Insurtech startup Sidecar Health’s valuation hits $1B  

The new startup unicorn’s insurance product enables members to shop for medical services and pay directly for care. The company raised $125 million in a recent funding round, boosting its valuation, which it will use to increase its footprint and launch new products.

Strategies that will help make 2021 a banner year for life sciences industries

Covid-19 showed that pharma companies can be nimble and implement changes that prevent processes from weighing down on operations. But which of these operational and strategic changes will stand the test of time and make this year and the future bright for the industry?

What we’re expecting in 2021, and beyond…

From telehealth to digital trials, customer engagement to healthcare data, Healthware Group outlines the key trends that are expected to shake up digital health this year.

Well, it goes without saying, COVID-19 has resulted in a rapid adoption of digital technologies across all industries, most notably in healthcare. There are several important aspects to these shifts for pharma, biotech and medical device companies, so what can we expect to see over the next 12 months and beyond?

Telehealth keeps maturing and integrates into care pathways

The adoption of telehealth, which was already accelerating pre-pandemic, has been exponentially driven by COVID-19. It’s swept aside several historic barriers to uptake, such as the healthcare professional and patient desire to physically meet, medical guidelines that focus on in-person diagnosis and reimbursement models that discourage remote consultation.

2020 was a psychological and systemic tipping point for telehealth, adoption of which will accelerate in 2021 as it becomes the norm, in the process driving new self-service approaches to medicine and participation-based reimbursement models.

Mental health worsens – digital tools continue to fill the gap

The emotional and psychological wellbeing of the world’s population has been put under tremendous strain because of the COVID-19 pandemic, exacerbating an existing global mental health epidemic.

There is an opportunity to address this at scale with digital tools and techniques, and expand support into just about any therapeutic area through the holistic integration of mental and behavioural health solutions that improve patient care.

Mental health support is key to improving outcomes in chronic diseases and can also provide an invaluable empathetic and psychological component of support for people dealing with other complex medical situations.

When coupled with conversational interfaces and AI, digital mental health solutions are perceived as highly personal by users and open the door for a profound transformation in people’s relationships with digital health tools and how they integrate them into their daily lives.

Clinical trials get more and more digitalised

As study enrolment continues to lag drastically behind target, patient recruitment is set to rely even more on digital marketing to improve its speed and accuracy. These techniques will also need to be applied to screening, interviews and the actual studies themselves, particularly as more trials move towards a virtual, decentralised or hybrid model.

Digital screening of subjects makes their geographical location less relevant, which may make studies more attractive as there is less requirement to travel. And with the support of remote sampling, and growing tools for gathering real world evidence about improved quality of life, the clinical trials of the future can be done faster, with lower costs and on a more decentralised basis.

‘Aging in place’ becomes more commonplace

Aging in place will become more common as the baby boomer generation ages and feels more comfortable leveraging tools like remote monitoring, telehealth and disease management platforms. Living independently will be critical to this age group and digital health tools will be critical in supporting them in this endeavour. The adoption and growth of digital tools is expected to explode as a result. This is certainly evident in the amount of investment in the category.

The inevitable invisibility of digital health

Technology will begin to dematerialise, as has already been seen in other industries, and digital health will increasingly be woven into everyday objects. We’re starting to see this happen through the emergence of smart homes and smart cars (i.e., steering wheels that also measure the driver’s heart rate). As more data is collected passively, there will be more opportunities for integration.

No more ‘business as usual’ for pharma’s customer engagement

Life sciences companies need to rethink their customer engagement paradigms in light of changing customer preferences. Pharma should update the role of the rep from simply delivering a sales message to more of a concierge service model, providing access to – and facilitating the delivery of – meaningful content that physicians want and need. As such, reps will need to be reskilled.

Self-service models for HCPs are also needed in order to provide access to content when and how they want it – as already seen in other industries, the expectation will be for 24/7 access.

While digital-only product promotion was laughed at just a year ago, we’ve already seen the first digital-only blockbuster launch, and we expect this will become a growing trend. Pharma companies will need to continually rethink what works and not be afraid to experiment with solutions they’ve never tried before.

A growing need for digital health proficiency

While 2014 is often quoted as the first year where the majority of working healthcare professionals were digital natives, 2020 was the year when the remaining digital immigrants were forced to travel into the online world. Post-pandemic, online engagement will continue to be commonplace and 2021 will see much broader rollouts of ‘digital’ training for medics (young and old), and all medical societies will have to embrace online learning and digital publishing models. In addition, the subject matter for ongoing disease research will focus even further on COVID-19 comorbidities and the longer-term impact of the virus.

Integration of telehealth strategy into commercial models

Amazon is making a serious global move into healthcare delivery with the acquisition of PillPack, and its recent launch of Amazon Pharmacy. With Amazon Care, it is starting to experiment with virtual health care services, offering them first to its own employees and with plans to expand them to health plans and other employers.

These moves are bringing Amazon closer and closer to a true end-to-end model, similar to the turnkey solutions offered by the likes of Hims, Ro and others in the category with an original focus on conditions with an associated stigma. We’re already starting to see some pharma build end-to-end solutions like this in birth control, and we’re expecting to see these efforts branch out into other disease areas. And beyond building end-to-end solutions like this to drive scripts, we expect pharma to begin approaching telehealth more generally as a potential marketing/sales channel, helping to remove barriers to care, improving online visits and even helping HCPs understand the benefits.

Consolidation of digital health platforms

Digital health platforms will likely see a wave of further consolidations, with a few leading platforms starting to stake out their respective positions across the healthcare spectrum. This trend can be seen as a net positive, in that it will enable digital therapeutic solution developers to concentrate on building the individual vertical products that will live on these platforms.

However, issues around data ownership and sharing will need to be addressed and resolved (by way of regulations) to avoid a situation where solutions that are competitive to platform owners’ own cannot find a way to be listed on them. Price controls will also need to be mandated to avoid the types of ‘access taxes’ currently seen, such as with Apple’s App Store fees on sales charged to app developers (upwards of 30% of sales collected), who have no way to sell their apps directly to iPhone users.

Services to manage and make sense of the health data explosion

We expect to see what we call Health Data as a Service (HDaS). As more solutions and devices generate increasing amounts of health data, there is a greater need to aggregate that data in a useful way for consumers. Consumers want and need tools to make sense of all that data. They also want to ensure they know who has access to that data, and control over where it can flow. So, we expect to see more tools supporting consumers in this way.

We look forward to continuing to contribute to the advancement of digital health and digital transformation across all aspects of the healthcare ecosystem and welcome your thoughts on the above.

About the authors

Roberto Ascione is Healthware Group’s CEO and founder, and a pioneer in digital health and a recognised thought leader, people-inspiring founder, serial entrepreneur and global manager.

 

Gerry Chillè is senior partner at Healthware Group, in charge of its digital therapeutics pipeline strategy and development.

 

Fulvio Fortini is Healthware’s managing director – Italy. With more than 20 years of experience, he is passionate about digital technology and an expert in the health and wellness sector.

 

Petteri Kolehmainen is managing director – Finland, leading Healthware’s Helsinki team, with focus the Nordic and Baltic countries, bringing strong experience in technology and business development.

 

Kristin Milburn is managing director at Healthware Labs, which was launched in New York in 2015 with a mission to accelerate digital health and therapeutic innovation.

 

Ariel Salmang is managing director at Intouch International, a unique joint venture between Healthware Group and the Intouch Group.

 

Paul Tunnah is Healthware’s chief content officer and managing director UK, and a recognised author, speaker and industry advisor with a passion for helping organisations tell authentic stories.

 

If you’d like to learn more about how we think please reach out to [email protected]

About Healthware Group

Healthware is a next-generation integrated consulting group. For more than 20 years it has been offering large companies and start-ups in the life sciences and insurance sectors a unique set of services and expertise in strategic consulting, communication, technology and innovation to drive the digital transformation of health.

The post What we’re expecting in 2021, and beyond… appeared first on .

Searching for vaccine information? Google wants to make it easier to find

As states begin to roll out vaccines to the broader public, Google will make it easier for people to find out when they are eligible and where they can get a vaccine. The effort is part of a broader push, including $150 million in grants to promote vaccine education and equitable access.

Mayo Clinic, Microsoft, Cerner join coalition to provide digital access to Covid-19 vaccine records

A group of organizations have come together to work on a solution that will provide digital access to Covid-19 vaccination records. As the country eyes a challenging transition to the new normal, a verifiable vaccine record will be necessary to ensure individual and community safety.

Patients report unmet care needs despite rising telehealth use

Roughly a third of adults had a telehealth visit in the first 6 months of the pandemic, according to a new survey conducted by the Urban Institute. But not everyone who wanted a telehealth visit was able to access it, leaving some adults with unmet care needs.

How digital health startups are staying competitive in a fast-growing arena

In an increasingly crowded landscape, digital health startups must figure out what sets them apart. Three startup leaders shared what differentiates their companies from the competition at this year’s J.P. Morgan Healthcare Conference.

Blue KC, HealthMine’s expanded partnership will extend digital rewards program to ACA members

The Missouri-based payer is expanding its partnership with the technology company to offer an incentive and rewards program for its Affordable Care Act members in an effort to increase engagement.

Digital Health: Avoiding a Second TechLash!

By JEFF GOLDSMITH

As John Glaser argued a recent piece in Harvard Business Review, many health care executives seem have been blinded by the shiny object that is digital health. Forgive us for a powerful feeling of déjà vu.   Since the last major digital innovation in health, the electronic health record, fell far short of expectations and probably generated a negative return on investment for many care systems, it is worth thinking about to avoid the same fate with this new wave of digital tools.

 As COVID raised concerns about the safety of in-person visits to clinics and physicians’ offices, digital health visits soared during the spring. Traditional health care organizations large and small -hospitals, health plans, physician groups- have since struggled to integrate digital technology effectively into their care offerings and management structure. 

In other industries, digital technology acts as a  force-multiplier for the core business -it helps firms make much more efficient use of their workforce, customers’ time and physical capital.  Amazon used its cloud-based IT infrastructure and sprawling  digital “catalog” to compress time to customer fulfillment,  eliminating the need for customers to visit stores to get what they needed.  And by leveraging other firms’ inventories, it reduced the need to purchase, warehouse and physically handle more than half of what they sell. 

Similarly, digital health applications should not be thought of as a “new product”. Indeed, the capability for digital visits and monitoring and digitally enabled remote work has existed (some say, languished)  for almost two decades.  Digital health tools should be thought of as force multipliers for the trusted relationships at the heart of healthcare. Clinicians can be in two places at once-  transforming how patients and clinicians interact by removing both time and physical location as constraints.  At the same time, telework enables healthcare enterprises to make more efficient use of scarce clinical and administrative person-power,  shrinking their physical capital footprint. 

Achieving savings in clinician time and reduction in overhead were the twin drivers of Kaiser Foundation Health Plans’ successful digital health strategy. Kaiser’s two-decade long investment in virtual care has resulted in more than half of Kaiser subscriber interactions with their caregivers (preCOVID)  being electronic. The savings in reduced clinic time and overhead dropped through directly to Kaiser’s bottom line by minimizing the consumption of resources inside Kaiser’s fixed capitation pool.  But you do not need to be fully, or even partially, capitated to reap digital health’s benefits.

Optimize Physician Time 

The biggest benefit digital health offers to care systems is optimizing use of clinician time, the scarcest resource in the health system. A digitally connected care giver can quickly field the first two or three questions about the patient’s condition in real time or closely asynchronously on their smart phone, potentially ruling out the need for an in-person visit or directing the person to seek immediate care for conditions that truly require it.

Often, the marginal visit is a product of patient anxiety, which can be alleviated by digital interaction- via email, text, voice or video. Virtual interactions will also help in dealing with administrative details related to care-prescription renewals or health insurance approvals-which presently result in medically  unnecessary visits.    This will lead to a bimodal distribution of digital “visits”- more short, focused transactional visits and more longer and detailed interactions perhaps leading to in-person examinations. 

It may be that the real advantage of telehealth is as a screening and staging tool, not as a full-on substitute for in person visits.  How these services are paid for is a sleeper issue; following the lawyers into billing per call or per minute is actually a terrible idea, with predictable political risks.  The optimal payment model is including telehealth interaction in a subscription (per month) fee. 

The reduction of triage and administrative visits frees up in person clinician time to focus on those conditions that require physical examination or detailed face to face interaction, and perhaps increases billable diagnostic testing.   These effects should be both countable and capturable as dollar savings or as accelerated patient revenues.    Digital technology can also dramatically improve the efficiency of continuing professional education and physician to physician consultation by eliminating the need for travel and its attendant costs. 

Optimize Patient Time

Creating speed-to-results/action is the key benefit digital health creates for patients.  Consider the pre-COVID state of the interaction from the patient’s standpoint.  Patient experiences a troubling symptom.   They voice call their physician’s office for an appointment (often waiting on hold for the scheduler), sometimes waiting days or weeks to see them.   When appointment day arrives, they must take time off work or home responsibilities, drive to the physician’s office, park, wait in the waiting room to be seen, fill out the inevitable clipboard, get whatever diagnostic tests are required, and  eventually see their physician.   All in, the appointment itself can wipe out the better part of a morning or afternoon- cancelling out a half day of work, and/or requiring childcare.    

Digital interactions should help reduce queues for visits, and enable better and tighter scheduling of the residual in-person interactions.  But crucially, real-time or “close” asynchronous telehealth interaction  with patients accelerates the health system response to problems that are time-sensitive that  require either intervention or prescription medication. This is particularly important for the unstable chronically ill patients who suffer from asthma, diabetes or cardiac arrythmia or other conditions that can quickly tip into life threat.  Avoiding unnecessary acute interventions by nipping problems in the bud is the key way digital health can reduce health costs.   Again, these savings should be quantifiable.   

Optimize the Onsite Health and Support Workforce And Reduce Overhead

The increase in clinical interactions that can be handled virtually dovetails with the increased amount of administrative activity that can be handled virtually via teleconference and remote asynchronous work done at home.  This can generate potentially large savings in reduced physical plant costs for offices and parking.   Just in the first six months of the pandemic, Americans saved a stunning 60 million hours of commuting time by telework arrangements, nearly a third of which savings went into working additional hours. 

Administrative  and physician office space freed up by digital technology can be compressed, or else subleased to other users.  Surplus parking space can be repurposed to serve the supply chain or else leased to other users. The health system’s carbon footprint and energy costs can also be reduced.  All these savings can be quantified.    Telework will also accelerate the acceptance of business process outsourcing for expensive functions like revenue cycle and IT management that are not location-critical, further enabling health systems to reduce headcounts and reduce their fixed expenses. 

You Cannot Manage What You Do Not Measure

Digital technologies can help make an overburdened and stressed care system more affordable and responsive.    Digital connectivity helps curate clinician time and enable health systems control their expenses under the immense pressure from COVID.  Patients’ time can be conserved by digital connectivity, assuaging safety concerns,  increasing patient loyalty and  solidifying healthcare enterprises’ market share. 

However, these benefits will not be realized unless health enterprises actively manage them.  Failing to measure the resultant savings in time against their investments in digital health could mean that care systems will be not realize an acceptable  return on their investment. No technology is inherently transformational; it is how it is managed that makes the decisive difference.   Soaring expectations could easily turn to disappointment without the disciplined application of these powerful digital tools. 

Jeff Goldsmith is President, Health Futures Inc, and author of  “Digital Medicine: Implications for Healthcare Leaders” (2003: Health Administration Press).

#Healthin2Point00, Episode 176 | Optum acquires Change & deals for Hinge, Liva, and Metronom

Insurgents have stormed the Capitol and we’re still here to talk about health tech deals. On Episode 176, Jess and I discuss Optum acquiring Change Healthcare in a $13.5 billion deal, bringing it back to Jess’s interview with CEO Neil Crescenzo bout what Change Healthcare does with the connective tissue of big healthcare. Hinge gets $300 million in a Series D – this is valued now at $3 billion. Finally Liva Healthcare, which is like European Livongo, raises €24.5 million and Metronom Health gets $22.2 million for yet another CGM. —Matthew Holt

Push for better patient outcomes drives new standard of care [Sponsored]

heart, doctor, cardiac

In this webinar on Feb. 10,healthcare experts from Desert Oasis Healthcare and iRhythm Technologies will discuss how Zio monitors, designed to be worn for longer duration than holter monitors, represent a new standard of care in remote cardiac monitoring.

#Healthin2Point00, Episode 175 | Haven, Color, RapidSOS & more

Today on Health in 2 Point 00, Jess and I chat about Haven finally closing its doors. On Episode 175, we cover Color raising $167 million growing fast as the major COVID tester in the Bay Area and 23andMe scoring $82.5 million. RapidSOS quietly raised another $51.2 million on New Year’s Eve, Fruit Street Health raises $22 million for chronic condition management, and finally Centene acquires Magellan for $2.2 billion. —Matthew Holt

No Safe Haven to be Found!

By MIKE MAGEE

Can you wrestle a collusive, private, profiteering Medical-Industrial Complex to the ground by throwing more private entrepreneurs at it? Apparently not.

The very public collapse of Haven – the widely heralded health joint venture of Amazon, Berkshire Hathaway, and JP Morgan Chase – is a case in point. After three years, it is unclear whether they were a public-spirited triad trying to bathe efficiency into our bizarre employer-based health insurance scheme, or becoming predatory investors in one of the most profitable segments of our national economy.

When launched nameless in January, 2018, most of the focus was on the three amigos – Warren Buffett, Jamie Dimon, and Jeff Bezos. The linking of hands of the nation’s biggest technology power player, her most revered and respected investor, and her highest ranked financial all star, was impossible to ignore.

What were they up to? No one was quite sure. But there was enough concern about disruption of a sector controlling nearly 1/5 of the American economy that prices of CVS Health, Walmart, Cardinal Health and Express Scripts dove south.

This week, with the announcement of the non-profit joint venture’s collapse, analysts wasted no time piling on. As one said, “Haven had a rocky three years, running up against vague marching orders, a lack of direction, and obstacles inherent to the healthcare landscape.”

But it didn’t start that way. Warren Buffett presented health care that day as “a hungry tapeworm on the American economy.” Jamie Dimon noted that we pay twice as much for poorer quality care than other developed nations. And Jeff Bezos suggested that it was time for PBM’s and insurers to trim their sails.

By the summer of 2018, the three signaled they were seriousby hiring widely acclaimed health leader, Atul Gawande, as their CEO. As Buffett said, “Jamie, Jeff, and I are confident that we have found in Atul the leader who will get this important job done.” It would be another nine months before they could settle on a name for the venture – Haven (as in safe haven for their 1.3 million combined employees).

CNN Business reporter Tami Luhby laid out the stakes at the time. “The expectations are enormous: Gawande has been given a lot of latitude, a lot of time — and most importantly, a lot of money — to curb the ‘hungry tapeworm on the American economy’…”

Gawande had many adoring admirers. Niall Brennan, chief executive of the Health Care Cost Institute, at the time stated, “The cynic in me … wonders if anybody can make a difference. The optimist in me would say that if anybody can make a difference, it’s probably Atul…He’s a god-like rockstar in health care…an incredible visionary thinker and clinician with also a track record of innovation.”

But the plan was fuzzy from the start. Gawande stated with a broad sweep, “The good news is the best results are not the most complicated or expensive. The right care in the right place is often more effective and less costly than what we get today.”

That didn’t threaten the Medical-Industrial Complex much. They’d heard it all before. But his June, 2019 speech at the Aspen Institutewas somewhat alarming. He said, “I think the only way we go is by having us collectively paying into a system that no matter where you’re employed, you have coverage all along the way, and that’s what I think people mean by single-payer. It’s the necessary way to go.”

Gawande set about assembling a first rate executive team, eventually amassing 57 employees in Boston to run the non-profit venture. But when his highly respected chief operating officer, Jack Stoddard, formerly the lead at United Healthcare’s Optum, up and left after only 8 months without explanation, analysts began to ask questions.

Investors became skittish. Some noted that Gawande was splitting his time – still writing for the New Yorker and working as a Harvard based surgeon. Others pointed to an absence of organizational cohesiveness. All three partners were also pursuing independent ventures in the health care space, and were continually running into proprietary roadblocks.

Amazon, in particular, had its own agenda. Their wearable health tracker, Amazon Halo, augmented by Alexa features, was now joined by virtual and in-person Amazon Care clinics for its own employees. Those employees have access to premium priced prescription drugs after the company purchased PillPack for $753 million in June, 2018.

Other analysts noted a lack of momentum. The first market forays – like their new no-deductible insurance policy – was slow to come and not overwhelmingly embraced by the 30,000 JP Morgan employees. There were also rumors that Amazon in particular was about to pull its financial support.

