Blog Archive - Page 3 of 16

Wrapping up 2021: An opinionated take on NEJM highlights for November-December 2021

Marc Herant January 6, 2022

In search of a diagnosis: deploying genomics at scale A substantial number of children have a disease identified as “rare” without having any kind of causative diagnosis (autism is not a causative diagnosis!). In a UK pilot study, 2,183 proband children were referred for exome sequencing with additional sequencing of family members if warranted. The overall diagnostic yield was surprisingly high, about 25% overall. Of the approximately half of probands who had neurological or sensory disorder, an explanatory diagnosis was reached in almost 40% of the cases. Two thoughts: 1)

The road ahead for genomic testing

Sarah Dolman December 24, 2021

New molecular diagnostics, especially tests based on next-generation sequencing and gene-panels, could revolutionize how diseases are evaluated. But experience shows that insurers won’t cover these tests just because they’re available – they need to improve clinical care. Here, we explore how researchers and test developers can prove value, and improve their chances at broad clinical uptake. Outside the niche realm of self-pay (where buyers have very different expectations[1]), the business opportunity of new molecular tests is driven by payer-coverage and reimbursement. Payers are beginning to manage[2] high-cost (>$1,000) lab tests

New York Magazine: The Great American Testing Crunch How it happened, what we can do about it, and when it might end.

Nikhil Bhojwani December 22, 2021

The ongoing physician affiliation land grab in Pennsylvania’s Capital District

Jacob Wiesenthal and Tory Wolff December 21, 2021

Closed vs. open Hospitals can compete for patient referrals either by exclusively affiliating with a subset of physicians (“closed model”) or by collaborating with as many qualified physicians as possible irrespective of competing affiliations (“open model”). (Both of these strategies are from the perspective of the facility, of course. A population health strategy would still focus on affiliating with physicians to aggregate patients, but with a goal of minimizing (not just directing) facilities based care.) The two strategies are generally incompatible. If most hospitals use the same approach in a

Optum opening new competitive terrain in Revenue Cycle Management

Tory Wolff November 21, 2021

What is revenue cycle management? Revenue cycle management (RCM) is the process of converting care delivery into cash. At its most comprehensive, services include: patient intake (scheduling/registration, coverage verification and financial counseling) claim submission (charge capture, coding, documentation, submission), and payment capture (payment processing, denials, customer service and collections). Effective RCM is challenging because of: The variety of plans and benefits designs (what’s covered, patient co-pays, rates, etc.), Ambiguities of payer approval of specific clinical services (prior authorization, etc.), Requirements and opportunities in characterizing the care and patient risk

Profit engine swap-outs: How UPMC sustained itself after the Highmark decoupling

Jacob Wiesenthal and Tory Wolff November 2, 2021

UPMC’s decoupling from Highmark exposed a critical vulnerability: economic dependence on its Allegheny County hospitals. In FY11-12,[1] these hospitals provided 70% of UPMC’s overall operating margin, an average of ~$270M annually.[2] A few years later, these operating margins had been cut in half and, by FY19, these same hospitals could contribute just $9M to the enterprise.[3] How did this happen? The Highmark dispute created severe economic headwinds for its western Pennsylvania (what we call “Core”)[4] hospitals: Decay in payer mix. As Highmark patients went elsewhere, the overall commercial share of

Taking on tough indications: An opinionated take on NEJM highlights for October 2021

Marc Herant October 29, 2021

What makes an indication especially tough? The combination of a lack of understanding about the mechanism of disease and a lack of clarity on what endpoints would be sufficient for approval of a therapy in studies of reasonable duration. This month, two good examples in the NEJM. A phase 2b success in NASH Non-alcoholic steatohepatitis (NASH) is a common slow-progressing disease and for most affected individuals the timescale to liver-related morbidity is at least 20 years, although some progress much faster. NASH is also a graveyard of clinical programs

The Puzzling Future of Healthcare

Nikhil Bhojwani October 10, 2021

This post is from a talk at the 2021 Link Ventures CEO summit. Original talk: Transcript: The practice of medicine has always been an information problem. Clinicians seek to diagnose an ailment and to prescribe a cure based on an incomplete understanding of what’s happening in a patient’s body as it relates to an incomplete set of knowledge about diagnoses and treatments. This aspect of medicine has remained the same for centuries even as our collective understanding of medicine has gone through three major phases. Until the 18th century, much

From bleeding edge to basics: an opinionated take on NEJM highlights for August and September 2021

Marc Herant October 4, 2021

The weird world of synthetic biology In biology 101, one learns about the alphabet that translates DNA/RNA code into amino acids sequences ultimately resulting in proteins. Given that there are 64 possible triplet codons and 20 amino acids, multiple codons can map to the same amino acids. But this mapping can be reassigned including incorporating new amino acids – it has been done in E. coli with the promise of generating biologics with novel properties, although applications are not yet clear. A more practical application is to create strains of

JAMA Network: Trends in the Concentration and Distribution of Health Care Expenditures in the US, 2001-2018

Max Holle September 14, 2021

Summer catch-up: an opinionated take on NEJM highlights for May-July 2021

Marc Herant August 15, 2021

Cancer and mutational complexity Probably the biggest news in cancer treatment this year is the approval of sotorasib (Lumkras, Amgen) which received accelerated approval in lung cancer with mutated KRAS (G12C) and has potential for use in other cancers (see here). Mirati is hot on the trail with adagrasib, but unusually for a drug in the approval process, their paper in the NEJM is a deep dive into the mechanisms of resistance to KRAS G12C inhibition that lead to treatment failure. They present very detailed in vitro studies in which

Harvard Business Review: Has the Delta Variant Disrupted Your Office Reopening Plans?

