250 years and more. Is it a “right”, a “privilege”, or simply a “necessity?”

I’m not a lawyer or Constitutional scholar. But I do know health care, its history, and its many strengths and weaknesses. What does our Constitution have to do with health care? The answer: That depends on how broadly you define “health.”

Before we were ever a nation, there existed a 300 year period of war and conquest, of genocide and superstition masquerading as science, of promises made and promises broken in the Americas. The naive fledgling nation that declared its independence in 1776, knew that what they were attempting was a long shot. As Alexander Hamilton wrote in the first Federalist paper, the pressing question was “… whether societies of men are really capable or not, of establishing good government from reflection and choice, or whether they are forever destined to depend, for their political constitutions, on accident and force.” It was, and is, an open question.

One hundred and seventy years after our Declaration of Independence, General George Marshall raised the same question when charged with rebuilding the destroyed societies of vanquished enemies, Germany and Japan, from ashes. Where should he begin? In 1946, he decided to begin by establishing national health plans in each of those nations. He believed that by creating services that emphasized safety and security; handed out compassion, understanding and partnership in liberal amounts; reinforced bonds between individuals, families and their communities; and processed a population’s collective fears and worries day in and day out, would help establish a level of trust and tranquility necessary to secure the foundations of a thriving and lasting democracy. It was, if you will, a “nation building” plan, The Marshall Plan.

General George Washington’s moment in history  on June 15, 1775 when he assumed the helm of the Continental Army was quite different. He had no such insights. He had his hands full assuring our immediate survival. Governance and representation, rights and privileges, checks and balances – these were issues decidedly on the table in 1776. Health of the population was not. Nowhere in those early years will you find an essay titled “How do we make America healthy?” Arguably, the aristocratic leaders of this fledgling nation spent much of their time doing just the opposite – figuring out how to subjugate women and harm a large portion of their fellow humankind, most notably indigenous natives and enslaved Africans. Had there been a broad goal of creating an equitable healthy population from the beginning, our Founding Fathers would have been forced into a “Truth and Reconciliation” process of our own – an impossibility according to many historians if the goal was to “unite” a group of disparate and independent minded colonies

We went with the “United States” as it was, as it still is. Trump and his Republican admirers are simply residual damage, evidence of the persistence of unhealthy and discriminatory behaviors, and proof positive that “life, liberty and the pursuit of happiness” is quite impossible without good health.

Health is foundational to a functioning democracy. Health is recognized by most throughout the world as a fundamental right, intertwined with our economic, social, and political systems. But health must be shared and be broadly accessible to be an effective enabler of good government.

Our Constitution is aspirational and idealistic – a “living document.”  We have the opportunity to actively pursue a healthy America. It is within our grasp to improve on the Founders vision and demonstrating to Hamilton, in modern times, that we are “capable of establishing good government from reflection and choice.”

The choice of Health Care for All is a basic and foundational component for a thriving democracy. Understanding the Constitution and our nearly 250 years of relevant case law has been an eye opener for me. I thought I really understood the history of health care in America. But viewing it through a legal lens has only reinforced my belief that we together, as Americans, deserve better. We have a right to share a healthy culture, lives of promise and productivity, and secure a bright future in this country we love.

Ignoring health has brought American culture to its knees, allowing weak values, fear, and ignorance to make Trump possible. We shouldn’t require any more proof than this. Surgical extirpation of this malignancy is underway. But that will only bring us back to neutral.

How will we finally make our American culture healthy. General George Marshall would say, “Begin with health. It is a necessity.”

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical-Industrial Complex.”

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“All Men Would Be Tyrants.” History Reverberates!

By MIKE MAGEE

“We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”

This striking and sweeping statement of values, the Preamble to our Constitution, was anything but reassuring to the wives, mothers, sisters and daughters of the Founding Fathers. Abigail Adams well represented many of them in her letter to John Adams in March, 1776, when she wrote:

“Remember the Ladies, and be more generous and favorable to them than your ancestors. Do not put such unlimited power into the hands of the Husbands. Remember all Men would be tyrants if they could. If particular care and attention is not paid to the Ladies we are determined to foment a Rebellion and will not hold ourselves bound by any Laws in which we have no voice or Representation.”

Her concern and advocacy for “particular care and attention” reflected a sense of urgency and vulnerability that women faced, and in many respects continue to face until today, as a result of financial dependency, physical and mental abuse, and the complex health needs that accompany pregnancy, birth, and care of small infants.