In May, 2020, Dr. Gawande announced his own exit, partially under the cover of more active reporting and commentary necessitated by the growing pandemic. Ultimately, he agreed to serve on President-elect Biden’s coronavirus advisory board.

On January 3, 2021, came the announcement that Haven would cease to exist next month. As one analyst put it, this “is a reminder that the U.S. healthcare sector is incredibly resistant to makeovers…”

And yet, it is useful to ask why none of the Triad seem to have regrets.

Jamie Dimon said, “Haven worked best as an incubator of ideas, a place to pilot, test and learn—and a way to share best practices across our companies. Our learnings have been invaluable.”

Warren Buffett said previously, that this was a “a first step in what is bound to be a long journey.“

And a Bezos spokesperson noted, “The venture’s backers found Haven was a good venue to test new ideas and best practices that could be better implemented individually.”

TIME correspondent Karl Vick, in an article titled “What Happens When Amazon Takes on Health Care”, in February, 2018, wrote:  “The U.S. health care system is the antithesis of Silicon Valley.”

But is it really? Are these three really any different than all the other collusive members of the Medical-Industrial Complex? Or are they simply entrepreneurs seeing a unique business opportunity?

There is a reason why all other developed nations maintain public regulatory oversight and control of their national health care systems. It is because they learned long ago that there is no “safe haven” when it comes to ceding control of health delivery oversight to profiteers.

Mike Magee, MD is a Medical Historian and Health Economist and author of “Code Blue: Inside the Medical Industrial Complex.“

Health Care: Don’t Be Evil

By KIM BELLARD

Google’s corporate motto – written in its original Code of Conduct — was once “Don’t be evil.”  That softened over time; Alphabet changed it to “Do the right thing” in 2015, although Google itself retained the slogan until early 2018.  Some Alphabet employees think Google/Alphabet has drifted too far away from its original aims: they’ve formed a union in order to try to steer the company back to its more idealistic roots.

Parul Koul and Chewy Shaw, two Alphabet software engineers, announced the Alphabet Workers Union in a New York Times op-ed, vowing to live by the original motto, and to do what they can to ensure that Alphabet and its various companies do as well.  They assert: “We want Alphabet to be a company where workers have a meaningful say in decisions that affect us and the societies we live in.”

It’s past time that health care workers, including physicians and executives, stood up for the same thing.

Ms. Koul and Mr. Shaw cite several grievances, including payouts to executives accused of sexual harassment, the firing of a leading AI expert over her efforts to address bias in AI, and company efforts to “keep workers from speaking on sensitive and publicly important topics.”  Doing the work, even doing it well and being well paid for it, is not enough:

We care deeply about what we build and what it’s used for. We are responsible for the technology we bring into the world. And we recognize that its implications reach far beyond the walls of Alphabet.

Their goal is for Alphabet “to be a company where workers have a meaningful say in decisions that affect us and the societies we live in.”  Alphabet, they say, “has a responsibility to prioritize the public good. It has a responsibility to its thousands of workers and billions of users to make the world a better place.” 

Investors may not quite agree.

In an AWU statement, Nicki Anselmo, Program Manager, explained: “This union builds upon years of courageous organizing by Google workers…Our new union provides a sustainable structure to ensure that our shared values as Alphabet employees are respected even after the headlines fade.”

Google’s official response, released by Kara Silverstein, Google’s director of people operations, was predictably bland:

We’ve always worked hard to create a supportive and rewarding workplace for our workforce.  Of course our employees have protected labor rights that we support. But as we’ve always done, we’ll continue engaging directly with all our employees.

So far, slightly over 200 Alphabet employees have signed on, out of some 120,000 employees (and roughly the same number of contractors or temps).  AWU is part of the Communication Workers of America (CWA) but has not had an employee election or ratification from the National Labor Relations Board, and so won’t have collective bargaining rights. 

Veena Dubal, law professor at the University of California, told NYT:

If it grows — which Google will do everything they can to prevent — it could have huge impacts not just for the workers but for the broader issues that we are all thinking about in terms of tech power in society,

I won’t try to predict how successful AWU will be, either in terms of building its membership or influencing Alphabet’s priorities, but I admire the goals.  But if there is an industry in which its employees need to speak up about their organizations’ need to prioritize the public good, it is health care.

Right now, of course, we have healthcare workers putting themselves at risk fighting the pandemic, putting their own health and lives at risk.  It’s admirable, it’s heroic, and it must be commended.  But those efforts can’t mask actions that those same organizations are taking or allowing that aren’t so noble.

In no particular order:

  • Even, or because, COVID-19 vaccines are scarce, we’re already seeing reports about rich or influential people “cutting in line” to get their vaccine early;
  • We want people to get COVID tests, and they’re supposed to be free, but some health care organizations have found ways to include “surprise bills” for them;
  • We’ve seen health care workers silenced, fired or forced to resign for speaking out about poor working conditions or lack of personal protective equipment (PPE) during the pandemic;
  • Health care workers have had to walk off the job over wage and labor condition disputes during the pandemic;
  • We still have hospitals suing patients for unpaid bills, even after promises not to during the pandemic;
  • As bad as the racial disparities are in our health care system normally, they’re even worse with COVID-19, and may further worsen with the vaccine rollout;
  • There are profound gender wage disparities among healthcare workers, and they may be getting worse;
  • While pharma is getting plaudits for its rapid response to develop COVID-19 vaccines, it is also busy further raising prices;
  • Already wealthy, nominally non-profit hospitals are raking in billions of disaster relief funds;
  • Health insurers have done exceedingly well financially during the pandemic.

“Don’t be evil” would seem to apply.

What we need are the health care front line workers and leaders who will stand up and say, this is not good for our patients.  This is not good for our society.  This is when the needs or goals of our organization do not take precedence over the public good.

There are unions in healthcare already, even for physicians, but as a percent of all healthcare workers they have made about as many inroads as AWU has at Alphabet, and over a much longer period of time.  I have mixed feeling about unions generally; while they brought workers many important protections and benefits, they’ve often fallen ended up being more about workers’ insular interests than about broader social priorities.  But sometimes organizing is necessary.

Every health care organization should be, to quote Ms. Koul and Mr. Shaw about their goals for Alphabet, “a company where workers have a meaningful say in decisions that affect us and the societies we live in,” and which “has a responsibility to prioritize the public good.” 

If that is not true of your healthcare organization, if your healthcare organization isn’t committed to “don’t be evil,” then what are you prepared to do about it?

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Goodbye, 2020. Hello, 2030

By KIM BELLARD

2020 is almost over; thank goodness.  It has been one of the strangest, and longest, years most of us have ever endured.  We’ve all probably known someone who contracted COVID-19; many of us have had lost loved ones from it.  Most of us have had to make drastic changes to our lives – masks, social distancing, limits on family visits, eating out, concerts, or trips among them.  No, 2020 can’t get over fast enough.

I was struck, though, by a quote I recently read.  Loren Padelford, a vice-president at Shopify, told The Wall Street Journal: “Covid has acted like a time machine: it brought 2030 to 2020.” 

Gosh, I hope not.

Mr. Padelford went on to explain: “All those trends, where organizations thought they had more time, got rapidly accelerated.” These trends include the shift from physical to online, further decline of cash, and work from home/remote learning.  Individuals/families without broadband are being left behind; companies not investing in IT and logistics may not be here in 2030.  Healthcare has not been exempt from these trends.

The pandemic has illustrated both the great strengths and the great weaknesses of the U.S. healthcare system.  Among the strengths are the courage and professionalism of our health care workers, the innovation that has delivered several vaccines within a matter of months, and the ability to adapt to an existing but underutilized mode of care in telemedicine. 

Among the weaknesses, of course, are the lack of planning and coordination that has doomed testing, contact testing, and supply of personal protective equipment; the patchwork quilt of insurance coverage that has left even more without coverage (e.g., due to loss of job based coverage and/or lack of Medicaid expansion); the refusal of many to act in their own best health interests, such as not wearing masks or taking vaccines

Legislators/regulators may be taking bold actions like throwing money at healthcare organizations, vowing that the COVID testing and vaccines are “free,” and loosening restrictions on telemedicine, but the underlying disfunction in our healthcare system has never been more visible.  We don’t test enough or fast enough.  We have sick people on gurneys in gift shops, we have dead people in refrigerator trucks, and we still have people crushed by their healthcare bills.

Please, don’t let this be a picture of 2030.

2030 is a decade, three Presidential administrations, six Congresses, and hundreds of state/local governments away, so it’s hard to predict what healthcare might look like then.  Some think our current crisis is the perfect opportunity to take big, bold political action on healthcare, and it should be, but I must admit I’m dubious we’ll take it.

Instead, I’ll offer a few more measured – but important — hopes for 2030:

Ensure a floor of coverage: ACA was supposed to achieve this, but a Supreme Court ruling and a number of ideological states kept it from happening.  I don’t know if we’ll ever get to true universal coverage, be that “Medicare For All or something else, but we should at least be able to ensure that cost is not a barrier to coverage for anyone, especially for the poorest among us.  Maybe we should shoot for “Medicaid For All” and let those who choose “buy up.”

Ensure a ceiling for spending: Again, ACA addressed this, with out-of-pocket maximums and cost-sharing reductions, but too many people still end up spending too much of their money on healthcare (think about surprise bills or non-covered services).  A healthcare system that drives people into bankruptcy and/or takes them to court for services they cannot afford is just indefensible.  We should stop defending it.

Oriented around virtual care: Telehealth/telemedicine/virtual care has been around for at least two decades, but barely was a ripple in the healthcare system until COVID-19 sparked it into prominence.  However, right now it still is being bolted on to our system, rather than being truly integrated, and those bolts aren’t even all that strong.  By 2030, virtual care – in whatever form it may take by then (think AI/holograms/etc.) should be part and parcel of all health care, the first point-of-contact for most needs. 

Quality first: We talk about quality in healthcare, but we don’t really know what it is, much less measure it.  Our various attempts at payment reform have failed either to improve quality or to control costs, and will continue to do so as long as there is not agreement on the quality that is delivered for those payments.  In a world of continuous monitoring, there’s no reason for us not to know which patients got how much better through what interventions from which health care professionals.  That information would allow us to tie reimbursement appropriately to quality of care/outcomes.

Big picture: In the big picture, health is not just connected to medical care but also to vision and dental care.  In the big picture, health is not just connected to care but also to lifestyle and environment (SDoH).  In the big picture, our microbiome is integral to “us” and to our health.  But most of our healthcare system and our solutions to improving it focus mainly on the smaller, medical picture.  That it so 19th century of us, yet 2030 brings us almost a third into the 21st century.  We need to think much, much bigger – starting now.

————

December has been the worst month of the pandemic in the U.S.  Many experts think that the worst is yet to come, despite vaccinations beginning.  2020 may be ending but what has happened in 2020 is going to have a long and very unpleasant tail. 

2020 is a decade after ACA passed, and, let’s be clear, our healthcare is much better for it.  But if 2030 doesn’t find us with significantly more improvements than the 2010’s brought us, well, expect many more bad years like 2020. 

We can muddle through another decade of incremental improvements in our healthcare system.  We can lurch from crisis to crisis, addressing each without tacking the underlying weaknesses that allow them to become crises.  We can continue to astonish the world with our profligate spending and very mediocre outcomes

Me, I’m hoping 2030 will astonish us by how far we’ll have come.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Need to Choose a Doctor? What Does AI Think About the Choices?

By ZEESHAN SYED

Tens of millions of Americans rely on consumer experience apps to help them find the best new restaurant or the right hairdresser. But while relying on customer opinion might make sense for figuring out where to get dinner tonight, when it comes to picking which doctor is best for you, AI might be more trustworthy than the wisdom of the crowd.

Consumer apps provide us with rich data categories that often take into account preferences, from location to free wi-fi, to help users narrow down choices. Navigating your health insurer’s network of physicians is a different proposition, and some of the popular ranking systems reportedly have significant limitations. Doctors are often categorized by specialty, insurance, hospital, or location, which may be effective for logistics, but fail to take into account a patient’s unique health conditions and say very little about what an individual patient can expect in terms of health outcomes. Research from my company Health at Scale shows that 83 percent of Medicare patients seeking cardiology care and 88 percent of cases seeking orthopedic care may not be choosing providers that are highly rated for best predicted outcomes based on each patient’s individual health conditions. 

Deep personalization is exactly what physicians, health systems, and insurers need to offer patients to improve outcomes and lower costs across the board. A study using our data recently published in the Journal of Medical Internet Research sought to quantify how consumer, quality and volume metrics may be associated with outcomes. Researchers analyzed data from 4,192 Medicare fee-for-service beneficiaries undergoing elective hip replacements between 2013-2018 in the greater Chicago area, comparing post-procedure hospitalization rate, emergency department visits, and total costs of care at hospitals ranked highly by popular consumer ratings systems and CMS star ratings as well as those ranked highly by a machine intelligence algorithm for personalized provider navigation.

The results showed that patients treated by hospitals ranked highly by the machine intelligence-based algorithm experienced better health outcomes and lower total costs of care than those treated in hospitals rated highly by the other approaches. Not only did machine intelligence outperform the field on all three metrics, but in some cases the hospitals ranked highly by other approaches had worse outcomes.

The machine intelligence algorithm employed here solves a problem long believed to be intractable: modeling how physician outcomes vary from patient to patient across a broad set of health factors. Using anonymized health record data from over a hundred million lives in the U.S., the machine intelligence algorithm constructs a detailed profile for each provider in a health insurance network and their history of optimal outcomes with specific patient profiles relative to one another. The model uses this information and a richly detailed profile of a patient to create a personalized ranking of providers for the patient. Using a nationwide dataset enables rigorous evaluation of the model across specialties and geographies, ensuring that the model is as accurate for assisting a heart patient in Houston as it is for the hip patient in Chicago. In short, by developing highly detailed profiles of both provider and patient, machine intelligence can apply big data solutions to a small data problem.

So what does all of this mean? The results show that relying on general, sometimes arbitrary metrics may be of limited utility when considering provider options relative to a personalized and outcomes-based approach. If insurers or care managers employ more precise machine intelligence tools to inform these patient decisions, they may take a step closer to care that is highly personalized and highly effective, based on selecting the right physicians based on each patient’s unique medical needs. Yet there is still room to grow: just 26% of patients in the study attended the hospital that machine intelligence determined was top rated for them.

To improve the health care system for patients, care managers and insurers need to use the best decision-making tools to guide their search for care, focusing on technologies that account for the health variables that make each patient unique and providing suggestions that prioritize measurable health outcomes. Machine intelligence is proving its ability to make care navigation simple and precise, demonstrating that we can make selecting a doctor both less like a drudge through the phonebook and more reliable than advice from strangers on an app.

Zeeshan Syed, CEO of Health at Scale, was a Clinical Associate Professor at Stanford Medicine and an Associate Professor with Tenure in Computer Science at the University of Michigan.

Startup gets Army funding to test wearable monitor for early Covid-19 detection

Remote monitoring startup BioIntelliSense and Royal Phillips received $2.8 million to test BioIntelliSense’s device for the early detection of Covid-19 symptoms. The startup received FDA clearance for its small, adhesive monitoring device last year.

Catching up on care post Covid-19 requires ‘digital compassion’

In addition to human empathy, we are also seeing a new “digital compassion” emerging as healthcare providers work to support patients in need during this uncertain time. Showing this kind of compassion has become easier as technology becomes more advanced and patient-centric in response to the pandemic.

Olive CEO Sean Lane on 2020’s Big Numbers: 3 Funding Rounds, $450M, & a 5-Point Plan for the Future

By JESSICA DaMASSA, WTF HEALTH

Arguably 2020’s hottest health tech startup, Olive (olive.ai) closed THREE funding rounds this year, totaling $450M and valuing the company at $1.5B. Backed by a “who’s who” of technology, healthcare, and health tech venture capital, Sean Lane, CEO, clues us in about just what makes Olive so damn fund-able. The company boasts a “healthcare AI workforce” that tackles all the back-office processes hospitals use to run their organizations. This is not sexy stuff — filing and tracking insurance claims, ordering inventory, managing suppliers, etc. What’s hot, though, is how Olive is able to automate these tasks (according to Sean, currently many of these processes are handled by spreadsheets and faxes), “learn” as she’s doing it, and create efficiencies and cost savings across all of Olive’s 600+ hospital client-base as she does. Could this be the end of “admin expense” in healthcare? If what Olive is currently doing isn’t enough, we dive deep into Olive’s strategic plan — ALL FIVE POINTS OF IT (!) — to learn what’s next. My favorite? Number 3. The one where Olive starts to INSTANT PAY CLAIMS to completely disrupt hospital cash flow.

Streaming, Baby Yoda, and Healthcare

By KIM BELLARD

I’ve never seen The Mandalorian.  I don’t have Disney+.  But I know who Baby Yoda is, and I’m pretty sure Disney is counting on that.  Hollywood, in case you haven’t been paying attention, is going through some radical changes.  There may be some lessons for healthcare in them. 

2020 has been the year of streaming.  Moviegoing isn’t entirely dead in the pandemic, but it may be on life support, with major chains like Regal and AMC barely staying out of bankruptcy.  “Yes, there is pent-up demand to see movies in a theater,” Hollywood insider Peter Chernin told The New York Times.   “But people change their habits.”

Indeed, they do.  A new Press Ganey survey found that telemedicine visits shot to 37% of all visits in May, then settled down to around 15% – far above less than 1% pre-COVID-19.  Habits do, indeed, change, even in healthcare. 

Hollywood has made some startling announcements in the past few weeks that illustrate how swiftly changes are coming to the entertainment industry:

Disney: Disney expects to have 100 new titles – TV shows or movies – each year for the next few years.  Disney chairman Bob Iger noted modestly: “The pipeline of original content we’re making is much more robust than originally anticipated.”  Of particular note, though, CEO Bob Chapek said, “Of the 100 new titles announced today, 80 percent of them will go to Disney Plus.” 

NYT characterized the move as: “Here is a 97-year-old company making a jump to direct-to-consumer hyperspace.”  (If you don’t get the reference, you probably didn’t get the Baby Yoda one either). 

The strategy appears to be working.  Disney said that its year-old Disney+ streaming service already has 87 million subscribers; it had originally projected to reach this number by 2024.  Now it expects to reach 260m subscribers by 2024.  And those numbers do not include Disney services Hulu (39m) and ESPN+ (12m).  Collectively, Disney now expects up to 350m subscribers by 2024. 

Warner Bros: Although Disney expects some of its movies to still have theatrical runs prior to streaming, Warner Bros announced in early December that all of its 2021 releases will be available for streaming on its HBO Max service upon release, rather than after the “traditional” 90+ day wait (outside the U.S., where HBO Max is not yet available, the movies will still be in theaters first).  It had previously announced that its big 2020 release – Wonder Woman 1984 – would be released this way.  Shares of major theater chains dropped precipitously after the latest announcement.

“We see an opportunity to do something firmly focused on the fans, which is to provide choice,” WarnerMedia CEO Jason Kilar wrote.  That’s all well and good, but it’s worth noting that Warner Bros is owned by AT&T, and AT&T views this strategy as a way to instill more loyalty to its wireless services, even at the potential cost to theater revenues.

———–

If you’re worried about the original streaming service – Netflix – don’t be.  Although its growth has slowed, that’s partly because it already has close to 200m subscribers worldwide.  Its stock is up over 50% YTD, and even the announcements from Disney and Warner didn’t seem to shake that.  Similarly, Amazon Prime has over 150m video users, more than half of them in the U.S., and continues to invest heavily in new streaming content.

It’s a new world for Hollywood.  Brooks Barnes, NYT entertainment reporter, wrote: “one Warner Bros. executive told me that “the town” felt like a dismantled movie set: The gleaming false fronts had been hauled away to reveal mere mortals wandering around in a mess.”  Another Hollywood insider told him: “I see this as a time of opportunity.  Sometimes you have to take it down to the studs and build something new.”

Healthcare’s “false fronts” have been torn down too.  We’ve exposed our glaring lack of public health infrastructure, our inability to generate enough PPE, our testing has been abysmal, and now our hospitals, particularly our ICUs, are overflowing.  We’re used to handling expected elective surgeries and even “normal” emergencies, but were caught flat-footed by a pandemic. 

 If ever there was a time to take healthcare “down to the studs and build something new,” this is it. 

We brag about the increases in telemedicine, but we should note the CMS rules that have expanded its use are only temporary.  We haven’t addressed the inter-state licensing issues.  We’re not even doing telehealth visits all that well; the Press Ganey survey concluded: “The bad news is that patients clearly feel that the process of telemedicine (logistical things like ease of scheduling and making audio/video connections) falls short.” 