Nikhil Bhojwani August 5, 2021

Iora Agonistes: High-touch primary care in Medicare Advantage is no sure bet after all

Tory Wolff June 20, 2021

Iora Health was one of the original primary care transformers offering a clinically capable, engagement-focused, and accountability-grounded care model. After an initial foray into commercial, Iora pivoted in 2014 to Medicare Advantage (MA), an alliance with HUM and a global capitation-oriented strategy broadly similar to Oak Street or ChenMed. MA – whose members often have chronic conditions that respond to management and with a payment model that rewards quality (via stars) and patient intimacy (via risk coding) – is fertile ground for Iora’s high touch primary care. And that terrain

Four plausible rationales for incumbent hospitals to embrace hospital@home despite the potential to divert “heads from beds”

Tory Wolff and Thomas Uhler May 24, 2021

We identify four different business strategy rationales for hospital@home depending on each hospital’s specific market situation and each with clear predictive implications for local markets. These are: on-demand capacity expansion, bed capacity rationalization, competitive matching and system consistency. Almost all participants in CMS’s current Hospital@home program could find one of these four rationales applicable. If these rationales become compelling business cases, the future of hospital@home is bright and it is time to start the healthcare ecosystem to prepare for its disruptive consequences. The cannibalization challenge Hospital@home uses innovative protocols, technology,

WMT’s MeMD acquisition: too small a play to make the difference

Tory Wolff May 14, 2021

Last week, WMT acquired MeMD, a virtual provider in Arizona. Per the press release, MeMD will “allow Walmart Health to provide access to virtual care across the nation including urgent, behavioral and primary care, complementing our in-person Walmart Health centers.” Can MeMD rescue Walmart’s struggling clinic strategy? I am skeptical. Virtual is a great complement to the clinics Adding virtual to the clinics could be a very good idea: Walmart’s clinics had the extraordinarily bad luck of rolling out during a pandemic. More importantly, they are weighed down with unresolved

Clinicaltrials.gov and AI-related studies: a brief status check in April 2021

Marc Herant May 2, 2021

Healthcare is by nature conservative; despite a huge level of interest for artificial intelligence (AI) and machine learning (ML) techniques, significant penetration in standard workflows of care will depend on demonstrations of safety and efficacy. As a result, it is today’s pipeline of clinical studies using AI/ML that will determine mainstream usage tomorrow. In order to better understand this pipeline, we have mined clinicaltrials.gov for characteristics and trends of registered studies making use of AI/ML. Unsurprisingly we see strong growth, but starting from a very small baseline. Although most of

Remodel, rewire, repopulate: an opinionated take on NEJM highlights for April 2021

Marc Herant May 2, 2021

Remodeling to health? Chronic disease progression is often due to a maladaptive tissue response which leads to remodeling – such as cardiac hypertrophy with hypertension. While most therapeutics focus on tamping down the injury, sotatercept (Acceleron Pharma) in pulmonary arterial hypertension (PAH) breaks new ground by focusing on the remodeling. This modulator of the TGF-beta superfamily looks to inhibit the remodeling of the pulmonary vasculature that worsens the PAH over time, and eventually leads to the demise of most patients. In a 24-week placebo-controlled phase 2 trial (N=106), the pulmonary

Balancing the humors: an opinionated take on NEJM highlights for March 2021

Marc Herant March 30, 2021

A new approach to schizophrenia Antipsychotic agents treat schizophrenia by manipulating the dopaminergic system. While they are effective at treating psychosis, they can have major side effects and they lack the ability to address so called negative symptoms e.g. apathy, lack of social connection, poverty of thought. Enter the muscarinic cholinergic system which is tricky to manipulate in the CNS without untoward systemic effects as Lilly found out with their M1/4 agonist xanomeline. Karuna Therapeutics has now licensed the molecule and cleverly combined with it with trospium, an antagonist with

How much are Humana’s value-based care models really taking out of utilization?

Tory Wolff March 8, 2021

All that effort for only 0.4% savings Since 2014, HUM has reported on the performance of primary care in value-based arrangements (“VBA”) vs. traditional contracts (“non-VBA”)[1] in Medicare Advantage (MA). One statistic regarding total medical expenditures (TME) is, at first blush, a stunner. The most recent data (2019) shows PMPM TME of VBA members measured only 0.4% less than for non-VBA members. Given HUM’s long-standing strategic commitment to value-based care, commentators are puzzled: is the whole value-based enterprise in vain? does healthcare transformation require quasi-geologic timeframes to deliver meaningful cost

All immunity: an opinionated take on NEJM highlights for February 2021

Marc Herant March 2, 2021

We can cure Hep C but not immunize against it Sovaldi and other drugs have made curing chronic Hepatitis C a routine, if expensive, proposition. Still, given how common Hep C infection is, and how it can irreversibly damage the liver without overt signs, a vaccine would be highly valuable. Unfortunately, an NIH sponsored trial with a GSK vaccine in 548 IV drug users at high risk of contracting the disease failed to show any protection: 28 participants developed chronic Hep C evenly divided between the placebo and treatment groups.

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