The U.S. Constitution is anything but static. In some cases, the establishment of justice, or the unraveling of injustice may take more than a century. And as we learned in the recent Dobbs case, if the Supreme Court chooses, it may reverse long-standing precedents, and dial the legal clock back a century overnight.

Roe v. Wade was a judicious and medically sound solution to a complex problem. Perfection was not the goal. But in the end, most agreed that allowing women and their physicians to negotiate these highly personalized and individualized decisions by adjusting the state’s role to the reality of the 1st, 2nd, and 3rd trimester made good sense. But getting physicians to step forward and engage the issue was neither simple nor swift.

In July, 1933, McCall’s magazine published one of hundreds of ads that year for contraceptive products. This one was paid for by Lysol feminine hygiene. It pulled punches, using coded messages, and suggesting that the very next pregnancy might finally push a women over the edge, and that would indeed be a “travesty.”

The ad read:

The most frequent eternal triangle:
A HUSBAND…A WIFE…and her FEARS

Few marriages would flounder around in a maze of misunderstanding and unhappiness if more wives knew and practiced regular marriage hygiene. Without it, some minor physical irregularity plants in a women’s mind the fear of a major crisis. Let so devastating a fear recur again and again, and the most gracious wife turns into a nerve-ridden, irritable travesty of herself.

Birth control had by then become a huge and unregulated business. As one report noted, “Capitalizing on American’s desire to limit family size in an era of economic hardship, pharmaceutical firms, rubber manufacturers, mail-order houses, and fly-by-night peddlers launched a successful campaign to persuade women and men to eschew natural methods for commercial devices whose efficacy could be ‘scientifically proven’. . . with the industry’s annual sales exceeding $250 million, Fortune pronounced birth control one of the most prosperous new businesses of the decade.”

This was a decided shift from the Roaring 20’s when coded messaging was the rule rather than the exception, and the AMA maintained a respectful, self-protective distance from the controversy.

As one report described, this was “…an era when the American Medical Association did not consider contraception part of medicine . . .The goal of the birth control movement in the 1920s and 1930s was to take power away from the commercial advertiser and place it in the hands of the physician.”

For Margaret Sanger, medicalizing women’s autonomy over birth decisions was essential. Having highly respected and politically powerful physicians as allies in the struggle provided much needed shielding nationwide. Sanger’s efforts to expand women’s health services, especially to immigrants fleeing the war clouds settling over Europe, demanded partnerships with physicians. But physicians were leery when it came to going public in support of birth control. Even noted academic supporters feared being accused of advertising birth control for profit which was distinctly outlawed under the AMA code of ethics.

By 1937, however, the AMA felt the winds of change blowing. FDR already knew a war was coming and that availability of contraception would be a critical factor in avoiding outbreaks of venereal disease among the troops as the nation had experienced in WW I. On the morning of June 9, 1937, the nation awoke to front page headlines in the top two columns of the New York Times that read “Birth Control Is Accepted By American Medical Body: Association Backs Doctors in Use of ‘Legal Rights’ on Contraceptive Advice.”

The body of the article explained that the association’s house of delegates – defined as “the supreme court of American medicine” – adopted two recommendations dealing with the issue. First, “that the American Medical Association investigate the various forms of contraception with a view to disseminating authoritative information on the subject to the medical profession”, and second, “that the association promote the teaching of proper methods of birth control in the medical schools.”

Labeling the action as “another landmark in the annals of American medicine,” they offered perspective noting that “For many years all efforts to gain official status for birth control, as a legitimate part of medical practice, have been bitterly fought and successfully blocked by powerful groups, religious and otherwise, within the ranks of American medicine.”

In the very next paragraph, the Times article asserted that, with this issue now out of the way, the delegates were focused on “the most important problem facing American medicine today” – whether to give official recognition to the principle that  “the health of the people is the direct concern of the government, and that a national health policy directed to all groups of the population be formulated…Whatever the outcome, every one here realizes that organized medicine in America now stands at the crossroads and that it can no longer champion the status quo as it has done in the past.”

Roughly three decades later, on June 7, 1965, in a 7 to 2 decision titled Griswold v. Connecticut, authored by Justice William O. Douglas, the Supreme Court issued a 7–2 decision and struck down Connecticut’s last state law banning the sale and advertising of  contraceptives.

In the Majority Opinion, Douglas wrote: “Would we allow the police to search the sacred precincts of marital bedrooms for telltale signs of the use of contraceptives? The very idea is repulsive to the notions of privacy surrounding the marriage relationship.”