We’ve seen dramatic declines not just in office visits but also in use of preventive services and screenings, elective surgeries, emergency room visits, even heart attacks.  We just don’t know if these declines are good or bad.  Researchers Allison H. Stokes, PhD, and Jodi B. Segal, MD, suggest in Health Affairs: “We see a unique methodological opportunity to evaluate the harms of low-value care.”  Another researcher, Dr. H. Gilbert Welsh agrees, telling NYT: “We are in the midst of an unprecedented natural experiment that gives us an opportunity to determine the effect of a substantial decline in medical care utilization.” 

But will we take advantage of that opportunity, or will we just go back to our old ways once the vaccines work their magic? 

E.g., will healthcare just expect patients to go back to the theater?  Or will major healthcare companies bet big on the future: “streaming” (aka telehealth) as the main consumer point-of-contact, with patient convenience as a main driver?  Where digital is the norm? 

Disney’s physical locations – its theme parks – are hemorrhaging money, and Warner Bros has suffered dramatic declines from theater revenues, but both are betting big on their virtual strategies – and the markets are rewarding them.  Warner says its announcement is only a strategy for 2021, but, as NYT put it:

It will be almost impossible to go back, and it may force other studios to abandon the old model. Fans trained to expect immediate gratification will not be eager to return to the days of giving theaters an exclusive period to play movies.

We shouldn’t expect patients to go back to the “old” healthcare system either. 

I’m not expecting healthcare to have a Baby Yoda caliber idea, but it can certainly do better than its current Jar Jar Binks strategies.   

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Kaiser Permanente tests referring patients to 6 digital mental health tools

The managed care company picked six mental health apps that it made available to its members over the past two years. It recently published a paper showing patients were more likely to download or use digital health tools when referred by a physician.

#Healthin2Point00, Episode 174 | Cityblock, Elation, Modern Health, LeanTaaS & Well

Today on Health in 2 Point 00, Jess has me weigh in on Cityblock Health’s big raise of $160 million bringing their total up to 300 million to improve health for low-income patients. On Episode 174, Elation, which is Cityblock’s EMR as well as that for some other independent primary care clinics, raises $40 million and working their way into a tough market. Modern Health raises $50 million for the “fourth” pillar of care, providing another mental health platform. LeanTaaS raises $130 million, providing a digital front end for hospitals and smooth out patient access, in contrast to companies like Olive working on the backend. Finally, Well gets $40 million in a Series A using AI and behavioral economics to provide health information and coaching. —Matthew Holt

The Pathway to Health Leads Through Clean Energy Technology

By MIKE MAGEE

Health reporting this week is rightly dominated by the challenging worldwide distribution of the Pfizer vaccine for Covid-19. Bringing the virus to bay is job #1, not only to preserve human life but also our global economy. But this week, on the 5th anniversary of the Paris Agreement, we are reminded that our long term human health, including clean air and water, mitigation of weather-related human disasters, and regulations that lessen our chronic burden of disease, depend as much on energy policy as they do health policy.

Nowhere is this more evident (though largely hidden from sight) than in our planet’s positioning to address global warming. The Paris Agreement, the climate accord signed by 195 nations, was abuptly dismantled by Trump four years ago. But President-elect Biden has signaled that his first order on January 20, 2021, will be to rejoin the agreement.

As Trump patronized his fossil fuel funders, and promised that “we’re going to have clean coal and we’re going to have plenty of it,” the oil and gas industry wrote down the value of its assets $170 billion in the first 6 months of 2020.

Acknowledging as much this past week, a cabal of energy investors, with combined assets of $9 trillion, signaled a shift in their strategy with a pledge to harmonize their investments with net-zero carbon emissions by 2050.

Those investors haven’t suddenly “discovered religion.” No. They’re looking at the numbers.

Clean energy options like solar and wind, combined with the latest battery technology, are now 79% cheaper to produce than US coal production. Investors realize that 90% of the new energy capacity generated worldwide in 2020, as reported by the International Energy Agency, has come from clean energy.

Efficiency, profitability, and technology in clean energy are now aligned. The cost of solar panels has dropped 89% in just the last decade, while wind turbines are close behind with a 59% drop in the same time period. The cost of batteries have declined in tandem by 89% resulting in just a two year horizon before electric vehicles reach cost parity with the venerable fossil fuel guzzling internal-combustion engine.

But what about jobs? The news here is even better. Clean energy is currently generating three times as many jobs as fossil fuels. Solar jobs alone are outpacing overall job growth five-fold.

As Trump was fiddling, American cities and states were quietly adjusting their energy investment strategies. Much of the credit goes to former Vice-President Al Gore, whose leadership in this arena has been tireless and earned him a well-deserved share of the 2007 Nobel Peace Prize.

Al Gore will be highly visible as part of the US delegation in November, 2021, when all signators of the Paris Agreement reconvene in Glasgow, just a 1 hour and 11 minute drive north from the Trump Turnberry Golf Course. But the true celebrity at that historic gathering will be infromation technology.

Gore helped Climate Trace in 2019. As their site describes:

 “In 2019, a group of nonprofits including US-based WattTime and UK-based Carbon Tracker teamed up to apply for Google.org’s AI Impact Challenge with a proposal to monitor all global power plant emissions from space. Google.org not only selected the project for a $1.7 million grant, but also sent a group of seven skilled data engineering and machine learning Fellows to work alongside WattTime and Carbon Tracker for six months to help bring the initiative to fruition.

After the announcement of the Google.org grant, the teams were surprised to immediately hear from over 50 other organizations and scientists around the world offering to help. So they began systematically investigating: Could mixing and matching innovations from various groups improve global emissions monitoring even further? Among the new collaborators was Vice President Gore, who had long suspected that improved global emissions monitoring through satellites and AI held dramatic potential to accelerate climate progress.”

Gore sees the ability to track real-time atmospheric carbon emissions as a “game-changer.” Combined with efficiency, low cost, and jobs, Gore writes, “This precision tracking will replace the erratic, self-reported and often inaccurate data on which past climate agreements were based.”

If you feel Al Gore is overly optimistic, consider the words of thought leader and Silicon Valley entrepreeur, Tony Seba, co-founder of RethinkX, an independent think tank that analyzes and forecasts the speed and scale of technology-driven disruption. Last month in a report titled, “Rethinking Energy 2020-2030: 100% Solar, Wind and Batteries is Just the Beginning”, he stated,

“The implications of this clean electricity disruption are profound. Not only can it solve some of society’s most critical challenges but it will usher in hundreds of new business models and create industries that collectively transform the global economy. When a system generates hyperabundant electricity at a marginal cost close to zero, the potential for new value creation is limitless. This isn’t a problem of overcapacity. This is a Super Power solution.”

Mike Magee, MD is a Medical Historian and Health Economist and author of “Code Blue: Inside the Medical Industrial Complex.“

The Evernorth Digital Health Formulary & the Disruption of the Digital Health Payment Model

By JESSICA DaMASSA, WTF HEALTH

Last December, Express Scripts — now a part of Evernorth — became the first PBM to go to market with a digital health formulary. Basically, adapting the vetting, organizing, and pricing functions of a traditional medication formulary to the digital (health) age. Mark Bini, Chief Patient Experience Officer, spearheaded the effort, meant to alleviate the burden faced by Evernorth’s clientbase of 4,000 employers and health plans, who’s HR benefits teams want to make digital health solutions available to the 100+ million members of their health plans, but don’t have a frictionless, repeatable way to do so. As Mark puts it, “if you’ve seen one digital health startup, you’ve seen one.” And, for an HR benefits administrator whose inbox is inundated by digital health companies, the challenge of dealing with different levels of clinical validation, different data needs, different contracts, and, probably, most frustrating, different payment models that are often separated from their health benefit and pharmacy benefits, Evernorth’s Digital Health Formulary eases a real burden. So, a year in… how’s it going? Have Evernorth’s clients bought into more digital health solutions as a result of the formulary? What’s uptake been like among the populations they manage? And, how has this been working out for digital health startups? Mark gives us an update, talks through the details of the selection process, AND reveals what he’s got planned next. Spoiler: The evolution of the Formulary means adding more cohorts of digital health solutions more frequently, increasing the number of digital health solutions covered under drug benefits, getting a beat on longitudinal digital health engagement, and working out how to help consumers navigate all the various health tech options that are available to them.

Docs are ROCs: a simple fix for a “methodologically indefensible” practice in medical AI studies

By LUKE OAKDEN-RAYNER

Anyone who has read my blog or tweets before has probably seen that I have issues with some of the common methods used to analyse the performance of medical machine learning models. In particular, the most commonly reported metrics we use (sensitivity, specificity, F1, accuracy and so on) all systematically underestimate human performance in head to head comparisons against AI models.

This makes AI look better than it is, and may be partially responsible for the “implementation gap” that everyone is so concerned about.

I’ve just posted a preprint on arxiv titled “Docs are ROCs: A simple off-the-shelf approach for estimating average human performance in diagnostic studies” which provides what I think is a solid solution to this problem, and I thought I would explain in some detail here.

Disclaimer: not peer reviewed, content subject to change 


A (con)vexing problem

When we compare machine learning models to humans, we have a bit of a problem. Which humans?

In medical tasks, we typically take the doctor who currently does the task (for example, a radiologist identifying cancer on a CT scan) as proxy for the standard of clinical practice. But doctors aren’t a monolithic group who all give the same answers. Inter-reader variability typically ranges from 15% to 50%, depending on the task. Thus, we usually take as many doctors as we can find and then try to summarise their performance (this is called a multi-reader multicase study, MRMC for short).

Since the metrics we care most about in medicine are sensitivity and specificity, many papers have reported the averages of these values. In fact, a recent systematic review showed that over 70% of medical AI studies that compared humans to AI models reported these values. This makes a lot of sense. We want to know how the average doctor performs at the task, so the average performance on these metrics should be great, right?

No. This is bad.

The problem with reporting the averages is that human sensitivity and specificity live on a curve. They are correlated values, a skewed distribution.

The independently pooled average points of curved distributions are nowhere near the curves.

What do we learn in stats 101 about using averages in skewed distributions?

In fact, this practice has been criticised many times in the methodology literature. Gatsonis and Paliwal go as far as to say “the use of simple or weighted averages of sensitivity and specificity to draw statistical conclusions is not methodologically defensible,” which is a heck of an academic mic drop.


What do you mean?

So we need an alternative to average sensitivity and specificity.

If you have read my blog before, you would know I love ROC curves. I’ve written tons about them before (here and here), but briefly: they visually reflect the trade-off between sensitivity and specificity (which is conceptually the same as the trade-off between overcalling or undercalling disease in diagnostic medicine), and the summary metric of the area under the ROC curve is a great measure of discriminative performance. In particular the ROC AUC is prevalence invariant, meaning we can compare the value across hospitals even if the rates of disease differ.

The problem is that human decision making is mostly binary in diagnostic medicine. We say “there is disease” or “there is no disease”. The patient needs a biopsy or they don’t. We give treatment or not*.

Binary decisions create single points in ROC space, not a curve.

The performance of 108 different radiologists at screening mammography, Beam et al, 1996.

AI models on the other hand make curves. By varying the threshold of a decision, the same model can move to different places in ROC space. If we want to be more aggressive at making a diagnosis, follow the curve to the right. If we want to avoid overcalls, shift to the left.

The black line is the model, the coloured dots are doctors. From Gulshan et al, 2016.

As these examples show, groups of humans tend to organise into curves. So why don’t we just … fit a model to the human points to characterise the underlying (hypothetical) curve?

I’ll admit I spent quite a long time trying various methods to do this, none of which worked great or seemed like “the” solution.

I’m not alone in trying, Rajpurkar et al tried out a spline-based approach which worked ok but had some pretty unsatisfying properties.

One day I was discussing this troubling issue with my stats/epi prof, Lyle Palmer, and he looked at me a bit funny and was like “isn’t this just meta-analysis?”.

I feel marginally better about not realising this myself since it appears that almost no-one else has thought of this either**, but dang is it obvious in hindsight.

Wait … what about all those ROCs of docs?

Now, if you read the diagnostic radiology literature, you might be confused. Don’t we use ROC curves to estimate human performance all the time?

The performance of a single radiologist reported in Roganovic et al.

It is true, we do. We can generate ROC curves of single doctors by getting them to estimate their confidence in their diagnosis. We then use each confidence level as a threshold, and calculate the sensitivity and specificity for each point. If you have 5 confidence levels, you get a 5 point ROC curve. After that there are established methods for reasonably combining the ROC curves of individual doctors into a summary curve and AUC.

But what the heck is a doctor’s confidence in their diagnosis? Can they really estimate it numerically?

In almost all diagnostic scenarios, doctors don’t estimate their confidence. They just make a diagnosis*. Maybe they have a single “hedge” category (i.e., “the findings are equivocal”), but we are taught to try to avoid those. So how are these ROC curves produced?

Well, there are two answers:

  1. It is mammography/x-rads, where every study is clinically reported with a score out of 5, which is used to construct a ROC curve for each doctor (ie the rare situation where scoring an image is standard clinical practice).
  2. It is any other test, where the study design forces doctors to use a scoring system they wouldn’t use in practice.

The latter is obviously a bit dodgy. Even subtle changes to experimental design can lead to significant differences in performance, a bias broadly categorised under the heading “laboratory effects“.

There has been a fair bit written about the failings of enforced confidence scores. For example, Gur et al report that confidence scores in practice are concentrated at the extreme ends of the ranges (essentially binary-by-stealth), and are often unrelated to the subtleness of the image features. Another paper by Gur et al highlights the fact that confidence scores do not relate to clinical operating points, and Mallet et al raise a number of further problems with using confidence scores, concluding that “…confidence scores recorded in our study violated many assumptions of ROC AUC methods, rendering these methods inappropriate.” (emphasis mine)

Despite these findings, the practice of forced confidence scoring is widespread. A meta-analysis by Dendumrongsup et al of imaging MRMC studies reported that confidence scores were utilised in all 51 studies they found, including the 31 studies on imaging tasks in which confidence scores are not used in clinical practice.

I reaaaaally hate this practice. Hence, trying to find a better way.


Meta meta meta

So what did Lyle mean? What does meta-analysis have to do with estimating average human reader performance?

Well, in the meta-analysis of diagnostic test accuracy, you take multiple studies that report the sensitivity and specificity of a test, performed at different locations and on different populations, and you summarise them by creating a summary ROC (SROC) curve.

Zhang and Ren, a meta-analysis of mammography diagnostic accuracy. Each dot is a study, with the size of dot proportional to sample size (between 50 and 500 cases). Lines reflect the SROC curve and the 95% confidence interval.

Well, it seems to me that a set of studies looks a lot like a group of humans tested on a diagnostic task. Maybe we should try to use the same method to produce SROC curves for readers? How about Esteva et al, the famous dermatology paper?

This is a model that best fits the reader results. If you compare it to the average (which was reported in the paper), you see that the average of sensitivity and specificity is actually bordering on the inner 95% CI of the fitted model, and only 4 dermatologists perform worse than the average by being inside that 95% CI line. It certainly seems like to SROC curve makes more sense as a summary of the performance of the readers than the average does.

So the approach looks pretty good. But is it hard? Will people actually use it?


Is it even research?

I initially just thought I’d write a blogpost on this topic. I am not certain it really qualifies as research, but in the end I decided to write a quick paper to present the idea to the non-blog-reading community.

The reason I felt this way is that the content of the paper is so simple. Meta-analysis and the methods to perform meta-analysis is one of the best understood parts of statistics. In fact, meta-analysis is generally considered the pinnacle of the pyramid of medical evidence.

Metanalysis is bestanalysis.

But this is why the idea is such a good solution in my opinion. There is nothing fancy, no new models to convince people about. It is just good, well-validated statistics. There are widely used packages in every major programming language. There are easily accessible tutorials and guidelines. The topic is covered in undergraduate courses.

So the paper isn’t anything fancy. It just says “here is a good tool. Use the good tool.”

It is a pretty short paper too, so all I will do here is cover the main highlights.


What and why?

In short, a summary ROC curve is a bivariate model fitted on the logit transforms of sensitivity and specificity. It comes in two main flavours, the fixed effects model and the random effects model, but all the guidelines recommend random effects models these days so we can ignore the fixed effects versions***.

When it comes to the nuts and bolts, there are a few main models that are used. I reference them in the paper, so check that out if you want to know more.

The “why do meta-analysis?” question is important. There are a couple of major benefits to this approach, but the biggest one by far is that we get reasonable estimates of variance in our summary measures.

See, when you average sensitivity and specificity, you calculate your standard deviations by pooling the confusion matrices across readers. Where before you had multiple readers, you now have one uber-reader. At this point, you can only account for variability across samples, not readers.

In this table, adapted from Obuchowski in a book chapter I wrote, we see that the number of readers, when accounted for, has a huge impact on sample size and power calculations. Frankly, not taking the number of readers into account is methodologically indefensible.

SROC analysis does though, considering both the number of readers and the “weight” of each reader (how many studies they read). Compare this SROC curve re-analysing the results of Rajpurkar and Irvin et al to the one from Esteva et al above:

With only 4 readers, look how wide that confidence region is! If we draw a vertical line from the “average point” it covers a sensitivity range between 0.3 and 0.7, but in their paper they reported an F1 score of 0.387, with a 95% CI of 0.33 to 0.44, a far narrower range even accounting for the different metric.

Another nice thing about SROC curves is that they can clearly show results stratified by experience level (or other subgroups), even when there are lots of readers.

From Tschandl et al. The raw reader points are unreadable, but summarising them with SROC curves is clean and tidy.

There are a few other good points of SROC curves which we mention in the paper, but I don’t want to extend this blog post too much. Just read the paper if you are interested.


Just use SROCs!

That’s really all I have to say. A simple, off-the-shelf, easily applied method to more accurately summarise human performance and estimate the associated standard errors in reader studies, particularly of use for AI human-vs-machine comparisons.

I didn’t invent anything here, so I’m taking no credit^, but I think it is a good idea. Use it! It will be better^^!

You wouldn’t want to be methodologically indefensible, right?


* I’ll have more to say on this in a future post, suffice to say for now that this is actually how medicine works when you realise that doctors don’t make descriptive reports, they make decisions. Every statement made by a radiologist (for example) is a choice between usually two but occasionally three or four actual treatment paths. A radiologist who doesn’t understand the clinical implications of their words is a bad radiologist.

**This actually got me really nervous right after I posted the paper to arxiv (like, why has no-one thought of this?), so I email-bombed some friends for urgent feedback on the paper while I could still remove it from the processing list, but I got the all clear :p

*** I semi-justify this in the paper. It makes sense to me anyway.

^ Well, I will take credit for the phrase “Docs are ROCs”. Not gonna lie, it was coming up with that phrase that motivated me to write the paper. It just had to exist.

^^ For anyone interested, it still isn’t perfect. There are some reports of persistent underestimation of performance using SROC analysis in simulation studies. It also doesn’t really account for the fact most reader studies have a single set of cases, so the variance between cases is artificially low. But you can’t really get around that without making a bunch of assumptions (these are accurate empirical estimates), and it is tons better than what we do currently. And heck, it is good enough for Cochrane :p^^^

^^^ Of course, if you disagree with this approach, let me know. This is a preprint currently, and I would love to get feedback on why you hate it and everything about it, so I can update the paper or my friends list accordingly :p

Luke Oakden-Rayner is a radiologist in South Australia, undertaking a Ph.D in Medicine with the School of Public Health at the University of Adelaide. This post originally appeared on his blog here.

CityBlock, a primary care startup focused on underserved communities, passes $1 billion valuation

CityBlock Health, a startup focusing on providing care to Medicaid and dual-eligible patients, raised $160 million in funding. The Alphabet-spinout plans to use the funds to reach more patients and build out its digital care offerings.  

Bayer G4A Agents of Change: Watch the Panels, Meet the Co’s that Got Deals

By JESSICA DaMASSA, WTF HEALTH

Bayer G4A, the global life science company’s digital health innovation arm, held their splashy “Agents of Change” event last month to not only introduce their latest cohort of health tech partners, but to also demonstrate the pharma co’s commitment to digital transformation. The entire C-suite of Bayer’s Pharma division became a panel itself — marking the first time the full leadership team of a major pharmaceutical company appeared together to talk strategically about tech’s role in shaping the pharma business model of the future. 

The rest of the program’s agenda teased out G4A’s priorities: consumer health, health disparities, women’s health, and investing. Matthew and I both moderated “star-studded” panels with health tech greats: he tackled health tech investment, ridiculous valuations, and advice for startups with a powerhouse crew of investors, while I led my women’s health panel past the usual talk of period-tracking and into a real push for a paradigm shift in thinking about what actually constitutes women’s health data. Rounding out the program were fascinating discussions about health equity and access led by Indu Sabiaya, and a ‘who’s-interviewing-who-here’ fireside about patient-centered tech with OneDrop’s Jeff Dachis and DiabetesMine founder Amy Tenderich, both entrepreneurs with diabetes who have a lot to say about how most tech misses the mark when it comes to grappling with patient needs in everyday life.