Griswold v. Connecticut  became one of the most referenced landmark cases in history. All Americans now had their “sexual privacy” protected from government intrusion. As a result, a series of cases were successfully built on top of this precedent setting ruling. These included:

Eisenstadt v. Baird (1972) – Contraceptives for Single Adults.
Roe v. Wade(1973) – Abortion Legal in Non-viable Fetus.
Lawrence v. Texas (2003) – Texas Anti-Sodomy Law Unconstitutional.
Obergefell v. Hodges (2015) – Same Sex Marriage Legal.

When the Dobbs decision that effectively reversed Roe v. Wade was handed down, Justice Clarence Thomas in a concurrence statement wrote, “…in future cases, we should reconsider all of this Court’s substantive due process precedents, including Griswold, Lawrence, and Obergefell.”

In a Clarence Thomas world, historic precedent and scientific progress be damned. Bodily autonomy is a product of the state. Health is a luxury, doled out in small measure only to those who toe the religious party line.

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical Industrial Complex.”

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THCB Gang Episode 111, Thursday December 22, 1pm PT 4pm ET

It’s the Christmas special THCB Gang where we review the year! Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday December 22 will be privacy expert Deven McGraw (@healthprivacy), fierce patient activist Casey Quinlan (@MightyCasey); Jennifer Benz (@Jenbenz); and medical historian Mike Magee (@drmikemagee). And then in our end of year tradition a few other gang members will drop in towards the end.

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

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HLTH 2022: Mental Health IT Infrastructure Proves Highly Fundable – Inside NeuroFlow’s $25M Series C

By JESSICA DAMASSA, WTF HEALTH

At the intersection of two (still) hot areas of health tech investment – IT infrastructure and mental health – sits NeuroFlow, a tech platform that integrates into care management systems and EHRs to help clinicians and care managers identify behavioral health conditions in patients as they are getting their annual check-ups, post-partum exams, and other routine healthcare services. The startup just added another $25 million in growth capital to its coffers in mid-October, bringing their total funding to just under $60 million. We chat with CEO Chris Molaro about how this new funding will be used to continue fueling the company’s scale-up efforts and how provider orgs are responding to the added responsibility that comes with providing this type of mental health care screening across its care teams.

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Netflix for Drugs?

By KIM BELLARD

A relative — obviously overestimating my healthcare expertise — asked my thoughts on The New York Times article Can a Federally Funded ‘Netflix Model’ Fix the Broken Market for Antibiotics? I had previously skimmed the article and was vaguely aware of the Pasteur Act that it discusses, but, honestly, my immediate reaction to the article was, gosh, that may not be a great analogy: do people realize what a tough year Netflix has had?

I have to admit that I tend to stay away from writing about Big Pharma and prescription drugs, mainly because, in a US healthcare system that seems to pride itself on being opaque, frustrating, and yet outrageously expensive, the prescription drug industry takes the cake. It’s too much of a mess.

But a “Netflix model” for drug development? Consider me intrigued.

It’s easy to understand why market forces might not do well with rare diseases that need an “orphan drug,” but the “subscription model” approach that the Pasteur Act seeks to address is something that most of us need: antibiotics. Antibiotic resistance has made many of our front-line antibiotics less effective, but discovering new antibiotics is a slow, expensive process, and many pharmaceutical companies are reluctant to take the risk. The Pasteur Act would essentially pay for their development in return for “free” use of subsequently invented drugs.

Credit: Sevahn K. Vorperian/Stat News

There is widespread support for the bill (including, no surprise, PhRMA). Carlos del Rio, president of the Infectious Diseases Society of America (among other roles) writes: “PASTEUR is a unique financing model that creates a reliable market for critically needed antimicrobials — and as a result, promises to ignite a desperately needed revitalization in antimicrobial development.” That’s the hope.

It is worth noting that the U.K. has been testing such a model since 2020, but results so far are inconclusive. Glover, et. alia argue:

…the current subscription funding does not convincingly reward innovative research into new chemical space, a field that many small and medium-sized enterprises are struggling to attract funding for….Rather than supporting a resilient, innovative, commercial antibiotic ecosystem, there seems to be a marked risk that the UK subscription model could fall prey to what is termed the folly of rewarding A when hoping for B.

It wasn’t their intent, but I don’t think I’ve ever read a better description of the US healthcare system than “rewarding A when hoping for B.”