And… if you’re curious about what Bayer G4A actually invested in and who they decided to sign partnership agreements with, check out my exclusive WTF Health interviews featuring these companies by way of the playlist below. 

Spoiler Alert: Not a single digital therapeutic. 

What else could there possibly be for a pharma co to invest in? Watch and see. But, so you know a bit about what you’ll be getting into:

  • Caria is women’s health startup focused on menopause 
  • Sweetch is using just-in-time-interventions linked to mobile data to help “outsmart” chronic diseases
  • ONCARE is a care plan content management platform that lets any healthcare provider upload a care pathway that a patient can then follow via an app on their phone
  • Decipher Biosciences is using genomic testing to disrupt the way prostate cancer is diagnosed and treated 
  • Elly is helping improve the quality of life for cancer patients and those with chronic disease by way of educational and motivational content delivered via voice technology

Michelin Star Medicine: Food Start-Up Epicured Delivers Meals for GI & Chronic Condition Care

By JESSICA DaMASSA, WTF HEALTH

Food-as-Medicine startup, Epicured, looks and acts a lot like the consumer meal delivery startups booming during this pandemic (think Freshly, which was just acquired by Nestle for $1.5B) but with one important difference: all the meals are based on diets that have been clinically validated as treatments for chronic disease. The three year old company got its start in GI disorders, turning complex Low FODMAP diets, gluten-free diets, etc. into home-delivered, ready-to-eat dishes that patients with Crohn’s disease, Colitis, IBS, IBD, celiac, or other gastro conditions could actually integrate into their daily lives. (Just Google the list of restrictions on a Low FODMAP diet and imagine the lack of adherence over a 6-8 week period while trying to calm an IBS flare-up…)

Richard Bennett, Epicured’s CEO & co-founder, stops by to talk about why he believes this more convenient, yummy, and easy solution will not only continue to win the hearts of healthcare consumers, but why, ultimately, healthcare payors will look to invest more into innovation around nutrition, particularly as its proven to help with other, more common and costly conditions like diabetes, renal disease, and cancer. Backed in part by Mount Sinai (which not only invested in their seed round, but also lent their GI team to the co-design a special IBS menu), Rich let’s us know a bit about some yet-to-be-released clinical study results AND how Epicured has taken a page out of the “digital therapeutics playbook” by partnering with AbbVie to wrap their solution around one of the pharma co’s drugs as a way to improve medication adherence. Chicken Cacciatore wins over companion app any day!

#Healthin2Point00, Episode 172 | MedArrive, PointClickCare, Consejo Sano & FOLX Health

Today on Health in 2 Point 00, we’ve got quite a diverse set of companies to cover. MedArrive, which is Dan Trigub’s company – the former CEO of Uber Health – raises $4.5 million. Jess also asks me about PointClickCare acquiring Collective Medical, connecting data from EMRs in the acute care space into their long term care solution (I interviewed both CEOs on THCB Spotlights here). Consejo Sano quietly raised $17.1 million for their patient engagement and communication solution for the Hispanic community, and FOLX Health raises $4.4 million to provide care to LGBTQIA+ folks. —Matthew Holt

PointClickCare buys Collective Medical

By MATTHEW HOLT

I was a little surprised to find out that PointClickCare, a Canadian-based EMR that has a big market share in SNFs and long term care was buying Collective Medical, a Utah-based interoperability-sniffer (that’s a term I just made up). Collective specializes in extracting data from acute care EMRs to find where patients have received care (think: ERs), and transmit that information (think: meds & diagnoses) to other providers. (Press Release here). The logic is that the “post acute” landscape is getting more complex and better integrated with the rest of care, and Collective Medical will help get PointClickCare’s SNFs and the hospitals & home care agencies they work with much more accurate tracking of patient movements between them. Given the mess that sector is experiencing with COVID-19 right now, this should be a good idea.

I spoke to PointClickCare’s Dave Wessinger & Collective Medical’s CEO Chris Klomp about the deal. They of course wouldn’t tell me the price, but Blake Dodge at Business Insider sniffed it out and thinks it’s $650m. Moody’s reports that PointClickCare raised $550m in debt to help–although I doubt those cunning Canucks handed over too much of that cash, and they certainly sound like they want to keep the whole Collective Medical team around.

This is Your Brain on Microwaves

By KIM BELLARD

Those of us of a certain age well remember the 1987 ad campaign from the Partnership for a Drug-Free America. It equated frying an egg to what drugs did to our brains. The ad certainly impacted awareness, but it is less clear that it impacted drug use or, for that matter, that it actually was like what drugs did to our brains.

Well, it turns out that there is something that can scramble our brains, but it’s microwaves, and it appears that “malevolent actors” are using them to do just that. We’re now in the age of “directed, pulsed radiofrequency energy.” 

There were reports coming out of Havana in 2016 of State Department employees complaining of mysterious symptoms, including dizziness, fatigue, headaches, memory loss, balance issues, and hearing loss. Over the next couple years there were more reports, in Cuba and in other countries, including China and Russia, with CIA officers also seemed to be common targets. It has been labeled “the Havana syndrome.”

As least 44 people from Cuba and 15 from China were treated at Center for Brain Injury and Repair at the University of Pennsylvania, with more believed to have been treated elsewhere. No one could pin down exactly what was happening. 

Now the National Academies of Science, Engineering and Medicine has issued a report concluding that the directed, pulsed microwave bursts were “the most plausible mechanism” to explain what happened. They evaluated but ruled out other mechanisms, such as background microwaves, chemical agents, infectious diseases, and even “psychological issues.” 

Committee chairman David Relman, a professor of medicine at Stanford University, said:

The committee found these cases quite concerning, in part because of the plausible role of directed, pulsed radiofrequency energy as a mechanism, but also because of the significant suffering and debility that has occurred in some of these individuals.  We as a nation need to address these specific cases as well as the possibility of future cases with a concerted, coordinated, and comprehensive approach.

One thing in particular that concerned the Committee was the presence of persistent symptoms in many victims – “persistent postural-perceptual dizziness (PPPD), a functional (not psychiatric) vestibular disorder that may be triggered by vestibular, neurologic, other medical and psychological conditions and may explain some chronic signs and symptoms in some patients.”  i.e., not only can you be impacted by such an attack, but the impairment can last an indefinite time. 

Many have suspected Russia as a likely culprit, and, indeed, the committee noted Russian research that dates back several decades. Dr. Relman told Andrea Mitchell of NBC News:

What we found was that there is a literature that describes health effects of a particular form of microwave energy, which is pulsed and directed. And that literature now goes back a number of decades, and was published largely by the former Soviet Union. That literature does mimic and is consistent with a number of the clinical findings that we noted.

The committee suggested that further studies “be undertaken by subject-matter experts with proper clearance, including those who work outside the U.S. government, with full access to all relevant information” – suggesting they suspected there was classified information they did not have access to. 

The State Department, which requested the report but which only allowed the release after NBC News and The New York Times obtained it, was diplomatic in its response: “We are pleased this report is now out and can add to the data and analyses that may help us come to an eventual conclusion as to what transpired…The investigation is ongoing, and each possible cause remains speculative.” 

Dr. Relman seems to have fewer doubts, telling NPR: “What we can say is that something real and significant clinically happened to these people. At least some, if not many, of the signs and symptoms that were reported in these patients can be explained by this particular form of microwave radiation.” The committee looked ahead and:

…was concerned about the possibility of future new cases among DOS [Department of State] or other U.S. government employees working overseas, either similar or dissimilar to these, and the ability of the U.S. government to recognize and respond to these cases in a coordinated and effective manner. The next event may be even more dispersed in time and place, and even more difficult to recognize quickly.

Somewhat disappointingly, most of the committee’s recommendations revolved around more data collection and analysis, and, when necessary, being prepared to “activate the necessary response”  — whatever that might be.   

Lest anyone think this is only an issue for diplomats or other people Russia might target, a few weeks ago there were reports that Chinese troops were turning “the mountain tops into a microwave oven,” according to The Times, in order to force Indian troops to retreat during a border dispute.  “In 15 minutes, those occupying the hilltops all began to vomit,” a Chinese professor said. “They couldn’t stand up, so they fled.”

Curiously, Indian defense officials call the report “FAKE.” One Indian official explained that the attacks are impractical in that situation and the symptoms are not consistent with what is known about such weapons, especially the nausea. Technology journalist David Hambling tends to agree, but notes:

However, it is possible that China has a microwave weapon based on a different physical principle, perhaps something like the Electromagnetic Personnel Interdiction Control (EPIC) device researched by the Pentagon in the early 2000s.

One thing is clear: it’s pretty scary to think about a weapon that you’re not quite sure you’re being attacked by, from where, against which you don’t have any defense, and that can cause lasting physical and mental damage. The committee report warned:

…the mere consideration of such a scenario raises grave concerns about a world with disinhibited malevolent actors and new tools for causing harm to others, as if the U.S. government does not have its hands full already with naturally occurring threats.

Mr. Hambling believes: “Grey zone warfare, in which conflict remains just under the level of shooting war, is a feature of the 21st century. The Chinese may now think they have the weapon to win it.” And they may not be the only ones. 

Imagine if terrorists got their hands on these weapons. Or militia groups. Or police departments using them to quell protests. I don’t know about you, but I’m thinking maybe those people with tinfoil hats might be on to something.

Kim Bellard is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Level Ex pitches gaming as a tool for reaching doctors

Interactive, cloud-based video games are designed to tackle pharma’s current challenge: engaging doctors virtually during a pandemic. But the tools are likely to outlive the circumstances in which they were born.

#Healthin2Point00, Episode 171 | Massive deals & a massive IPO

Today on Health in 2 Point 00, we have a huge IPO coming up – JD Health, a Chinese company which has a valuation of $28 billion, could raise up to $4 billion in its upcoming IPO. On Episode 171, Jess asks me about Everlywell raising $175 million in a Series D for at-home testing, everyone’s favorite keto startup Virta Health raising $65 million bringing its valuation to a billion, Olive Health already putting their funding raise to good use by acquiring Verata Health, and dtx company Click Therapeutics raising $30 million. —Matthew Holt

#Healthin2Point00 Episode 170 | Olive, WithMe, Andor & more

Today on Health in 2 Point 00, Jess & I are together in Marin County before Jess sets off! On Episode 170, Jess asks me about Olive raising $225 million following a recent raise as well, WithMe Health closing a $20 million Series B, Andor Health getting an undisclosed amount in a Series A with an investment from M12, Microsoft’s venture fund, Upfront Healthcare raising $11.5 million in a Series B, and Voluntis – which is a publicly traded DTx company in France – raising $7 million. —Matthew Holt

RWJF Emergency Response Challenges Video

On November 19, 2020 Catalyst @ Health 2.0 hosted the finals of the RWJF Emergency Response Challenges, one for tools for the General Public and the other for the Health System. The promise of the tools that have been built as part of these challenges is immense in the battle against this COVID-19 pandemic and the ones yet to come. The finalists for the General Public challenge were:

Binformed Covidata– A clinically-driven comprehensive desktop + mobile infectious disease, epidemic + pandemic management tool targeting suppression and containment of diseases such as COVID-19. The presenter was veteran health IT expert Rick Peters.

CovidSMS– A text message-based platform providing city-specific information and resources to help low-income communities endure COVID-19. In contrast to Rick, CovidSMS’ team were undergraduates at Johns Hopkins led by Serena Wang

Fresh EBT by Propel– A technology tool for SNAP families to address food insecurity & economic vulnerability in times of crisis – highlighted by Michael Lewis on his Against the Rules podcast about coaching earlier this year. Stacey Taylor, head of partnerships for Propel presented their solutions for those in desperate need.

The finalists for the Health System challenge were:

PathCheck– A non profit just spun out of MIT. It has a raft of volunteers and well known advisors like John Brownstein and John Halamka among many others, and is already working with several states and countries. Pathcheck provides privacy first, free, open source solutions for public health to supplement manual contact tracing, visualize hot spots, and interface with citizen-facing privacy first apps. MIT Professor Ramesh Raskar was the presenter.

Qventus– A patient flow automation solution that applies AI / ML and behavioral science to help health systems create effective capacity, and reduce frontline burnout. Qventus is a great data analytics startup story. It’s raised over $45m and has lots of health system clients, and they have built a suite of new tools to help them with pandemic preparedness. Anthony Moorman, who won the best facial hair of the day award, showed the demo.

Tiatros – A mental health and social support platform that combines clinical expertise, peer communities and scalable technology to advance mental wellbeing and to sustain meaningful behavioral change. They’ve done a lot of work with soldiers with PTSD and as you’ll see entered this challenge to get their tools to another group of extremely stressed professionals–frontline health care workers. CEO Kimberlie Cerrone and COO Seth Norman jointly presented.

We also presented the Catalyst @ Health 2.0 Covid19 SourceDB between the two competitions. Please enjoy the video

Healthcare on the Edge

By KIM BELLARD

Perhaps you read about, or were directly impacted by, the massive, multi-hour Amazon Web Services (AWS) outage last week.  Ironically, AWS’s effort to add capacity triggered the outage, although apparently was not the root cause.  It’s no surprise that AWS sought to add capacity; it, like most cloud service vendors these days, has seen skyrocketing growth.  Even healthcare has jumped into the cloud in a big way.

But, as the outage reminds us, sometimes having core computing functions done in far-off data centers may not be always a great idea.  Still, we’re not about to go back to local mainframes or networked PCs.  The compromise may be edge computing. 

Definitions vary, and the concept is somewhat amorphous, but goal is to move as much computing to the “edge” of networks, primarily to reduce latency.  PwC predicts: “Now, with the rise of IoT, the centralised cloud is moving down and out, and edge computing is set to take on much of the grunt work.” 

As they describe it:

With edge, instead of pushing data to the cloud to be computed, processing is done by devices ‘at the edge’ of your network. The grunt work is done closer to the user, at an edge gateway server and then select or relevant data is sent to the cloud for storage (or back to your devices).

The oft-cited example is self-driving cars; you really don’t want the AI to wait a single millisecond longer than necessary to make a potentially life-saving decision.  An article in Nextgov pointed out:

Thus, a Tesla isn’t just a next-generation car; it’s an edge compute node. But even with Tesla, a relatively straightforward use case, building and deploying the edge node is just the beginning. In order to unlock the full promise of these technologies, an entire paradigm shift is required.

If this sounds like techy “inside baseball” stuff, think again.  This is a big shift.  Analyst and fund manager Stephen McBride believes edge computing is the “next great tech revolution.”  He says: 

The key takeaway is that edge computing makes the “impossible” possible. Technologies like self-driving cars, IoT, AR, and the commercialization of 5G will never get off the ground without edge computing.

It’s not just Mr. McBride who sees edge computing as a paradigm change.  The 2020 State of the Edge Report calls edge computing “the Third Act of the Internet.  Arpit Joshipura, the General Manager, Networking, Edge, and IOT for The Linux Foundation (which help create State of the Edge) proclaimed: “We stand on the precipice of a profound re-architecting of the Internet called edge computing, which will impact all areas of society.” 

The press release warned:

Where we stand today is at the edge. Today’s Internet struggles to support the newest use cases, particularly those that require real-time and low-latency interactions, not to mention handling connections with billions of devices generating petabytes of data. Only a radical restructuring of the Internet at the edge will solve for these emerging challenges, which will require thousands of companies to invest billions of dollars in new infrastructure.

The report estimates over $700b in capital infrastructure on edge infrastructure and data center facilities over the next decade, with healthcare identified as one of the leading industries that will adopt edge computing.  Mr. Joshipura believes “edge computing will overtake cloud computing” by 2025, which is a pretty bold statement.

More recently, IDC forecast edge computing as being a $251b market by 2024, asserting: “Edge products and services are powering the next wave of digital transformation.”  Healthcare is again cited as one of the impacted industries. 

There are plenty of hardware companies positioning for the edge computing movement, such as Akamai Technologies, Cloudflare, Fastly, or Telefónica, but also software vendors like Google, Microsoft or Red Hat. Earlier this year, Red Hat President and CEO Paul Cormier said:

We can look at the edge as the newest IT footprint, becoming an extension of the data center just like bare-metal, virtual environments, private cloud and public cloud.

The edge is open. The edge is hybrid. And the edge is powered by Red Hat.

Glenn O’Donnell, writing for Forrester in ZDNet, sees 2021 as an “inflection point for edge computing.  He predicts three key developments:

  • Data center marketplaces will emerge as a new edge hosting option – “We see a promising new option emerging that unites smaller, more local data centers in a cooperative marketplace model;”
  • Private 5G will push enterprises to the edge – “Private 5G is here now, and we expect it to fuel edge computing in 2021…2021 will be the inflection for 5G, but it will be private, not public.”  
  • New edge vendors will shave five points off public cloud growth – “As edge computing becomes a “cool” new platform for business computing, it will siphon some of the money that would otherwise have gone to cloud expansion.”

Health care is going to be impacted in a big way.  Most forecasts about the healthcare system of even the near future expect more real-time patient monitoring – the so-called Internet of Bodies (Iob) that includes “an expanding array of devices that combine software, hardware, and communication capabilities to track personal health data, provide vital medical treatment, or enhance bodily comfort, function, health, or well-being.”

We’re not going to get that without edge computing.  As PwC predicts: “5G and edge computing will enable the low-latency, real-time guaranteed conditions necessary to use IoT devices for patient monitoring and at-home care. For rural patients unable to access the care provided in larger metropolitan facilities, this could be a game-changer.”

The future of healthcare is on the edge.

I’m not smart enough to know exactly what edge computing will look like, in healthcare or anywhere else, much less how it works (then, again, don’t ask me how cloud computing or even PCs work!), but I’m smart enough to predict that this is a trend that no industry, especially healthcare, can overlook. 

As the 2020 State of the Edge report warned –not specifically about health care, but definitely including it – “Edge computing is crucial for many industries that currently find themselves in the midst of the digital revolution…It is crucial that industry players respond to these demands—if they don’t they will be substituted for players who can and will.”

Ignore it at your own risk.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Healthware Group announces acquisition of Make Helsinki

Healthcare agency, consultancy and digital health group, Healthware, has announced the acquisition of Finland-based digital service development and creative agency Make Helsinki.

  • Healthware strengthens its geographical coverage with the creation of a hub dedicated to the Nordics and Baltics region
  • The deal combines Healthware’s consulting, full-service agency and digital health capabilities with Make Helsinki’s additional expertise in Virtual Reality, Customer Experience, Design and recruitment for Clinical

Salerno/Helsinki, 1 December 2020 Healthware, founded in 1997 and led by digital health expert Roberto Ascione, has seen rapid growth in the past few years and has evolved into a partner able to guide the transformation of life sciences, health tech and health insurance companies, as well as the start-ups to partner and connect with the healthcare stakeholders. Make Helsinki Ltd., founded in 2015 brings complementary services spanning Virtual Reality, Customer Experience, Design, Augmented Reality and recruitment for Clinical Trials on top of a full service agency.

The acquisition builds on successful prior collaboration between the two organisations, including best-in-class full-service agency offerings, digital transformation, technology / enterprise solutions and corporate venturing. In addition, Make Helsinki brings knowledge of the Finnish technology playground and Nordic market.

Petteri Kolehmainen, CEO and co-founder of Make Helsinki, who will assume the role of Managing Director Finland at Healthware Group, said:

“We have been cooperating together for several years, and have found that we strongly share similar focuses, cultures and targets. As part of Healthware Group we can serve our existing and new customers better, faster and with wider expertise than ever before.”

Due to both companies being privately owned, the terms of the deal have not been disclosed. Make Helsinki will rebrand to Healthware and will function as a regional hub, continuing to offer its services in addition to the entire Healthware Group offering. Existing employees in the region will report into the new organisation.

Roberto Ascione, CEO & founder at Healthware Group, said:

“We are excited about this new acquisition, which extends our global footprint with a Nordics & Baltics presence and reinforces our expertise in key disciplines that are increasingly important to the future of health.”

Healthware Group is privately owned and backed by FITEC, a leading European VC fund focusing on technology. This has accelerated the company’s growth and enabled key strategic investments and acquisitions within life sciences and digital health.

The post Healthware Group announces acquisition of Make Helsinki appeared first on .

Investors pour $91M into growing clinical-trial software firm

The Covid-19 pandemic is altering behavior and fueling demand for remote technologies in clinical trials with Medable, a company in the clinical trial software space, looking to capitalize.

#Healthin2Point 00, Episode 169 | They’re real and they’re SPACtacular!