Critics of the Pasteur Act wrote a letter to Congress in November, warning: “Under the Pasteur Act, taxpayer dollars will be wasted as a blank check to pharmaceutical manufacturers for antimicrobials of limited benefit,” One of the signators of that letter, Reshma Ramachandran, argues in The Hill: “PASTEUR would instead signal to drug companies that they can continue the same lackluster antimicrobial development — paid for in large part by the public already — divorced from improving patients’ health.”

Let’s see: the existing business model has led to huge profits for Pharma, high prices for consumers, and yet not enough antibiotics or rare disease drugs, so, no, I’m not keen on subsidizing that industry with guaranteed, upfront payments.

Credit: REUTERS/Srdjan Zivulovic/File Photo

The NYT article mentions other approaches that are being tried to incent antibiotic development. Carb-X (Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator) is a global partnership whose mission is: “Accelerate a diverse portfolio of innovative antibacterial products towards clinical development and regulatory approval with funding, expert support and cross-project initiatives.” It announced its latest funding rounds, targeted at three product categories, in October.

Another NYT article discussed development not of antibiotics but for rare diseases, mentioning n-Lorem, a non-profit foundation that “is focused on creating individual treatments for patients in the United States with nano-rare diseases caused by genetic mutations that affect approximately < 30 patients in the world.” It relies on donations, and has been surprisingly successful in its fundraising to-date, but, as the NYT notes: “Some rare disease experts are skeptical that one nonprofit organization will be able to serve every patient who needs help.”

Some researchers have proposed, instead of the Pasteur Act, setting up federally funded non-profits, staffed by microbiologists, medical chemists, and pharmacologists and overseen by a board of patient advocates, doctors, industry representatives, and others. Dr. Brad Spellberg, one of the authors of the proposal, told KHN: “They would not focus on one drug, per se. They would focus on discovering and developing new, impactful technologies.”

What I don’t want to see, and what I fear the Pasteur Act might do, is to lock in existing approaches with existing companies. As I’m fond of saying, it’s the 21st century; we need 21st century approaches. In particular, taking advantage of our microbiome and synthetic biology.

Just in the past few weeks, we’ve learned that the gut microbiome may drive our motivation to exercise, can be used to improve symptoms of autism and inflammatory bowel disease, and is connected to multiple sclerosis (MS) and depression, binge-eating, and heart-failure. We’re just scratching the surface of the impact of our microbiome on our health, but we know that all those antibiotics we’re keen on wreak havoc on it. Oh, and by-the-way, it is pretty good at developing antibiotics of its own.

We’ve been testing what I’ll call primitive efforts of using fecal transplants to boost the microbiome (the FDA just approved the first such treatment last month). Kate Macbride, writing in Inverse, says: “This approval is likely only the start of a promising future for prescription poop” (otherwise referred to as referred to as fecal-microbial therapy, or FMT).

Alison Halliday, PhD, goes a step further. In Technology Networks, she writes: “Scientists are harnessing the power of synthetic biology to develop a variety of medical applications — from powerful drug production platforms to advanced therapeutics and novel diagnostics.”

Credit: Technology Networks

Jim Collins, Termeer professor of medical engineering and science at MIT, tell her: “By approaching biology as an engineering discipline, we are now beginning to create programmable medicines and diagnostic tools with the ability to sense and dynamically respond to information in our bodies.” He notes: “By applying synthetic biology, we have designed a living therapeutic that has the potential to help counter the potential negative effects of antibiotic use.”

Ms. Macbride points out: “Advances in synthetic biology are enabling researchers to create engineered probiotic bacteria that can sense, record and report on changes occurring inside the gut.” That’s some 21st century medicine.

So, don’t give me a “Netflix” for drugs that gives us reruns and spinoffs, from the same old companies that have been producing them. Give me one that looks ahead to new approaches (like synthetic biology), new theories of medicine/health (like microbiome-based).

Kim Bellard is a former payer exec, former editor at Tincture.io and now THCB regular

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HLTH 2022: Market State-of-Play with Stephanie Davis of SVB Securities

By JESSICA DAMASSA

“If last year was EUPHORIA…‘We made it! Digital health is relevant!’ This year, it’s a little more panic. More, ‘Are we okay???’” SVB Securities’ Senior Managing Director Stephanie Davis says that she’s been getting asked for a lot of advice this year, so we jump on the bandwagon. Should digital health and health tech be worried? What about exits? What areas of health innovation are still hot? Which are not? And, what the heck is “creative destruction” and why is it her favorite buzz phrase from HLTH 2022?

Stephanie answers all our questions, reassures us of the healthcare market’s resiliency, and offers up some high-level perspective on which “wallet” (payer, pharma, or provider) startups will want to align with to weather the short-term.

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Bad Backs & Deductibles

It’s time again for me to use my bad back as a case study in why American health care has such crazy incentives. 

About a month ago at the HLTH conference in Vegas, over the course of a few hours I developed debilitating leg pain. To quote from my earlier twitter  thread on my time in Vegas,  “After 3 days of excruciating pain, my wife insisted I went to the ER. The public policy person in me was horrified but we had already spent our deductible, so the cost was actually lower than paying cash for an MRI”

What actually happened was that after 3 days of dreadful pain & inability to walk (including getting myself home from Vegas using multiple wheelchairs, and being that guy who crawls off the plane onto a wheelchair), I got in to see my chiropractor. He said, you need an MRI to figure out what’s wrong with you. The alternatives were 

Looking good on the gurney!

1) Get insurance to pre approve the MRI. His guess was that that would take a few days or more. I actually called One Medical‘s urgent care video line and the PA I spoke to told me that usually insurance would only approve an MRI after I had done 6 weeks of physical therapy.

2) Pay $500 cash for a free standing MRI that could probably get me in during the next few days 

3) Go to the ER

Now the “incentives” part of this starts to really matter.

It’s November and due to some unrelated medical conditions my family has already spent the $4k deductible connected to our insurance, which comes from a big regional Blues plan via my wife’s employer. (For you health policy wonks, the employer happens to NOT be self insured, so apologies to those of you in the Boston area but the TL+DR is I am helping your rates go up next year!). Of course 6 weeks from Nov 15 is a new year and my deductible resets on January 1st.

So after we leave the chiropractor’s office, I talk to One Medical on the video line which is where I get the news about 6 weeks of PT required before an MRI (and get prescribed some oral steroids which didn’t seem to do too much). At that point my wife takes over and insists I look up the cost of ER care.

It’s a $150 fee once deductible has been met.

She says, “you are in dreadful pain and need care now. And we aren’t waiting 6 weeks for an MRI, and it costs less to go to the ER than paying cash”. 

This discussion was held at a mall where we stopped for lunch on our way home. She had dropped me off about a 20 ft walk from a table. I tried to walk with my stick but I was yelping in pain so much and going so slowly that three little kids came to help me and get me onto a chair! I could tell that she wasn’t very interested in me doing “watchful waiting” at home.

The local hospital was literally 1/2 a mile from the mall, so after lunch my wife drove the car as close to the table as possible, I basically crawled into it, and she took me to the ER. The ER had a wheelchair which made life easier.

They admitted me and asked lots of questions for the Epic EMR. No I wasn’t thinking about suicide, at least not yet! Yes I drink alcohol. No, I wasn’t there just to get opiates. On the other hand, if they happened to have some….

One thing that they never asked at triage or in my intake interview me was to see my insurance card. And they didn’t have me sign anything, yet…

Al Lewis will get very upset with me and them

Here’s a quick detour as to what Al Lewis & Quizzify tell you to do about ER costs. If you are going to an ER and have NOT spent your deductible, they have a great idea for you. They tell you that when the ER gives you its terms and conditions, you physically write in that you will only pay 200% of the Medicare rate. Medicare pays about 1/10th of what many ERs charge, but once you change the contract and sign it, the hospital can’t get out of it because of the EMTALA regulations they have to treat you. I know this because last year my kid fell off my shoulders in a pool, cut his chin (on my head incidentally!) and we had to take him to the same ER. But because it was during Covid they only let one parent in, and I forgot to tell my wife about that trick. It cost us our $4,000 deductible (about $1.5k a stitch!)

Now remember that this time, I already knew our deductible was spent so my cost for me to go to the ER was going to be just $150. I waited for the payment form to see how or if I could change it as Quizzify suggests but they never gave me one! In fact, I didn’t sign anything until I was already on a gurney. While I was waiting, a clerk came in and had me sign on an iPad. He told me it was my HIPAA authorization, then he had me sign one other thing (not a payment form). Then later he asked for my insurance card, I don’t recall signing any payment authorization, but I didn’t care.

I didn’t care because I knew my max cost was $150. In fact as I was going there to get an MRI, I didn’t want them to think they would only get the Medicare x 200% rate. I wanted them to be incented to give me the MRI, and I specifically asked for it. The doctor told me I might not get it, but then an hour later a spot in the MRI schedule had miraculously opened up! A cynic might suggest that seeing a fully insured patient show up demanding an MRI was too good for Marin Health to turn down.