Today on Health in 2 Point 00, It’s a whacky SPACy world, as a new SPAC rolls “UpHealth” and has me singing Bob Marley, meanwhile there’s $91m for remote clinical trial software player Medable, $76m more for Spring Health joining the throng of mental health companies, while K-Health gets $42m to introduce chat bot front ends to Korean pop music…or something like that. —Matthew Holt

#Healthin2Point 00, Episode 169 | They’re real and they’re SPACtacular!

Today on Health in 2 Point 00, It’s a whacky SPACy world, as a new SPAC rolls “UpHealth” and has me singing Bob Marley, meanwhile there’s $91m for remote clinical trial software player Medable, $76m more for Spring Health joining the throng of mental health companies, while K-Health gets $42m to introduce chat bot front ends to Korean pop music…or something like that. —Matthew Holt

Comcast, Independence BlueCross’s Quil: Fast-Forward Past Video Content to Home Sensors for Seniors

By JESSICA DaMASSA, WTF HEALTH

It’s not just eyeballs that Comcast NBCUniversal and Independence BlueCross’s joint venture, Quil, is after these days. Carina Edwards, Quil’s CEO, paints a compelling picture of the full-scale business model for “health-in-the-home” that her company is enacting. What started out with trusted healthcare content for surgery prep (able to be deployed across a household’s army of devices, including their TV for those 1.3M Comcast Xfinity cable subscribers) is now expanding with more tech and more services to meet the needs of seniors aging-in-place and the fifty million unpaid caregivers looking after them. Ambient, “context-aware” sensors. Voice integrations with smart speakers. And that’s nothing to say of the caregiver-focused programming that addresses everything from caregiver burnout to tackling tough conversations about a range of issues from paying for care to end-of-life wishes. Quil’s pilot of this new senior-focused offering will be rolled out with Comcast’s help this winter, with the full direct-to-consumer commercial launch expected in Q3 2021. As Carina says, “Comcast knows how to pilot technology.” And, Quil has shown its ability to impact healthcare quality measures thanks to studies around its initial surgery-prep offering. Will it be enough to take on others looking to help turn our living rooms into exam rooms? Tune-in around 17:20 to hear just how integrated Comcast and IBX are in the strategy at Quil.

RWJF Emergency Response Challenge Results!

by MATTHEW HOLT

Yesterday Catalyst @ Health 2.0 hosted the finals of the RWJF Emergency Response Challenges, one for tools for the General Public and the other for the Health System. It was a great session, sadly virtual and not at a conference with cocktails afterwards. But the promise of the tools that have been built as part of these challenges is immense in the battle against this COVID-19 pandemic and the ones yet to come.

The finalists for the General Public challenge were

  • Binformed Covidata– A clinically-driven comprehensive desktop + mobile infectious disease, epidemic + pandemic management tool targeting suppression and containment of diseases such as COVID-19. The presenter was veteran health IT expert Rick Peters.
  • CovidSMS– A text message-based platform providing city-specific information and resources to help low-income communities endure COVID-19. In contrast to Rick, CovidSMS’ team were undergraduates at Johns Hopkins led by Serena Wang
  • Fresh EBT by Propel– A technology tool for SNAP families to address food insecurity & economic vulnerability in times of crisis – highlighted by Michael Lewis on his Against the Rules podcast about coaching earlier this year. Stacey Taylor, head of partnerships for Propel presented their solutions for those in desperate need.

The finalists for the Health System challenge were

  • PathCheck A non profit just spun out of MIT. It has a raft of volunteers and well known advisors like John Brownstein and John Halamka among many others, and is already working with several states and countries. Pathcheck provides privacy first, free, open source solutions for public health to supplement manual contact tracing, visualize hot spots, and interface with citizen-facing privacy first apps. MIT Professor Ramesh Raskar was the presenter.
  • Qventus A patient flow automation solution that applies AI / ML and behavioral science to help health systems create effective capacity, and reduce frontline burnout. Qventus is a great data analytics startup story. It’s raised over $45m and has lots of health system clients, and they have built a suite of new tools to help them with pandemic preparedness. Anthony Moorman, who won the best facial hair of the day award, showed the demo.
  • Tiatros IncA mental health and social support platform that combines clinical expertise, peer communities and scalable technology to advance mental wellbeing and to sustain meaningful behavioral change. They’ve done a lot of work with soldiers with PTSD and as you’ll see entered this challenge to get their tools to another group of extremely stressed professionals–frontline health care workers. CEO Kimberlie Cerrone and COO Seth Norman jointly presented.

Videos of the whole session and the demos will be up soon.

And the winners were…

A tie in General Public challenge between CovidSMS & BInformed, who split the $25,000 first prize (and the $10,000 second prize!)

Qventus in the Health System challenge who take home $25,000

But there were no losers. A great culmination of a lot of work to get tech solutions to help us deal with the pandemic.

Matthew Holt is Publisher of THCB and also Co-Chairman at Catalyst @ Health 2.0

#Healthin2Point 00, Episode 168 | Is Amazon taking over the world of healthcare?

Goodbye health insurance, hello Amazon Prime membership! Today on Health in 2 Point 00, we talk about all the Amazon news now that they’re moving into pharmacy via Amazon Prime. Jess and I also discuss AliveCor raising $65 million for its personal EKG technology and Talkspace acquiring Lasting, a relationship counseling app. Levels raises $12 million in a seed round, adding more fun things you can do with your CGM, and another SPAC takes a company public—Barry Sternlicht’s SPAC is acquiring Cano Health at a $4.4 billion valuation. —Matthew Holt

#Healthin2Point00, Episode 167 | Bridge Connector, Togetherall, Solv Health & more

Today on Health in 2 Point 00, the big news is about another COVID vaccine… or is it the collapse of the telehealth and digital health market as we know it? On Episode 167, Jess asks me about Bridge Connector shutting down 2 months after getting a $25.5 million raise, UK-based online mental health platform Togetherall raising $10 million, Cerner partnering with Well Health for provider-patient communication services, Solv Health—the OpenTable for healthcare—raising $27 million, and Springtide raising $18.1 million for its clinic and platform for children with autism. —Matthew Holt

Bayer G4A Agents of Change: Digital Health & the Future of Pharma

By JESSICA DaMASSA, WTF HEALTH

Lots of changes at Bayer G4A: a new investment thesis, new additions to their portfolio, a new Global Head of Digital Health to meet, and a hot new virtual health forum (a free one!) coming up on November 18, 2020. Dominick Kennerson and Sophie Park join us from Berlin, where they’ve got their eyes on the trends shaping the worldwide digital health market. Are pharma companies changing the way they look at digital health companies in the face of the pandemic? Have we gone, well, beyond “beyond the pill”? Dom says Bayer’s been ahead of the curve when it comes to prioritizing digital innovation, and that we’re all going to be “very surprised” in the next 12-18 months about what we see come out of one of the world’s largest life sciences companies. For more clues and additional insight on Bayer’s priorities when it comes to digital health and the future of pharma, give this interview a quick listen then register for G4A’s Agents of Change event. HINT: From the “mad genius” herself…the agenda for the event is Bayer G4A’s roadmap. Bold move!

For more on the Agents of Change event, visit www.g4a.health.

The Catalyst @ Health 2.0/Wipfli Survey on the State of Digital Health

By MATTHEW HOLT

Catalyst @ Health 2.0, supported by professional services firm Wipfli, is launching a survey about the state of Digital Health. We hope to get a comprehensive analysis of the impact of COVID-19 on digital health companies and the rest of the ecosystem. This survey should take under 8 minutes to complete (and probably less). For your time we will get you a copy of the results when they are released. As an added bonus TWO respondents drawn at random who complete the survey will get advertising for their company for 6 months on The Health Care Blog (worth $5,000).

We are interested in hearing from leaders working in digital health companies, or those connected to digital health in health systems, payers, life sciences, consulting or investment companies.

To take the survey CLICK HERE

NOTE–None of the data from this survey will be shared by Catalyst @ Health 2.0 (even with our friends at Wipfli) other than as aggregate survey results. So you can be assured that your answers are completely confidential.

Matthew Holt is Co-Chairman of Catalyst @ Health 2.0 & Publisher of THCB

Covid-19, the “Quarantine 15” & Healthcare’s Focus on Weight Management in 2021

By JESSICA DaMASSA, WTF HEALTH

Potential digital health trend for 2021? Weight loss and weight management. Not only has obesity been an “epidemic” of its own for a number of years (40% of U.S. adults are obese, another 32% are overweight) BUT it’s also considered a risk-factor if infected with covid-19 and is a common co-morbidity for a number of chronic conditions. Add to that all the banana bread we’ve been seeing on Instagram and the “quarantine 15” memes that sum up the weight gain brought about by our increasingly sedentary, baked-goods-filled shelter-in-place lifestyles, and you can see where this is likely to go. So, how can health tech help? As healthcare payers and employers look toward weight management as a way to help prevent adverse health outcomes (covid-related or otherwise), we get some advice from Dr. Greg Steinberg, a clinical innovation expert who gained experience piloting novel, health tech solutions for weight management at Aetna. We demystify the relationship between healthcare payers and weight loss solutions, talk about what matters from a cost/value perspective, and, of course, find out what makes for optimal end-user success.

Which healthcare startups will present at Pitch Perfect for INVEST Pop Health Virtual?

contest, spotlight

The healthcare startups targeting chronic conditions and population health presenting at INVEST Pop Health November 16-18 span prescription drug delivery to addressing social isolation.

Accolade’s CEO Raj Singh: IPO Backstory & Pop Health Predictions for 2021

By JESSICA DaMASSA, WTF HEALTH

When Accolade went public in July at a $1.2B valuation, the BIG question facing the health tech unicorn pre-dated the covid-19 pandemic and the chaos facing its clientbase of large, self-insured employers: Could they scale? Raj Singh, Accolade’s CEO, tackles the question head-on, buoyed by customer growth that has doubled twice over a fiscal-year-and-a-half and an expanded need for his company’s high-touch, concierge health benefits navigation services. As beleaguered employers struggle with making sure their employees have the health benefits they need to weather the pandemic, Accolade’s focus on making sure that those benefits remain as cost-contained as possible seems to be more attractive than ever. What else is resonating with self-insured employers these days? Raj talks about what will (and won’t) change when it comes to population health management in 2021 and gives us a reality check on whether or not employers and their employees are really using digital health tools like Livongo, Virta, Hinge, Kaia, Ginger, et. al when baked into their benefits ecosystem.

#Healthin2Point00, Episode 166 | $100 million, scandal, & more

Today on Health in 2 Point 00, we have scandal, drama, intrigue, $100 million and murder! Wait, no; not murder. On Episode 166, we catch up on more deals before Jess gets carried away again. The $100 million goes to Carbon Health in a Series C, which is another Bay Area-based primary care startup; they’re doing a lot of work in COVID testing and growing fast. Next we have many health plans uniting with Cigna Ventures, Humana, and Anthem all investing in Buoy Health which just raised $37.5 million in a Series C. That leads us to a scandal with the former CEO of Navigating Cancer suing Merck’s Global Health Innovation Fund. Finally, in the world of DTx, NightWare has received FDA clearance for its Apple Watch app designed to wake people with PTSD up from nightmares. —Matthew Holt

RWJF Emergency Response Innovation Challenges: Virtual Pitch Event on 11/19!

By ELIZABETH BROWN

As COVID-19 brought to light the lack of emergency response preparedness in the health care system, the Robert Wood Johnson Foundation (RWJF) and Catalyst @ Health 2.0 saw an opportunity to highlight digital health’s potential to support health care stakeholders and the general public. RWJF and Catalyst partnered to launch two Innovation Challenges on Emergency Response for the General Public and Emergency Response for the Health Care System. 

The Emergency Response Innovation Challenges asked innovators to develop a health technology tool to support the needs of individuals as well as health care systems affected by a large-scale health crisis, such as a pandemic or natural disaster. The Challenges saw a record number of applications— nearly 125 applications were submitted to the General Public Challenge and over 130 applications were submitted to the Health Care System Challenge. 

An expert panel of judges across the health tech, venture capital, design, and emergency response industries evaluated the entries and selected three finalists from each challenge to compete at a virtual pitch hosted by Catalyst @ Health 2.0 on Thursday, November 19th at 10am PT/1pm ET. Registration for this event is now open! RSVP for the pitch event HERE.

Finalists will present their solutions to an audience of investors, provider organizations, health plans, tech companies, foundations, government officials and members of the media. During the pitch, a judge panel will select the first, second, and third place winner based on impact, UX/UI, innovation/creativity, scalability and strength of presentation. The winners will be awarded $25,000 for first place, $15,000 for second place, and $5,000 for third place. To learn more about the finalists, click on the links listed below, and to RSVP for the pitch event, click HERE

Emergency Response for the General Public Finalists:

  • Fresh EBT by PropelA technology tool for SNAP families to address food insecurity & economic vulnerability in times of crisis.   
  • CovidSMS CovidSMS is a text message-based platform providing city-specific information and resources to help low-income communities endure COVID-19.
  •  Binformed CovidataBinformed is a clinically-driven comprehensive desktop + mobile infectious disease, epidemic + pandemic management tool targeting suppression and containment of diseases such as COVID-19.

Emergency Response for the Health Care System Finalists:

  • QventusQventus is a patient flow automation solution that applies AI / ML and behavioral science to help health systems optimize resources for Covid, create effective capacity, and reduce frontline burnout.
  • PathCheckPathCheck provides privacy first, free, open source solutions for public health to supplement manual contact tracing, visualize hot spots, and interfaces with citizen-facing privacy first apps.
  • Tiatros IncA mental health and social support platform that combines clinical expertise, peer communities and scalable technology to advance mental wellbeing and to sustain meaningful behavioral change.

For further updates on the RWJF Emergency Response for the General Public and Emergency Response for the Health Care System Challenge and other programs, subscribe to the Catalyst @ Health 2.0 Newsletter, and follow Catalyst on  Twitter @catalyst_h20.

Elizabeth Brown is a program manager at Catalyst @ Health 2.0

Telehealth, Digital Health Market Update from Europe & Frontiers Health Preview

By JESSICA DaMASSA, WTF HEALTH

Looking for more proof that telehealth has truly become a global trend in healthcare delivery? Our “man-on-the-street” in Italy, Roberto Ascione, CEO of Healthware Group, offers a detailed state-of-play on virtual care uptake across Europe, including how policy-makers, entrepreneurs, and investors are playing much more significant roles in spurning an increasingly “digital friendly” healthcare ecosystem in the wake of covid-19. On the eve of Frontiers Health 2020 — one of Europe’s leading health innovation conferences, of which Roberto is Chairman — we find out how those backing healthcare’s quickly evolving “tele-everything” revolution are planning to come together to push this agenda even further.

Note: Frontiers Health takes place THIS WEEK, on Thursday November 12 and Friday November 13. Check out the full agenda at www.frontiers.health.  Fans of WTF Health get a discount! Just use code FH20WTF25 for 25% off registration fees. See you there!

Health in 2 Point 00, Episode 165 | Centene, Koa Health, Eko and Medically Home

Today on Health in 2 Point 00, there is so much to talk about between the election, the Affordable Care Act, and Pfizer’s COVID vaccine news. On Episode 165, we talk about how this is impacting the markets and cover more deals. ACA darling Centene has acquired Apixio, Koa Health spins out from Telefónica and gets $16.5M in initial funding, Eko raises $65 million in a Series C for their connected stethoscope and ECG, and Medically Home raises $40 million in another continuous clinic play, bringing their total to $65 million. —Matthew Holt

It’s (Cyber)Criminal

By KIM BELLARD

One of the redeeming aspects of crises is that, amidst all the confusion, suffering, and loss, there are usually moments of grace, of humans showing their best nature.  With COVID-19, we’ve seen health care workers working long hours in dangerous conditions.  We’ve seen other essential workers — including not just first responders but also grocery workers, meatpackers, trash collectors, and countless others — putting their own safety at risk so that our lives can go on.  There are heroes all around.

Unfortunately, crises also tend to bring out the worst of our natures.  With the pandemic, those trillions of dollars in play have brought out not just those seeking to profit, but also those looking to profit by breaking the law.   We’ve seen people stealing or counterfeiting stimulus payments, defrauding COVID unemployment payments, getting fraudulent PPP loans, and stealing PPE

And then there are the cyberattacks. 

Last week the federal Cybersecurity & Infrastructure Security Agency, the FBI, and HHS issued a joint alert Ransomware Activity Targeting the Healthcare and Public Health Sector, warning that they have “credible information of an increased and imminent cybercrime threat to U.S. hospitals and healthcare providers.”  I’ll spare you the technical details of the expected attack strategies or suggested mitigation efforts, but I will note that they warned: “CISA, FBI, and HHS do not recommend paying ransom.”

Hospitals could ask Universal Health Services (UHS) about that.  UHS took some three weeks to resume “normal services” after a ransomware attack that hit their 250 U.S. hospitals in late September.  UHS claims thatWhile our information technology applications were offline, patient care was delivered safely and effectively at our facilities across the country utilizing established back-up processes, including offline documentation methods.”   E.g., paper records.

Or they could ask the family of the woman in Germany who died as the result of having to be diverted to another city for her medical emergency because the closer facility had suffered a ransomware attack.  One suspects there may have been other deaths, and other adverse outcomes, due to cyberattacks, and that we can expect there to be more.

The expected attacks have already started.  The Wall Street Journal reports attacks on hospitals in New York, Oregon, and Vermont, while The Washington Post cited hospitals in California, New York, and Oregon.  Security firm Check Point found that October saw a 71% increase in ransomware attacks against the healthcare sector. 

“I think we’re at the beginning of this story, Mike Murray, CEO of Scope Security, told MIT Technology Review.  Similarly, cyber strategist John Ford warned:

The seemingly crazy predictions of the past around the cost of ransomware attacks on the healthcare industry stand to be proven true in 2021. We’ve seen a substantial rise in ransomware since the onset of COVID, and as the space race 2.0 continues, so will the prevalence of attacks.

There’s never a “good” time for a ransomware attack when it comes to hospitals, but this could possibly be one of the worst.  “Right now resources are very stretched for a lot of health centers,” Mitch Parker, the chief information security officer with Indiana University Health Inc, told WSJ. “With this resurgence of COVID, a lot of people’s attention is focused on staying operational.”

Cyber attacks include not just ransomware, where thieves try to extort money in return for return of control of impacted systems, but also theft of patient and other clinical data, and potential manipulation of data.  We’ve already seen pharma companies in India and in Japan working on a COVID-19 vaccine get hit with cyberattacks, with other attacks impacting clinical trials.  Germany’s Robert Koch Institute for infectious disease control was hit with a cyberattack last week. 

Charles Carmakal, CTO of cybersecurity firm Mandiant, told NPR:

We are experiencing the most significant cybersecurity threat we’ve ever seen in the United States…Most threat actors aren’t willing to deploy ransomware and cause destruction to hospitals right now during the pandemic because they’re worried about impacting lives,” he said. But in this case, the attacker is deliberately targeting hospitals “and has no real fear of potential human impact, and is just looking to make money.”

“We expect panic,” the hackers reportedly predicted

If we think attacks on hospitals and other healthcare organizations are the worst case scenario, think again.  Rand has a new report out on the “Internet of Bodies,” which includes not just wearables but also an array of implantable devices. Rand warns:

Vulnerabilities could allow unauthorized parties to leak private information, tamper with data, or lock users out of their accounts.

In the case of some implanted medical devices, hackers could potentially manipulate the devices to cause physical injury or even death.

It is, the report says, a threat to national security, and Alex Berezow Ph.D., of Geopolitical Futures, agrees.  He warns that such attacks are not just a threat to public health but also to national security; “undermining a nation’s ability to respond to infectious disease outbreaks or other natural disasters may allow some countries to achieve geopolitical objectives.”

“We are outnumbered—the people that are doing bad things, whether it’s a nation-state type of activity or cybercrime—the good guys and gals were vastly outnumbered prior to the pandemic,” David Shearer, CEO of (ISC)2, lamented to CNBC.  It is particularly a problem for health care, which is often viewed by security experts as not having the appropriate infrastructure or personnel to combat such attacks, despite being responsible for life-critical technology and extremely personal information.  And the hackers know it.

Healthcare is still patting itself on the back for going digital, despite not doing that well (think EHRs’ poor usability and interoperability).  But it needs to recognize that we live in a scary digital world; there are bad actors out there looking for vulnerabilities.  Cybersecurity may now be as important to our health as clinicians, and healthcare better invest accordingly.

It’s bad enough that our lives are under attack by an actual virus, but it’s another thing altogether if/when are lives can be put at risk due to a cybervirus.  Whether we like it or not, whether we’re ready for it or not, cyber-criminals are coming for healthcare.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

#Healthin2Point00, Episode 164 | Election Day Edition

Today on Health in 2 Point 00, Jess is wondering which European countries let Americans in without a quarantine. On Episode 164, we’ve got more deals for you. Human API gets $20 million seeking to make the world interoperable, Curve Health raises $6 million for its skilled nursing tech platform which has seen a bump in COVID times, 7Wire spends more of their Livongo money with $18 million going into Homethrive which does navigation for seniors, KēlaHealth raises $12.9 million in a seed round which applies AI to surgical outcomes, and Ontrak acquires behavior change platform LifeDojo. I’ll leave you with my forecast for the election and for the Senate, so we’ll see what goes down tonight. —Matthew Holt

#Healthin2Point00, Episode 162 | Whoop, Honor, Sidekick Health & more

Today on Health in 2 Point 00, Jess is dismayed at her rising premiums. On Episode 162, Jess and I have more deals to cover. Whoop, which makes a wearable, raises $100 million (including SoftBank money!), bringing their valuation to $1.2 billion. Next, Honor raises $140 million in a Series D and I weigh in on how this tech-enabled home care startup has evolved since it started out. DTx company Sidekick Health raises $20 million for its gamified medication management platform,, and SaaS telehealth platform eVisit gets $14 million—is this any different? Finally, Cricket Health which manages complex kidney diseases early names new CEO Robert Sepucha and raises $15 million. —Matthew Holt

Can You Say “Chemputer”?

By KIM BELLARD

I learned a new word this week: “chemputer.”   It’s not a new word – it’s been around since at least 2012 — but chances are, unless you are a chemist or maybe a synthetic biologist, it’s not a word you knew it either.   Even if you don’t care about chemistry, biology, or, for that matter, etymology, this is something you might want to pay attention to, because it may end up revolutionizing healthcare. 

The term is credited to Professor Lee Cronin of the University of Glascow.  Back in 2012, when he was first discussing the concept, he told The Guardian: “Basically, what Apple did for music, I’d like to do for the discovery and distribution of prescription drugs.”

Fast-forward most of a decade and a pandemic, and Dr. Cronin and others are closing in on that goal — although they’ve updated their analogy to “Spotify for chemistry.”

I won’t pretend to understand either the chemistry nor the programming involved, but, simply put, chemputers automate the production of molecules – including prescription drugs, such as, for example, COVID-fighting Remdesivir.  CNBC recently profiled activity in the field, spurred by some new papers from Dr. Cronin and Dr. Nathan Collings of SRI Biosciences. 

The new paper from Dr. Cronin and his collaborators appeared in Science earlier this month, with the catchy title A universal system for digitization and automatic execution of the chemical synthesis literatureThe big breakthrough is more automation of the process, allowing robotic systems to do most of the work. 

Dr. Cronin described their work:

What we’ve managed to do with the development of our ‘Chemical Spotify’ is something similar to ripping a compact disc into an MP3s.  We take information stored in a physical format, in this case a scientific paper, and pull out all the data we need to create a digital file which can be played on any system, in this case any robot chemist, including our robotic system which is an order of magnitude lower cost than any other similar robot.

Dr. Cronin’s team uses a chemical description language called XDL.  CNBC says: “XDL is to the “chemputer” as HTML is to a browser—it tells the machine what to do.”  Software called SynthReader scans descriptions of chemical processes, usually natural language processing (NPL) and translates them into XDL, when the chemputer then can actually execute in the lab. The code can be corrected without programming knowledge and the process is hardware independent.

It’s not entirely free of human involvement – “The human will always need to be there to make sure you don’t have a dumpster on fire.” Dr. Cronin believes – but they are “dedicated to making chemical synthesis accessible to everyone, regardless of training.”

 Dr. Cronin has big ambitions:

We’re hoping that the system we’ve built will massively expand the capabilities of robot chemists and allow the creation of a huge database of molecules drawn from hundreds of years’ worth of scientific papers.

Our system, which we’re calling Chemify, can read and run XDL files which have been shared among users.  Putting that kind of knowledge directly in the hands of people with access to robot chemists could help doctors make drugs on demand in the future. 

He brags: “We’ve invented the CPU [central processing unit] for chemistry.  That’s really important right now, because all the chemistry robots in the world are not only expensive, but they can’t be programed in the same way.”

Kim Branson, the global head of artificial intelligence and machine learning at GSK, is wowed, telling CNBC: “The chemputer as a concept and the work [Cronin]’s done is really quite transformational.” 

Dr. Collins’ latest research has a similar title – Fully Automated Chemical Synthesis: Toward the Universal Synthesizer – and reports similar breakthroughs.  Their synthesizer AutoSyn “makes milligram-to-gram-scale amounts of virtually any drug-like small molecule in a matter of hours.”  Their paper demonstrated synthesis of ten known drugs and predicts success for a high percent of many other FDA approved small molecule drugs. 

Dr. Collins is a big believer in the combination of AI and automation to improve the pharma R&D process.  He wrote earlier this year: “Progress in AI offers the exciting possibility of pairing it with cutting-edge lab automation, essentially automating the entire R&D process from molecular design to synthesis and testing – greatly expediting the drug development process.”

“The majority of chemistry hasn’t changed from the way we’ve been doing it for the last 200 years. It’s very manual, artisan driven process,” Dr. Collins told CNBC.  “There’s billions of dollars of opportunity there.”  No wonder Dr. Branson and other pharma executives are paying close attention.

Darpa is also paying close attention.  SRI International, the parent of Dr. Collins’ Bioscience division, just received $4.3 from Darpa for a tool to help automate production of therapeutics for pandemics and other biological threats. 

Darpa also is funding a Make-It program to automate “small molecule discovery and synthesis to propel the field beyond conventional batch-based, intuition-driven capabilities,” and a related Accelerated Molecular Discovery program, in which, as Anne Fisher, the program manager, told CNBC: “We’re now trying now to harness what we’ve done in Make-It and expand it out so we can teach computers how to discover new molecules.”

Think about that “Teach computers how to discover new molecules” and let that sink in.  As Dr. Collins says, “This is still a very new science.  It’s started to explode really in the last 18 months.”

All this is taking place as 3D printing for pharmaceuticals is also starting to take off, such as for “low-cost production of customized pill medications for patients who need special dosing, quantities or composition of drugs. Pills can be 3D printed in unique sizes, shapes and with slow-release capabilities.”  The FDA is still working on how to regulate 3D printing of medical products (which now include prostheses, orthopedic and other implants, pharmaceuticals, and even organs. 

It better start thinking about chemputers, or at least the products made by them.  

At the very least, we can expect that chemputers and 3D printing could greatly speed and democratize the production of pharmaceuticals.  Imagine your doctor or pharmacist producing your medicine on the spot – or perhaps doing it yourself, in your own home.  Further development of AI could also greatly speed up on the discovery process, which could have major implications not just for our health but also for the pharmaceutical industry.  The old models are up for grabs. 

So, get to know chemputers.  They may be in your future. 

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.  

#Healthin2Point00, Episode 161 | Partnerships galore & a new SPAC

Today on Health in 2 Point 00, we have some hot gossip re: Glen Tullman starting his own SPAC. On Episode 161, Jess and I discuss Bind Benefits raising $105 million, BridgeHealth merging with Transcarent and raising $40 million in a Series A, and Loyal raising $12.5 million in a Series A. Jess also asks for my take on a slew of new partnerships between Lyra and Calm, Cigna and MDLive, and Doctor on Demand and CareLinx. —Matthew Holt

Healthcare CIO survey reveals how Covid-19 is impacting startup collaboration

light bulb, innovation, idea

A new survey finds that health system leaders are actively seeking new commercial relationships with startups regardless of when “normal” returns but startup success hinges on not only addressing solutions that are on health systems’ shortlist but also data supporting a clear ROI.

Remote Patient Monitoring Sets Up Big Tech to Revolutionize Telemedicine and Healthcare

By JAMES MOELLER

Remote patient monitoring has emerged as the next significant challenge for virtual healthcare and that challenge is creating significant opportunities for many companies largely outside of the traditional healthcare technology marketplace. In particular, it is potentially setting up an opportunity for Big Tech companies like Apple, Google, and Amazon, to revolutionize telemedicine and healthcare similar to what those companies have accomplished in mobile phones, Internet search, and retail.

Next Generation Remote Health Monitoring

Next generation remote healthcare monitoring will likely look much different than anything done before. What is emerging today is the potential for the broad adoption of remote health monitoring devices and systems that leverage consumer wearables, smart home communication systems, and big data to produce holistic views specifically for healthcare providers. The pandemic has thrust telemedicine solutions forward by years if not a decade or more in the short span of three to six months. This is creating an opportunity for remote patient monitoring to provide even better visibility into patients beyond what can be accomplished with basic video conferencing.

But while telemedicine is now becoming more firmly established, remote monitoring seems to still have a long way to go. This is evident in a new report by KLAS Research (a healthcare industry research firm) published on August 27th, where they interviewed 19 executives from 18 healthcare organizations regarding their challenges and solutions during the outbreak of the pandemic. Not surprisingly, telemedicine was the top challenge with 32% of the executives. Overall, though, 84% of the executives indicated that the telemedicine issues were already solved and the remining 16% indicated that the solutions were in progress. However, remote patient monitoring ranked as the second most significant challenge with 26% of the respondents. But furthermore, only 22% of the executives indicated the remote monitoring challenges were solved, with 33% saying it was in progress, and 45% indicating it was completely unsolved. So, a clear opportunity exists.

Big Tech’s Virtual Healthcare Market Leverage

For Big Tech, the leverage into virtual health comes from the ability to offer remote monitoring solutions across wearables, ambient sensors, and smart home communication devices, as well as the capability to apply big data, AI, and machine learning to the information from those devices. Big Tech is even combining these technology solutions with healthcare specific services like telemedicine, prescription drug delivery, and medical testing. Market evidence suggests that Big Tech is already putting these pieces together and using this leverage to expand into the broader healthcare market.

Wearables and Ambient Sensors

Wearables and ambient sensors, and particularly consumer-oriented versions of these products, are a key enabler of next generation remote healthcare monitoring by serving as the principle connection with the individual. Over just the last few years the overall market for wearables has increased significantly and the market demarcations are blurring between traditional medical wearables and consumer health and fitness wearables.

Apple leads the overall wearables market with its Watch, Beats, and AirPod products. Across those product lines the company shipped 29+ million units in Q2 2020 and holds an approximate 30% market share, which is nearly three times the size of its nearest competitor. In addition, the Apple Watch is aggressively pushing into classical medical applications with its ability to measure blood oxygenation levels, its electrocardiogram (ECG) capability, and its ability to detect atrial fibrillation (AFib) as well as other cardiovascular conditions. (5)

Fitbit, which is in the process of being acquired by Google, typically ranks 5th in the wearables segment with a market share of approximately 3%. While Fitbit’s market share has been declining as of late, it would still position Google with an immediate unit shipment customer base (for Q2 of 2020) of approximately 2.5 million as well as its active user base of approximately 30 million.

Not to be left out, Amazon recently introduced its own wristband wearable device for health and fitness tracking called Halo. Its aiming to differentiate in the wearables market by offering capabilities to measure and track body fat, sleep temperature, and emotional state.

Smart Home Communication Devices

Smart home communication devices such as smart speakers and home control systems will also be a key component of next generation virtual healthcare. These systems can serve as communication access points to the Internet for lower power wearables and ambient sensors, and also enable intelligent personal assistant capabilities, such as reminders to take medications, and help in monitoring exercise and other behavioral health aspects.

Amazon is the dominant market leader in smart home communication devices with its Echo Alexa personal assistant, which has estimated 50%+ market share as of January 2020. Amazon was first-to-market with its smart speaker system and continues to augment its capabilities with an ever-expanding array of interactive skills. This includes skills to integrate Amazon’s Ring home security and control system, its portfolio of Alexa wearable devices, and numerous third-party products.

Google has the second position in the smart home communications device market with an approximate 30% market share for its Nest smart speaker products. (8) Recently the company make a $450 million investment in ADT, Inc. with the aim of growing its Nest deployments specifically in the home security market. Google also has a relationship with the Cleveland Clinic that has recently materialized into a capability for its Nest smart speakers that allow users to ask for Cleveland Clinic health tips. This is a perfect example of the virtual healthcare synergies that can be accomplished with smart home communication devices.

Apple is behind the competition in the smart home communications market. The company’s HomePod smart speaker is a distant 4th in market share at only 2.8%. So, while Apple’s Siri assistant has been an integral part of its iPhone for quite some time, the company has yet to make an impact in combining Siri and HomePod for the home market.

Big Data

The big data processing of medical information will become increasingly important as virtual healthcare remote monitoring grows. The ability to analyze the vast amounts of real-time, streaming data to produce trends, correlations, and medical diagnoses can potentially transform how healthcare is applied at both an individual and societal level. Big Tech is uniquely positioned with shear corporate size and technology assets to pursue remote monitoring big data. In addition, Big Tech is already pursuing healthcare data relationships with significant healthcare providers and can leverage those projects into new applications processing remote monitoring data.

In 2019 Google made waves in establishing relationships with both Ascension Health and the Mayo Clinic to partner on the development of digital tools that integrate healthcare data into new patient care models. While the Ascension deal, in particular, raised concerns about patient data privacy, the two relationships will provide Google valuable experience in processing healthcare data that can be leveraged into future remote monitoring data applications.

Apple is leveraging its iPhone and wearables products in its health data initiatives. In 2018 the company introduced a health records app for the iPhone where Apple partners with healthcare providers to deliver a patient’s records to their mobile phone. In addition, Apple has established a variety of research relationships with organization such as Harvard’s T.H. Chan School of Public Health, Brigham and Women’s Hospital, University of Michigan, and others, that focus on cardiovascular projects related to the Apple Watch and hearing projects related to the AirPod earbuds.

Amazon’s principle relationship for health data is with Cerner Corporation, which has an approximate 25% share for electronic health records systems across the entire healthcare marketplace. In 2019, Cerner chose Amazon Web Services as its preferred cloud provider for its healthcare patient data. More recently the companies announced a further collaboration where consumers using Amazon’s Halo wearable can opt-in to share their activity and health data and allow that information to be stored in their patient record in Cerner’s systems. The patient’s healthcare provider can then access and evaluate that information directly in the patient’s records. This is another example of virtual health synergies accomplished via the integrated capabilities of a consumer wearable, health data systems, and a patient’s healthcare provider.

Healthcare Services

As the most straight-forward initiatives toward revolutionize healthcare, Big Tech is also directly entering the healthcare provider and services market, which at a minimum provides a convenient platform to leverage its healthcare technology and data solutions.

In 2018 Apple launched a group of health clinics called AC Wellness for its employees and their families. These clinics are generally focusing on providing primary care but have extended that to also included on-site lab testing and wellness care such as exercise and dietary programs.

Last September Amazon introduced its pilot telemedicine program, Amazon Care, for its employees in Seattle. This service includes virtual primary care as well as home consultations and prescription drug services via Amazon’s PillPack division, a virtual pharmacy Amazon acquired in 2018.

Google’s most recent activity takes a different approach where on August 24th it announced it was investing $100 million in telemedicine provider Amwell. The synergies mentioned in the deal specifically focused on Google’s cloud computing services, but the intersection extends into its data processing and machine learning expertise and can potentially tap into its home personal assistant products for remote monitoring capabilities.

Challenges and Opportunities Ahead

When Big Tech pursues business growth, the companies must think big and look for markets that are ripe to be thoroughly transformed. With the global healthcare market size at more than $8 trillion and new technologies poised to transform how healthcare is executed, a prime opportunity exists. But significant questions remain in terms of the technological solutions, the market competitive and relationship dynamics, and of course, concerns about regulatory and information privacy.

Despite the market positions of Big Tech in wearables, smart home communications, and big data, there continues to be significant venture capital and start-up activity in the technological areas of virtual health that tend to focus on opportunities that Big Tech hasn’t yet pursued. The companies that achieve some degree of success will likely experience a very attractive market to be acquired by not only Big Tech competitors like Apple, Amazon, and Google, but also the leading telemedicine companies like Teladoc Health, Amwell, MDLIve, and SOC Telemed as well as technology-oriented insurers like UnitedHealth Group. From a Big Tech product portfolio perspective, two of the more significant gaps pertain to Apple’s position in smart home communications and Amazon’s position in wearables. In the smart speaker market, Apple’s 4th place position behind Sonos Inc. has led to speculation that Apple might buy Sonos purely to increase its market share. This is very unlikely to happen given Apple’s reluctance to large M&A deals and, more importantly, its recent announcement that it is will stop selling Sonos products in the Apple Store. So, for the moment, Apple looks to be preparing to grow its market share on its own. For Amazon in the wearables market, the situation is similar. There doesn’t look to be any wearable or smartwatch companies that help Amazon’s market position. Even if Amazon were to acquire a company like Garmin, it would only improve its market share by a few percentage points.

The competitive and relationship dynamics of the virtual healthcare market will continue to be very active as broad industry solutions come together. Ultimately, this market is a non-trivial combination of technology, information systems, and healthcare providers. Big Tech has significant positions in many key markets, but lacks considerable exposure to others, most notably in the healthcare provider area. The first six months of the Covid-19 pandemic has thrust telemedicine providers like Teladoc Health, Amwell, MDLive, and SOC Telemed to the forefront and positions them as key parts of future virtual health solutions. Teladoc just recently announced an $18.5 billion deal to acquire Livongo, a company focused on remote monitoring and virtual health services for diabetes and related health issues. Amwell, MDLive, and SOC Telemed are all accessing the public markets to shore up access to capital and the ability to leverage stock as an acquisition currency. So, watch for all these companies to be active acquirers. But for Big Tech there are many more private telemedicine companies that could be acquisition targets to improve Big Tech’s connection to the healthcare provider market. These include companies such as Doctor on Demand, Crossover Health, 98point6, and HealthTap. In fact, Amazon just recently announced a partnership with Crossover Health to provide health services to its employees and health centers near its fulfillment and operations facilities. This could potentially be a precursor to a more significant acquisition opportunity.

Last, but certainly not least, are the concerns over regulatory issues and information privacy. For Big Tech, under the current environment, any initiatives to capture significant portions of the next generation virtual healthcare market are likely to attract even more scrutiny regarding antitrust issues and the companies’ abilities to keep patient information private. But even these challenges are unlikely to deter Big Tech’s pursuit of healthcare. The market opportunity is just too attractive.

Jim Moeller provides business intelligence data analytics consulting services into projects involving strategic planning, competitive analysis, technology assessment, and intellectual property research.

Technology can ease pandemic challenges faced by hospitals, ambulatory surgery centers

To keep critical revenue flowing, hospitals and ambulatory surgery centers need to resume elective surgeries and procedures as quickly as possible and mobile apps can help by giving patients and staff vital information, provide advance symptom screening and help providers reduce elective procedure no-shows through better patient compliance.

Best practices for physicians in adopting compliant and efficient data sharing

hand touching visual screen

By making responsible and strategic technology investments, practitioners will have access to robust data, be in a position to analyze and interpret trends and outcomes and provide health care informatics that ultimately will be the insights they need to be successful in a value-based health care environment.

Not Just Faxes

By KIM BELLARD

I missed it when it was first announced in Japan, but fortunately the U.S. mainstream media has finally picked up on the story, with articles in both The Washington Post and The Wall Street Journal: Japan’s new Administrative Reform Minister Taro Kono has “declared war” on fax machines, among other paper-based traditions. 

Wait, what?  “Administrative Reform Minister?”  The U.S., or at least the U.S. healthcare system, has to hear about this. 

Mr. Kono is a well known Japanese politician, including stints as Defense Minister and Foreign Minister.  He is thought of as something of a maverick, at least by Japanese political standards.  New Prime Minister Suga installed Mr. Kono in mid-September, making overhaul of bureaucracy a top priority: “Wherever there are problems, I want all of them brought to Mr. Kono for handling on behalf of the nation.” 

Mr. Kono set up a hotline for people to report government red tape, which was quickly overwhelmed with thousands of examples.  It soon reopened.

It didn’t take long for Mr. Kono to start calling for significant changes.  “To be honest, I don’t think there are many administrative procedures that actually need printing out paper and faxing,” he said in a press conference in late September.  “My job is to clear the road of obstructions to allow the Ferraris and Porsches of digital innovation to speed through.”

I wonder what Honda and Toyota thought about that.

Part of the problem in Japan is the hanko, a personal stamp that is routinely used for authentication (and which thus requires paper.)  He’s now at war with that as well, tweeting:

We checked 800 most often used government procedures with hanko, or name stamp or seal, and found few of them need to continue with hanko. This is the first step to make those procedures online.

One ally, futurist Morinosuke Kawaguchi, pointed out:

More than 97 per cent of the documents that are produced in companies and government offices presently need a hanko, but these are hanko that can be purchased in a convenience store, so there is no meaning to this habit.  It makes no sense, it’s completely ridiculous.