As it happened, they had pumped me full of opiates which not only got me some relief from the pain for the first time in 4 days but as it turned out was necessary for me to get into the MRI.Had I gone to a freestanding MRI, not an ER, it’s likely that I wouldn’t have been able to actually get into the machine because you have to be able to straighten your leg (somewhat) to fit it in. In fact getting into the MRI was so painful on my leg that they gave me more opiates. But that is of course my post-facto justification for going to the ER.

So now you all want to know the answer. The charges finally appeared on my insurance website. They were 

$17,249.06 hospital

$399 ER medical group (CEP) 

$242 other doctor (I don’t know what that was but it came from a Foundation connected to the hospital)

Of course charges don’t mean anything if you have insurance. BCBS actually paid — $10,263, $235 & $132 respectively (I included my $150 copay in the $10,263)

Total cost = $10,630

Had I done this early in the year, I would either have used the Quizzify technique, in which case the ER (had it been paying attention) would have likely tried to boot me out without an MRI, or I would have suffered through the process of getting the MRI approved, or I’d have paid cash.

So the conclusion is, the incentives to me the patient to not care about cost because I had already spent my deductible–in other words based purely on the date–made a swing of over $10,000 in costs (and revenue) for the system.

And it gets worse, or better. I’m now receiving regular in home physical therapy via Luna (my plan covers that but not Hinge Health,  Sword Health  or Kaia Health which are remote PT care and would be much cheaper). I am getting better–probably about 50% of normal now. But I am likely to go for a steroid shot in my back at the 6 week mark.

Why? I will not go into what needs to be another post on how totally appalling the data surrounding back pain is, and how impossibly bad it is to try to make a decision based on 15 year-old papers that are inconclusive. But if you have a herniated disc or pinched nerve the best option is to try to work it out using physical therapy. The next progression is a steroid shot, and finally a microdiscectomy.

In order to discover what my options were I spoke to my PCP, my chiro and one surgeon. The consensus was to do PT and have a steroid shot if things weren’t better by about 5-6 weeks post-injury. I  tried to get hold of various pain doctors. Not easy. There’s yet another blog post to be written about how far behind the customer service from doctors’ offices is. Literally the internet state of play for most of them is for you to download a PDF, fill it in by hand and fax it in. And then hope they call you back in 72 hours.

Eventually I got hold of two different pain specialists and had very successful video calls with both of them (one via Doximity, one via Zoom connected to Epic). They were both able to diagnose me as I limped around in my office. Both recommended a steroid shot if I wasn’t better in 3 weeks. But one of them was busy for at least 8 weeks!  The other one thought he could get me in before and had his office call me.

I was offered Jan 3. 

Guess what I said. “Can you fit me in before Dec 31?”  Why yes, they could squeeze me in on Dec 27. Of course my deductible resets on Jan 1. So of course I want to have the procedure this year, not next!

I’ll let you know how that goes next year….but my apologies to Boston area insurees.

Matthew Holt is publisher of The Health Care Blog and hopes to be back on skis this winter

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HLTH 2022: Health Tech Market Check-Up with Lux Capital’s Deena Shakir

By JESSICA DAMASSA, WTF HEALTH

Deena Shakir, General Partner at Lux Capital, shares her take on the market state-of-play for healthcare innovation amid these “tumultuous” economic times. As an investor, Deena has been a passionate advocate for women and children’s health and her fund, Lux Capital, invests broadly in health tech – pre-seed to pre-IPO, from virtual-first care delivery businesses like women’s health clinic, Maven, (on whose Board Deena sits after Lux co-led their $110M Series D) to health tech infrastructure businesses like Commure and Tendo and those working in AI, ML, and robotics.

We get into which types of emerging health businesses Deena thinks are still “hot” despite the downturn, specifically talking about what’s changing in women’s health including current care gaps, health IT infrastructure and its “moment” this year, and how the opportunities in mental health investing are starting look more compelling on the diagnostic side of things.

Overall sentiment: Deena says, “As Venture Capital investors we have long time horizons. We want to invest in things and have a 10-year plus outlook, so it’s actually an incredible time to be doing early-stage investing.” But, what if you’ve sailed past your Series A? Well…tune in to find out what Deena has to say about her experience with later-stage startups and those who thought they may have had an exit planned this year.

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