If you’ve ever envied Japan for its bullet trains, its early adoption of robots, or its broad use of consumer electronics, you may be surprised to hear that more than 95% of Japanese businesses still use faxes, and 34% of Japanese households have a fax.  Mr. Kawaguchi admitted: “It may be 1970s technology, but it is extremely secure and very difficult for someone on the outside to hack…Digitisation may make things more efficient, but there is clearly a trade-off when it comes to security.”

Jonathan Coopersmith, a Texas A&M professor who is an expert on faxes, told WaPo:

The primary mode of writing is by hand, and this is a technology that fits this perfectly.  One of the reasons it’s still there is that you have an older generation that’s never really wanted to use computers, and a lot of small businesses that never adopted computers and didn’t need to.”

Not surprisingly, the COVID-19 pandemic has been a big driver in the anti-fax initiative.  Health care professionals were overwhelmed by the amount of reports that had to be prepared by hand and then faxed.  “Come on, let’s stop this already,” one physician tweeted.  “Even with corona, we’re handwriting and faxing.”  Mr. Kono quickly retweeted it, even though he was still in his former position as Defense Minister – and within a week the health ministry announced a system of online filing (which, not surprisingly, has not entirely succeeded).

An independent report on Japan’s response to the pandemic found that their system “made it difficult to grasp the spread of infection in real time nationwide, and exhausted health center staff.  The new coronavirus crisis was also Japan’s ‘digital defeat.’”

We don’t have hankos in the U.S., and we’re not as reliant on faxes as Japan is, even in our healthcare system.  But red tape, inefficiencies, and antiquated technology?  Yeah, we’ve got all that, especially in healthcare.  But where’s our Secretary of Administrative Reform?  Where are our Chief Administrative Reform Officers? 

Heck, where are our hotlines to report red tape? 

Even now, well over six months into our pandemic response, we have a slapdash, state-by-state (or even county-by-county) system of reporting, with hospitals and HHS still struggling to figure out what and how to report.  We’re driving by looking in our rearview mirror, and images – data — may be distorted.  They certainly aren’t real-time.  Dr. Ashish Jha, director of Harvard’s Global Health Institute, lamented: “The CDC during this entire pandemic has been two steps behind the disease,”

“We are woefully behind,” one senior CDC official said.  She likened the state of U.S. public health technology to “puttering along the data superhighway in our Model T Ford.”  Where are those Ferraris and Porsches Mr. Kono is expecting? 

And, to be fair, it’s not just the U.S.  Jen Spahn, Germany’s federal minister of health, admitted:

Faxes are still the most used way of communication in our health system, at least when it comes to communicating between the different players.  Within a hospital, that might be very much digitised, but as soon as you want to communicate with another hospital or another player in the healthcare system, it’s very much like the 1990s and not like 2020.

Yoshimitsu Kobayashi, chairman of Mitsubishi Chemical Holdings, sees the pandemic as an opportunity: “The very negative damage it has inflicted on Japan has in turn served as a powerful accelerator.  If we miss this chance, we won’t be able to do it next time.”

Economist Paul Romer is usually credited with the quote, “A crisis is a terrible thing to waste.”  Well, we certainly have a crisis, and I’m worried we’re going to waste it.  Using it to just get rid of faxes would be a waste.  We’re already using it to streamline development of therapeutics and vaccines, although not without problems.  But will we use it to solve fundamental problems in our healthcare system, such as inequities, inefficiencies, and infrastructure? 

Maybe we could recruit Mr. Kono to do the job. 

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

THCB Gang Episode 29 10/22 1PM PT/4 PM ET

Episode 29 of “The THCB Gang” will be live-streamed on Thursday, October 22th! Watch it below!

Matthew Holt (@boltyboy) will be by some of our regulars: patient safety expert Michael Millenson (@MLMillenson), MD turned leadership coach Maggi Cary (@MargaretCaryMD), guest Fard Johnmar (@fardj), digital health futurist, and guest Denise Pines (@MedBoardOfCA), Medical Board of California’s President. The conversation will cover the looming election, the ACA hanging by a thread, and more!

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khanproducer

Using digital engagement to solve pain points along the patient journey: How to deliver better outcomes for patients and brands [Sponsored]

Join us November 10th to learn how digital engagement can solve challenges for both patients and the brand and learn other benefits that will improve patient experience and address multiple barriers to medication adherence.

#Healthin2Point00, Episode 160 | Lawsuits galore, and a faux IPO

The thing to do in health tech this week? Trademark infringement. Today on Health in 2 Point 00, we try to make sense of all the lawsuits right now with Teladoc suing Amwell, Allscripts suing CarePortMD, and whose side are we on for Zocdoc suing Zocdoc? On Episode 160, Jess asks me to make sense of Augmedix’s faux IPO in a reverse merger and publicly traded company Newtopia arising $75 million. Twentyeight Health raises $5.1 million in a Series C and TestCard raises $5.8 million for at-home mobile urine testing. —Matthew Holt

THCB Spotlights: Jon Bloom, Podimetrics

By MATTHEW HOLT

This is a fun conversation with Jon Bloom, the CEO of Podimetrics. It’s one of a number of competitors trying to help prevent foot ulcers among people with diabetes. Some use socks, others use insoles, but Podimetrics’ approach is to use a pad which looks like a weight scale and can tell whether a patient might be developing a foot ulcer and is therefore at risk for amputation. Last week Podimetrics and Kaiser Permanente released a study that showed their service showed great success in reducing hospitalization, ER visits and foot amputations. But Bloom thinks that there’s much more to the care of very sick & underprivileged people with diabetes, and we had a great discussion about that that might look like.

Tying Health Care Investment to Performance

By BRIAN KLEPPER and JEFFREY HOGAN

GoodRx’s planned initial public offering recently made the news, notable because the company, launched in 2011, has been profitable since 2016. Evidently, it’s become unfashionable for investors to demand proof of performance, so GoodRx’s results shone like a beacon. By contrast, most health care firms seeking funding convey bold aspirations and earnest promises. Investors throw in with them and hope for the best. 

But few new entrants seem to do the necessary advanced due diligence to assess exactly where and how their product, service or innovation should be positioned in the health care ecosystem to derive maximum value. Ironically, COVID has intensified and highlighted the fragility of the health care ecosystem, as well as the greater disruption opportunities available to new entrants. 

Health care has become irresistible to investors, the outgrowth of the industry’s dominant players’ spectacular financial performance. Over the past 45 quarters, for example, major health plan stock prices have grown 4-6 percent per quarter, 1.2-2.2 times the growth rates of DJI and S&P (See the table below). Investors hope to either 1) capitalize on the health care’s ongoing culture of overtreatment and egregious pricing, or 2) support and share in the savings associated with rightsizing care and cost.

The result has been a torrent of investment. Mercom Capital reports that, in the last decade, investors have poured $50 billion into some 5,000 digital health startups, each one no doubt guaranteeing wholesale health system disruption that never arrived.

There are a couple of messages here. In the main, few health care startups are constituted to thrive. And apparently, few investors critically evaluate a venture’s broader design elements to gauge its chances for success. Many startups have great ideas and some even operationally execute those ideas well, but gaining traction in the health care marketplace requires much more than that. A viable venture must also integrate with its clients’ workflows, and connect with existing players in the larger health care management ecosystem. 

There’s a huge opportunity to disrupt the status quo, but it requires a thoughtful, comprehensive design.  As Michael Porter pointed out, “If all you’re trying to do is essentially the same thing as your rivals, then it’s unlikely that you’ll be very successful.”

Purchasers of health care risk management services – e.g., employers, worksite clinic firms, captive insurance arrangements, stop loss carriers, provider risk managers – exist in a high noise-to-signal environment and are constantly besieged by vendors. If they are value-focused, the question is whether the venture can quickly differentiate by demonstrating consistently superior results, meaning better health outcomes and/or lower costs than usual approaches. Assuming they can do that, there are more hurdles to clear to have a shot. For example:

  • Is the venture aimed at the right audience? If the venture achieves lower costs with equal or better outcomes, it may be wholly uninteresting to health plans that are still volume-based, that make more if health care costs more. Lower costs here likely translate to lower net revenues, earnings, stock price and market cap, results that health plans may avoid at all costs. But value-focused purchasers may be inclined to take notice.
  • Potential clients want to know about other clients’ experience. Are there testimonials from people you can talk with, attesting to a program’s operational excellence and vendor-client warmth?
  • Can the program scale, delivering consistent results independent of geographic location or the population’s demographics?
  • Are the services sticky, remaining effective over time? Can they provide ongoing, predictable management of clinical or financial risk?
  • Can clients come quickly up to speed on the services? Does the vendor provide training that facilitates ease of use with the program?
  • Are all key constituencies aware of the program. If a physician-based program improves health outcomes and reduces cost, are provider risk managers aware of it and demanding its use?
  • Do the processes integrate seamlessly into the clients’ existing workflows? If, for example, a new physician tool is on a different platform than the electronic health record, it may require unaffordable additional steps and will almost certainly fail.
  • Does the program exchange information easily with other critical management vendors? Is it mindful that it must fit into a broader existing management structure?
  • Is the vendor willing to financially guarantee the achievement of performance targets? Doing so puts its money where their mouth is, conveying confidence in its ability to deliver.

Some well-funded ventures have used marketing bluster to successfully convince the market that they’re excellent – see Al Lewis’ scathing review of Livongo – but in a health care market that increasingly considers value, purchasers are becoming more discriminating. In addition to performance data, many want to see independent, third party validation, like that provided by The Validation Institute, affirming that the approach in question works. 

Livongo and others are going directly to employers with their services, and desperate employers seem ready to listen. Other unique direct disruptors like Vera Whole Health and Integrated Musculoskeletal Care offer employers bonafide, at-risk solutions that supplant existing fee-for-service provider payment methods. They often use hybrid models that take responsibility for specific patients, and extend in-person and virtual primary care with the full functionality of advanced primary care. This agnostic model can steer to warranted episodes-of-care bundles for the biggest programmatic spend drivers. 

True innovation is exploding now, if you can spot the right firms. Companies like Dispatch Health are offering a quality at home urgent care solution that threatens brick and mortar urgent care. MediSync’s artificial intelligence-driven tool suite is revolutionizing chronic care management, which represents 75 percent of health care spend. ConferMed offers a national virtual specialty network that improves outcomes and drives out unnecessary care and cost.

Employers and at-risk organizations are increasingly abandoning traditional fee-for-service health care models in favor of value-based solutions, with payment systems that demand accountability and predictability. New ventures have a huge opportunity to succeed, but only if they have appropriately interpreted all of their opportunities in this new landscape. Most have not.

Brian Klepper is a health care analyst and Principal of Worksite Health Advisors, in Charlotte, NC.

Jeffrey Hogan is a health benefits advisor and Principal of Upside Health Advisors in Farmington, CT. 

THCB Gang Episode 28 10/15

Episode 28 of “The THCB Gang” was live-streamed on Thursday, October 15th! Watch it below!

Matthew Holt (@boltyboy) was joined by some of our regulars: communications leader Jennifer Benz (@jenbenz), data privacy expert Deven McGraw (@healthprivacy), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), CEO of Day Health Strategies Rosemarie Day (@Rosemarie_Day1), medical historian & health economist Mike Magee (@drmikemagee), policy & tech expert Vince Kuraitis (@VinceKuraitis). The conversation focused on the looming election, the new COVID-19 Surge, Amy Coney Barrett’s hearing, and health care costs rising in the US costs.

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan, producer

THCB Gang Episode 28 10/15

Episode 28 of “The THCB Gang” was live-streamed on Thursday, October 15th! Watch it below!

Matthew Holt (@boltyboy) was joined by some of our regulars: communications leader Jennifer Benz (@jenbenz), data privacy expert Deven McGraw (@healthprivacy), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), CEO of Day Health Strategies Rosemarie Day (@Rosemarie_Day1), medical historian & health economist Mike Magee (@drmikemagee), policy & tech expert Vince Kuraitis (@VinceKuraitis). The conversation focused on the looming election, the new COVID-19 Surge, Amy Coney Barrett’s hearing, and health care costs rising in the US costs.

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan, producer

#Healthin2Point00, Episode 159 | A quiet period?

Today on Health in 2 Point 00, we might be seeing a quiet period in health tech investing with the election coming up. On Episode 159, Jess and I talk about TigerConnect raising $45 million in a Series D, offering a HIPAA-compliant texting service for doctors; UK-based startup Numan getting £10 million, which is another online male health clinic. Next, Nym gets $16.5 million—lots of good investors in this round, this company uses natural language processing to automate hospital billing. Finally, Press Ganey acquires Doctor.com and a company called Binary Fountain. —Matthew Holt

#Healthin2Point00, Episode 159 | A quiet period?

Today on Health in 2 Point 00, we might be seeing a quiet period in health tech investing with the election coming up. On Episode 159, Jess and I talk about TigerConnect raising $45 million in a Series D, offering a HIPAA-compliant texting service for doctors; UK-based startup Numan getting £10 million, which is another online male health clinic. Next, Nym gets $16.5 million—lots of good investors in this round, this company uses natural language processing to automate hospital billing. Finally, Press Ganey acquires Doctor.com and a company called Binary Fountain. —Matthew Holt

#Healthin2Point00, Episode 158 | Datavant, Mira, Avail & more

On Episode 158 of Health in 2 Point 00, Jess and I talk about Datavant raising $40 million in a Series B for their open health data exchange platform, Mira raising $2.7 million for it’s Costco-esque health insurance alternative, Avail raising $100 million providing telehealth for the OR, ScriptDrop raising $15 million for prescription drug delivery, and Abridge raising $15 million to help patients transcribe doctor’s appointments. —Matthew Holt

#Healthin2Point00, Episode 158 | Datavant, Mira, Avail & more

On Episode 158 of Health in 2 Point 00, Jess and I talk about Datavant raising $40 million in a Series B for their open health data exchange platform, Mira raising $2.7 million for it’s Costco-esque health insurance alternative, Avail raising $100 million providing telehealth for the OR, ScriptDrop raising $15 million for prescription drug delivery, and Abridge raising $15 million to help patients transcribe doctor’s appointments. —Matthew Holt

Limbix digital therapeutic for adolescent mental health finds niche amid Covid-19 pandemic

The Silicon Valley startup plans to start its registration-directed study of Limbix Spark in the earlier part of next year and – if successful – would anticipate FDA clearance in early 2022.

#Healthin2Point00, Episode 157 | The phrase is “Takeout Speculation”!

Today on Health in 2 Point 00, Jess and I gossip about the wild rumor that UnitedHealthcare is acquiring Amwell. On Episode 157, we discuss Lark raising $55 million in a Series C along with a deal with Anthem to be their preferred DPP provider, Medicare Advantage plan Clover going public with a valuation of $3.7 billion, NOCD raising $12 million in a Series A providing specialized CBT and virtual OCD treatment, Cerebral raising $35 million in a Series A for its comprehensive digital mental health offerings, and Express Scripts adding to their digital health formulary with offerings targeting things like women’s health, tobacco cessation, muscle and joint pain, and more. —Matthew Holt

Startups with tech to improve payer and provider efficiency: Video from MedCity INVEST Digital Health

Next Generation of Workers

This Pitch Perfect contest track reflected technology to remove financial barriers for their patients, automating workflows, reducing inefficiency and waste associated with the Prior Authorization process, and more.

Will AI-Based Automation Replace Basic Primary Care? Should It?

By KEN TERRY

In a recent podcast about the future of telehealth, Lyle Berkowitz, MD, a technology consultant, entrepreneur, and professor at Northwestern University’s Feinberg School of Medicine, confidently predicted that, because of telehealth and clinical automation, “In 10-20 years, we won’t need primary care physicians [for routine care]. The remaining PCPs will specialize in caring for complicated patients. Other than that, if people need care, they’ll go to NPs or PAs or receive automated care with the help of AI.”

Berkowitz isn’t the first to make this kind of prediction. Back in 2013, when mobile health was just starting to take hold, a trio of experts from the Scripps Translational Science Institute—Eric Topol, MD, Steven R. Steinhubl, MD, and Evan D. Muse, MD—wrote a JAMA Commentary arguing that, because of mHealth, physicians would eventually see patients far less often for minor acute problems and follow-up visits than they did then.

Many acute conditions diagnosed and treated in ambulatory care offices, they argued, could be addressed through novel technologies. For example, otitis media might be diagnosed using a smartphone-based otoscope, and urinary tract infections might be assessed using at-home urinalysis. Remote monitoring with digital blood pressure cuffs could be used to improve blood pressure control, so that patients would only have to visit their physicians occasionally.

More recently, in an interview for my new book, Peter Basch, MD, an internist and health IT expert at MedStar Health in Washington, D.C., told me his colleagues believed that between 10% and 70% of patient encounters with primary care physicians could be done via telemedicine. “There are visits that are necessary—new patients, people with new episodes of a condition, or who have belly pain or chest pain. But what fills up most of my days as an internist are routine follow-ups for hypertension and diabetes and so forth. I need to see your BP and your blood sugar, and if there’s a question, come in.”

But Berkowitz went well beyond these prognostications in his podcast interview. He told his interviewer, non-physician Jessica DaMassa, “A lot of primary care can be commoditized: it’s routine and repeatable. I could teach you how to do it. An AI robot could tell the patient when they need to see a doctor.”

In fact, Berkowitz, added, a computer can do a better job of routine primary care than the typical doctor does, because the computer is less likely to overlook something.

Referring to the pressure on physicians to see more patients, he said, “Let’s automate base-level care; then doctors can focus on patients who really need their help.”

That remark reminded me of my old friend, Joseph Scherger, MD, a family physician and a longtime thought leader in health IT. Many years ago, Scherger was emailing routinely with his patients–at a time when that raised eyebrows among his colleagues—so that he’d have more time to spend with those who really needed to be seen in person.

When I asked Scherger what he thought of Berkowitz’s future vision of primary care, he said, “While this area [of telehealth] will grow and the generation under age 50 will welcome the convenience of getting care this way, it ignores the importance of the relationship with a primary care physician as people age and develop chronic health problems.  That role for FPs will endure.  Also, parents with children, especially under age 10-12, will want a physician most of the time.”

Scherger doesn’t view telehealth as operating in isolation from the doctor-patient relationship, as it would if “basic-level care” were automated. “When you already have a deep relationship with a patient, telehealth can be used for even more than minor stuff,” he said. “The more accessible the communication, the more reinforcing of the relationship it is. It’s much like communicating with your loved ones by email or FaceTime.”

In Eric Topol’s latest book, Deep Medicine, Scherger added, Topol argues strongly in favor of building on the doctor-patient relationship, but with better technology-mediated intelligence. The subtitle of the book: How Artificial Intelligence Can Make Healthcare Human Again.

While AI algorithms can be used to help doctors pinpoint a diagnosis or navigate a medical decision in some cases, it’s unclear how safe or effective they are when flying solo. As Hans Duvelt, MD, pointed out in a blog post entitled “Medicine is Not Like Math,” what a doctor does cannot be easily compared to a quantifiable, standardized endeavor like manufacturing. What a doctor runs through in his head in seconds when he sees a patient is based on experience and subtle symptoms that an algorithm “seeing” a patient on a telehealth hookup might miss.

As a patient, I find Berkowitz’s thesis troubling in other ways: If I were receiving automated care for symptoms that I thought were serious, how would I feel if the algorithm told me that my stomach pain didn’t rise to the level where I needed to see a clinician? How could I be confident that this conclusion was accurate?

Would the algorithm grasp that, with my particular chronic condition, I should be reminded to do certain things or seek particular kinds of care that had nothing to do with the reason I had contacted my doctor’s office?

If I were a patient who was likely to follow a doctor’s advice to say, quit smoking, would I do the same thing if a computer told me to? If I was a noncompliant type of patient, would the AI robot be able to persuade me that this time, I should really take my blood pressure medication regularly? Would I be able to explain that I couldn’t afford the drug, and perhaps the physician should prescribe something less expensive?

The questions are endless. But anyone who has spent time dealing with tech support chatbots will sympathize with my view that we’re already too much at the mercy of automated systems that don’t recognize our humanity and don’t care about our pain.

Berkowitz’s argument that telehealth should be used more widely and that it can help relieve physicians of some routine tasks is well taken. While we’re still not at the point where we can trust the accuracy of most home monitoring devices, they can help alert doctors to trends that might prove dangerous to a patient’s health. But if and when the technology becomes more reliable, we’ll still need to consult physicians who know us and have our best interests at heart.

Ken Terry is a journalist and author who has covered health care for more than 25 years. His latest book, Physician-Led Health Care Reform: A New Approach to Medicare for All, was recently published by the American Association for Physician Leadership.

How the value of innovation will be redefined in 2021

While payers and policymakers took a more narrow-minded perspective on innovation value in 2020, the year 2021 will bring an increased focus on a treatment’s societal value, how innovation interacts with digital technologies, and whether new innovations are able to reduce existing health outcome inequalities.

Attention, Walmart Patients

By KIM BELLARD

When Walmart announced earlier this summer that it was opening an insurance agency to sell Medicare-related products and services plans, I thought, “that’s it?”  When Walmart announced later in the summer that it was partnering (first with Microsoft, then with Oracle) in the bid to buy TikTok, I thought, “well, isn’t that interesting?”  And when Walmart announced a few days ago that it was partnering with Clover Health to offer Medicare Advantage plans, I thought: “it’s about time.”

You know Walmart.  265 million people (worldwide) shop at its stores each week.  Ninety percent of Americans live within 10 miles of a Walmart store.  It is estimated that 95% of Americans shop at Walmart during the year.  In over 200 U.S. markets, it accounts for at least 50% of grocery sales.  It is the fifth largest pharmacy chain by revenue. 

And Walmart has been shaking up healthcare for some time.  Way back in 2006, it introduced its $4 Prescriptions program that upended pharmacy pricing.  In 2008, it started offering in-store retail clinics, initially in partnership with hospitals and now operates on its own

Last year it started offering standalone clinics – Walmart Health – that went far beyond typical retail clinics.  They feature primary care, dental, lab and imaging, plus vision and audiology, and are starting to rapidly expand their footprint, aiming for 22 locations, in multiple states, by the end of 2021.  Patients can go online to view prices of services and book appointments. 

Then-President of Walmart U.S. Health and Wellness Sean Slovenski declared, “We’re bringing people into the health care system that have not traditionally been in it and identifying their needs.  We’re kind of creating an entire new market of customers.”  Commenting on the clinic’s low-cost, disclosed-in-advance prices and all-in-one services, Mr. Slovenski said: “We didn’t set out to disrupt healthcare. We set out to meet the needs of our customers at Walmart.”

To help its customers use technology in their health care journey, earlier this year it acquired technology from CareZone that “helps individuals and families manage medicine and chronic illness for each member of the household.”  They can also scan insurance cards or prescription drug labels. 

Walmart is beefing up its clinics by a new deal with Oak Street Health.  Marcus Osborne, Senior Vice President, Walmart Health said: “As we grow Walmart Health locations in other markets, we think Oak Street Health’s innovative value-based healthcare model will help us continue to deliver on our live better promise at these locations.”

Not to be outdone, Walmart subsidiary Sam’s Club just announced it is going nationwide on a collaboration with telehealth provider 98point6 that it piloted in September 2019.  It offers a subscription service that features unlimited $1 telehealth visits.  “Offering access to telemedicine was on our roadmap in the pre-COVID world, but the current environment expedited the need for this service to be easily accessible, readily available and most of all, affordable,” said John McDowell, Vice President, Pharmacy Operations and Divisional Merchandise, Sam’s Club. 

Walmart hasn’t been content to just offer health care services; it has been active on the payor front too.  In 2010, it partnered with Humana to offer a Medicare Part D plan, which it still offers.  For its own employee health program, it has had a Centers of Excellent program for over twenty years, and has tested ACOs, bundled payments, and value-based purchasing.  A couple years ago there was much discussion about a Walmart-Humana merger/acquisition, which did not pan out – yet. 

Which brings us to the Clover Health partnership, called LiveHealthy.  Clover Health President & CTO Andrew Toy said:

The Walmart brand is synonymous with the best value and low prices, and that’s exactly what we’re doing at Clover.  By offering affordable insurance plans with an open network  of doctors and hospitals, we are democratizing high-quality care and bringing it to individuals and communities that have previously been overlooked by other insurers.

LiveHealthy will start out in eight Georgia counties, with a network of 31 hospitals and 8,000 clinicians – including Walmart Health locations.  The plan is being billed as “Clover-powered,” but follows the Walmart value approach – zero premium, “free” primary care visits, lab tests, and preventive dental services, not to mention $100 every quarter to spend on OTC items at Walmart. 

In the scheme of things, Clover Health has a small membership/footprint.  Its main strength is its technology, specifically Clover Assistant that “gives your primary care doctor a complete view of your overall health and sends them care recommendations that are personalized for you, right when you’re in the appointment,” using “data, clinical guidelines, and machine learning to surface the most urgent patient needs.”

I’ve always wondered why Walmart hadn’t pursued partnerships with/acquisitions of managed Medicaid plans, such as Centene or Molina Healthcare (both of which are actively pursing their own acquisitions).   Clover Health’s website says: “Clover proudly serves many low-income and often overlooked communities, which is core to the company’s mission of bringing healthcare to people who are most in need and commonly ignored by other insurers.”  That dovetails quite nicely with serving a Medicaid or dual eligible (Medicare and Medicaid) population. 

Lest anyone think Walmart is solely focused on healthcare, there is:

  • The aforementioned interest in TikTok, which Walmart believes “will provide Walmart with an important way for us to expand our reach and serve omnichannel customers as well as grow our third-party marketplace, fulfillment and advertising businesses.”  It would especially boost Walmart’s presence for younger audiences.
  • The introduction of Walmart+, it’s answer to Amazon Prime that some analysts think could lead to 10 million subscribers by the end of 2021.  It includes unlimited free delivery on more than 160,000 items.
  • Its surging online sales, which have nearly doubled in the last quarter, especially for online groceries.  “You see Amazon following behind Walmart on this,” Edward Yruma, a retail analyst at KeyBanc Capital Markets, told The New York Times.

Walmart U.S. CEO John Furman believes: “The demand definitely tells us that Americans are looking for access to quality care, and we think Walmart — its footprint — should be a part of that.”  Maybe “Walmart” doesn’t carry the same cache as, say, “The Mayo Clinic” when it comes to healthcare, but its brand for value and convenience is hard to match, and that may be enough to make it a force in healthcare. 

Pundits spend a lot of time wondering what Amazon will do in healthcare, when.  It is, indeed, taking some interesting steps, but no one should be overlooking what Walmart is doing. 

Or soon will be.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

#Healthin2Point00, Episode 156 | Garage Sale Edition

Today on Health in 2 Point 00, Jess can’t figure out what’s going on with health tech investors. Episode 156 feels like rummaging through a garage sale… First up is mirrors, mirrors, mirrors, with a total of $225 million invested: Tonal gets $110 million, Tempo gets $60 million, and Fiture gets $65 million. Next up is socks; Siren, which makes socks, added $9 million to their B round, which already has $11 million. Our next category is doctors, aka startups from Europe with “doctor” in the name: DrDoctor gets £3 million in an A, HomeDoctor scored €3.7 million, and Your.MD gets $30 million. Finally, we have raccoons! Raccoon.World closes a $900 million seed round to provide physiotherapy in a video game platform. —Matthew Holt

KidsX to Unite Children’s Hospitals & Boost Innovation Investment in Pediatric Digital Health

By JESSICA DaMASSA, WTF HEALTH

Even though kids make up 20% of the total national patient population, investments in startups that use tech to improve their care is, at best, a dismal 1% of the total investments made in digital health and health tech each year. Why is there such a lack of innovation (and investment in innovation) in Pediatrics? Omkar Kulkarni, Chief Innovation Officer at Children’s Hospital of Los Angeles, talks us through the challenges that have so-far stymied a health tech takeover of the pediatric care market and how KidsX is out to change all that. Already, Omkar’s recruited several dozen of the world’s leading Children’s Hospitals and Pediatric care units into KidsX, bringing with them supportive payers and investors who want to add to the collaborative consortium’s ability to drive change into this stretch of the healthcare continuum. These “champions” aim to create more targeted opportunities for startups who want to pilot or co-develop peds-focused solutions with the leading pediatric care providers who will ultimately use them, the payers who will ultimately reimburse for them, and the investors who ultimately will fund scaling them. Startups are currently being recruited until October 7, 2020 to participate in the KidsX accelerator’s first cohort and it’s a pretty sweet deal. The bottom line: Lots of support, no equity take; this is NOT just for early-stage startups and it’s NOT just for health tech. Healthcare incumbents in care delivery orgs, health plans, and pharma companies are also invited to join in, along with those healthcare investors who want early-access to emerging pediatric startups and solutions, or a seat at the table as KidsX plans for its own investment fund.

#Healthin2Point00, Episode 155 | Is UnitedHealth Group taking over the world?

Today on Health in 2 Point 00, Jess and I discuss UnitedHealth Group acquiring DivvyDose for $300 million, which is a knock off of PillPack. Is there anything left for them to buy? We cover many more deals in Episode 155—Noyo raises $12 million in a series A, helping health plans exchange data, Medigate raises $30 million working on cybersecurity for connected devices in hospitals, OnCall raises $6 million helping health systems launch their own virtual care platforms, RapidAI raises $25 million to improve MRI and CT quality using AI to layer those images, and Medefer raises £10 million offering telehealth and referrals to patients within the NHS. —Matthew Holt

Telehealth Reality Check: Who’s Really Going to “Win” the Race to Virtual Care Market Leadership?

By JESSICA DaMASSA, WTF HEALTH

It’s the telehealth market reality check you’ve been waiting for! “Rogue” digital health consultant Dr. Lyle Berkowitz unpacks the numbers and the market potential for virtual care from the unique vantage point of a primary-care-physician-turned-health-tech-entrepreneur with nothing to lose. Having been 1) a clinician, 2) the Director of Innovation at Northwestern Medicine, 3) the founder of a health tech startup (Health Finch) that successfully exited to Health Catalyst, and 4) the former Chief Medical Officer at one of telemedicine’s biggest players, MDLive, few can boast such a wide-reaching, deep understanding of the inner workings of both the innovation and incumbent sides of the virtual care market — AND have a willingness to talk about it all with complete candor!

This is an analyst’s perspective on the telehealth market — with a twist of insider expertise — so expect to hear some good rationale behind predictions about how much care will remain virtual once hospitals and doctor’s offices return to normal, how “real” health system enthusiasm is for building out telehealth capacity to execute on the “digital front door” idea, and whether or not all these well-funded telehealth startups will have what it takes to win market share from traditional care providers.

BONUS on Primary Care: Is this the area of medicine that’s going to be the “battleground” where digital health and virtual care companies will be going head-to-head with incumbents for market share? Lyle says 50-plus percent of primary care “can and should be automated, delegated, virtualized, etc.” and boldly predicts that in 10-20 years we won’t even have primary care physicians anymore. Tune in to find out why starting at the 8:00 minute mark, where we shout out Crossover Health, Oak Street Health, Iora Health, and more.

Telehealth die-hards, don’t think for a second I’d miss this chance to also get some input on Teladoc-Livongo, Amwell, Doctor On Demand, SOC Telemed, the impending IPOs there, digital first health plans, virtual primary care, health systems (who Lyle hopes “don’t shoot themselves in the foot” with their opportunity to jump into the space) and, ultimately, who’s really going to ”WIN” in virtual care moving forward. For this, jump in at 17:00 minutes and hold on!

Trying to Make AI Less Squirrelly

By KIM BELLARD

You may have missed it, but the Association for the Advancement of Artificial Intelligence (AAAI) just announced its first annual Squirrel AI award winner: Regina Barzilay, a professor at MIT’s Computer Science and Artificial Intelligence Laboratory (CSAIL).   In fact, if you’re like me, you may have missed that there was a Squirrel AI award.  But there is, and it’s kind of a big deal, especially for healthcare – as Professor Barzilay’s work illustrates. 

The Squirrel AI Award for Artificial Intelligence for the Benefit of Humanity (Squirrel AI is a Chinese-based AI-powered “adaptive education provider”) “recognizes positive impacts of artificial intelligence to protect, enhance, and improve human life in meaningful ways with long-lived effects.”  The award carries a prize of $1,000,000, which is about the same as a Nobel Prize

Yolanda Gil, a past president of AAAI, explained the rationale for the new award: “What we wanted to do with the award is to put out to the public that if we treat AI with fear, then we may not pursue the benefits that AI is having for people.”

Dr. Barzilay has impressive credentials, including a MacArthur Fellowship.   Her expertise is in natural language processing (NLP) and machine learning, and she focused her interests on healthcare following a breast cancer diagnosis.  “It was the end of 2014, January 2015, I just came back with a totally new vision about the goals of my research and technology development,” she told The Wall Street Journal. “And from there, I was trying to do something tangible, to change the diagnostics and treatment of breast cancer.”

Since then, Dr. Barzilay has been busy.  She’s helped apply machine learning in drug development, and has worked with Massachusetts General Hospital to use A.I. to identify breast cancer at very early stages.  Their new model identifies risk better than the widely used Tyrer-Cuzick risk evaluation model, especially for African-American women. 

As she told Will Douglas Heaven in an interview for MIT Technology Review:  “It’s not some kind of miracle—cancer doesn’t grow from yesterday to today. It’s a pretty long process. There are signs in the tissue, but the human eye has limited ability to detect what may be very small patterns.”

This raises one of the big problems with AI; we may not always understand why AI made the decisions it did.  Dr. Barzilay observed:

But if you ask a machine, as we increasingly are, to do things that a human can’t, what exactly is the machine going to show you? It’s like a dog, which can smell much better than us, explaining how it can smell something. We just don’t have that capacity.

She firmly believes, though, that we can’t wait for “the perfect AI,” one we fully understand and that will always be right; we just have to figure out “how to use its strengths and avoid its weaknesses.”   As she told Stat News, we have a long way to go: “We have a humongous body of work in AI in health, and very little of it is actually translated into clinics and benefits patients.”

Dr. Barzilay pointed out: “Right now AI is flourishing in places where the cost of failure is very low…But that’s not going to work for a doctor… We need to give doctors reasons to trust AI. The FDA is looking at this problem, but I think it’s very far from solved in the US, or anywhere else in the world.” 

A concern is what happens when A.I. is wrong.  It might predict the wrong thing, fail to identify the right thing, or ignore issues it should have noticed.  In other words, the kinds of things that happen every day in healthcare already.  With people, we can fire them, sue them, even take away their license.  With A.I., what we do to whom/what is not at all obvious.

“This is a big mess,” Patrick Lin, director of Ethics and Emerging Sciences Group at California Polytechnic State University, told Quartz. “It’s not clear who would be responsible because the details of why an error or accident happens matters.” 

Wendall Wallace, of Yale University’s Interdisciplinary Center for Bioethics, added: “If the system fails to perform as designed or does something idiosyncratic, that probably goes back to the corporation that marketed the device.  If it hasn’t failed, if it’s being misused in the hospital context, liability would fall on who authorized that usage.”

“If it’s unclear who’s responsible, that creates a gap, it could be no one is responsible,” Dr. Lin said. “If that’s the case, there’s no incentive to fix the problem.”  Oh, great, just what healthcare needs: more unaccountable entities.

To really make AI succeed in healthcare, we’re going to have to make radical changes in how we view data, and in how we approach mistakes.

AI needs as much of data as it can get.  It needs it from diverse sources and on diverse populations.  All of those are problematic in our siloed, proprietary, one-step-from-handwritten data systems.  Dr. Barzilay nailed it: “I couldn’t imagine any other field where people voluntarily throw away the data that’s available. But that’s what was going on in medicine.” 

Despite our vaunted scientific approach to medicine, the fact is that we don’t really know what happens to most people most of the time, and do a poor job of counting even basic healthcare system interactions, like numbers of procedures, adverse outcomes, even how much things cost.  As bad as we are at tracking episodic care, we’re even worse at tracking care — much less health — over time and across different healthcare encounters. 

Once AI has data, it is going to start identifying patterns, some of which we know, some of which we should have known, and some of which we wouldn’t have ever guessed.  We’re going to find that we’ve been doing some things wrong, and that we could do many things better.  That’s going to cause some second-guessing and finger-pointing, both of which are unproductive.

Our healthcare system tends to have its head in the sand about identifying errors/mistakes, for fears about malpractice suits (justified or not).  Whatever tracking does happen is rarely disclosed to the public.  That’s a 20th century attitude that needed to be updated in an AI age; we should be thinking less about a malpractice model and more about a continuous quality improvement model.

“The first thing that’s important to realise is that AI isn’t magic,” David Champeaux of Cherish Health said recently.  It’s not, but neither is what we already do in healthcare.  We need to figure out how to demystify them. 

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

Health in 2 Point 00, Episode 147 | The Most Confusing Episode So Far

With 3 consecutive days of $100M in funding, here is the most confusing (or rather the most confused we have been) Episode 147 of Health in 2 Point 00. Jess asks me about Verily partnering with Swiss Re to get into the stop-loss insurance game, Prescryptive Health raising a $26M Series A for their maybe GoodRx-like or PBM platform, Sonde Health acquiring NeuroLex for its vocal biomarkers platform, Aetion reopening their Series B and raising another $19M to the $36M they have already raised, and Otsuka after investing millions of dollars in Proteus, deciding to buy the rest of it with $15M, but we don’t know why any of these deals happenedMatthew Holt

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COVID-19 is Bringing Data Privacy into the Spotlight – This is How Healthcare Companies Should Respond

By DAN LINTON

Privacy concerns across the country continue to increase, and consumers expect their healthcare information to be private. Headline-making data sales, skepticism of Silicon Valley privacy practices, and COVID-19 contact tracing concerns compounded with a general lack of consumer awareness have continued to generate an ongoing storm ofnegative press and political scrutiny.

With COVID-19 continuing to rampage throughout the country, there is a need for the contact tracing and other technology applications to assess public health. At the same time, changing HHS rules are giving Americans more access and control over their own health data. Both availability and the promise of positive impact of data on people’s lives has never been greater.

Despite the critical need and incredible potential, there is still a great deal of confusion, lack of awareness and heightened concern among consumers. Studies show that the vast majority of Americans think the potential risks of data collection outweighs the potential benefits.

Clamping down on data privacy stifles innovation, and moving forward as we’ve been doing presents a potential privacy minefield. So, what should the healthcare industry do about it?

It is clear that data privacy, and particularly health data privacy, is crucial to consumer trust. Yet we also know thatconsumers are unclear who may be collecting their health data, or how it is being used.

That said, a recent study has shown that consumers want privacy protection, informed choice, and control over their data. It also revealed that people are more willing to share health data for altruistic reasons – either to advance their own health or to help advance public health and medicine in general.

Consumers believe that their health data is private information, yet they are more willing to share their data for the right reasons, with the right levels of communication, and with privacy protection. However, one thing is lacking: Thehealthcare industry does not do a good job of providing education or communication to consumers on the critical need that health data can fulfill. 

What can healthcare companies do

To accelerate innovation through the use of patient data, healthcare organizations need to start taking consumer privacy expectations seriously.

Educate and communicate: Most people do not understand how health data can be used to develop new therapies, and only 29% believe it is being used to improve healthcare outcomes. Yet many consumers would share their health data if they knew it would be used to improve healthcare outcomes for others. Altruism is a stronger motivator for sharing health data than even paid compensation.

Provide informed choice: The vast majority of people believe that their health data should either not be shared or only shared with their permission. In addition, privacy legislation and consent requirements are getting more complex world-wide. An opt-in mechanism ensures that organizations have the opportunity to educate consumers on the amazing work that their health data can contribute to. This approach of including patients more directly in data collection will also create additional health research opportunities beyond the data recorded in medical records.

Address the generation gap: Boomers are well known to be more distrustful of technology and data collection. The same study showed that less than 30% of those ages 55 to 75 (an age group that might benefit most from COVID-19 interventions) indicated a willingness to download a contact tracing application compared to about 65% of Millennials (ages 25 to 39). Again, education is key – lack of communication about data access and storage significantly decreases the likelihood of downloading.

Let’s get on this

Data is essential to driving progress and innovation in healthcare, and the COVID-19 pandemic has placed the spotlight directly upon privacy. Interventions such as contact tracing and related technology applications in digital health have created an urgent need for companies to provide greater clarity around how health data is used.

To achieve the advances necessary to tackle COVID-19 and other healthcare challenges, organizations must proactively consider and respond to these privacy concerns. Addressing expectations and spending the time and money needed to educate the general public, particularly on the altruistic reasons for sharing data, is key to ensuring that data-driven insights continue to add value to the healthcare industry.

Dan Linton is the Global Data Privacy Officer at W2O, where he supports internal and client data privacy and protection practices with a specific focus on GDPR, CCPA and the impact of global privacy legislation on healthcare marketing and communications.

THCB Gang Episode 23 LIVE 8/27 1PM/4PM ET!

Episode 23 of “The THCB Gang” will be live-streamed on Thursday, August 27th! Tune in below!

Joining Matthew Holt (@boltyboy) today are some of our regulars: health futurist Ian Morrison (@seccurve), WTF Health Host Jessica DaMassa (@jessdamassa), health care consultant Daniel O’Neill (@dp_oneill), and a few more! The conversation will revolve around the recent investments & growth in health tech, new policies around clinics & centers around COVID19, and more!

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan