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Matthew Holt is the founder and publisher of The Health Care Blog and still writes regularly for the site and hosts the #THCBGang and #HealthInTwoPoint00 video shows/podcasts. He was co-founder of the Health 2.0 Conference and now also does advisory work mostly for health tech startups at his consulting firm SMACK.health.

Matthew’s health care tidbits: Oh, the DEA makes me sigh….

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I have always thought that the dual role of the Drug Enforcement Agency (DEA) was an anachronism that severely hampers America’s complex relationship with pharmaceuticals. Congress deems some medicines legal and regulates them via the FDA, and deems others illegal and tells the DEA and other law enforcement agencies to attempt to control their supply. Leaving aside the basic futility of this task, somehow DEA was also given the task of regulating the prescribers of legal prescription (and non-prescription) drugs–in particular those around controlled substances.

This has led to decades of DEA-led persecution of doctors, patients and even convenience store clerks in the name of reducing the diversion of opiates and methamphetamines. Of course going after any of these folks is much easier and less risky than hunting a Mexican cartel or busting real criminals, so it’s easy to see why the DEA has taken that approach. Has it worked in reducing the supply of opiates? Maybe. Has it had any impact on the opiate crisis? Not really. Have a whole lot of patients been caught in the crossfire? Yup.

Now the DEA is moving onto the next phase–re-regulating the online prescribing of controlled substances that was liberalized at the start of the public health emergency in 2020. As you can imagine, their proposals are not exactly bursting with reason.

The DEA is essentially banning all controlled prescribing without a face to face visit first. This is despite the fact that the demand for those mental health medications increased dramatically during the pandemic as rates of depression and anxiety went up by a factor of three. While you can argue that in 2021 and 2022 some online services (notably Cerebral) may–and I stress may–have crossed the over-prescribing line for ADHD and other conditions, there’s no evidence that what happened is any worse than the in-person care that the DEA has been inadequately overseeing for decades. More importantly, those online services have already pulled out of those exact therapeutic markets the DEA is alarmed about. Who is left providing online ADHD care? Local clinicians and reputable services. And of course DEA knows full well, and is doing nothing about, the lack of access to mental health professionals that existed long before the increase in demand.

Is there any reason to suspect DEA will improve the quality of the system dealing with these medications? Highly doubtful. There are two current examples suggesting why not. First, due to the increased demand from the pandemic induced mental-health crisis and production problems at pharma company Teva, there’s a massive shortage of ADHD medication already. The DEA could help patients out here, but have declined to increase production quotas–sending millions of patients and their parents on a wild goose chase hunting down pharmacies with actual supply of Adderall and related meds.

Secondly, the DEA wants to also ban the the online prescribing of another drug, buprenorphine, which is used to help wean patients with substance use disorder off opiates and other substances. OK, so there’s a one month grace period here but essentially this is a short-sighted ban that will directly lead to patients going to the black market to acquire opiates, leading to more addiction and death.

My conclusion is that the DEA should be removed from its oversight of licensed clinicians and that role be given to FDA or HHS. At the least these proposed  regulations should be abandoned and rolled back to what we have now. The only good news is that there is still time to comment on the regulations. I went and did so and I hope you will too. Patients have suffered enough already.

Matthew’s health care tidbits: Medicare Advantage is now a provider fracking contest

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Yes it’s time to talk Medicare Advantage (MA). It’s been a huge couple of weeks for the world of MA. On the commercial side, CVS bought the biggest pure play MA provider, Oak Street Health for $10bn. This pissed me off as if they paid $2 a share more I’d have made a profit on the stock I foolishly bought “on a dip” in 2021.

But this amazed many of us on THCB Gang, as they paid a huge premium and it works out to some $60k per patient. Now health care organizations have been overpaying for patient “lives” as long as I can remember–going at least as far back as Aetna nearly going out of business when it bought US Healthcare in 1996. So why is today’s incarnation of Aetna buying providers?

Well that’s to do with the regulatory side of MA. I have been on record since the very first post of THCB that Medicare FFS is an inefficient and expensive program–even if 80% of American hospitals say they lose money on it and have to charge commercial insurers more to make up for it. But while it’s possible to agree with George Halvorson that MA delivers better care at a lower cost than FFS Medicare, it is simultaneously possible to believe that MA costs more than it should. That’s because of aggressive RAF upcoding that’s been built both into home visits from companies like Signify and also into the EMRs doctors have been using to code MA members’ health status.

There are lots of proposals on how to fix this–including this one from Chenmed on how to change MA from paying for inputs (i.e how sick people are when they join MA) to outputs (how much better they got while in MA). But it’s clear that CMS is now officially coming after upcoding including full cross plan audits back to 2018. Even if not back to 2011. The MA plans will grumble about those past audits and tie CMS up in court but they know going forward the game is up

To make more money in MA they need to get hold and shake loose or frack some of the 85% of the premium that goes to provider organizations. Hence they are all getting into bed with them or buying them outright. UHG, Humana & now Aetna/CVS have been buying physician groups that serve MA populations at a quickening rate, and their goal is to put more of the 50% of seniors already into MA into those groups.

Will this save any money?  Well probably not, at least not yet. Humana has been reporting on the costs in its full risk capitated MA groups versus its FFS ones for a couple of years, and the difference is a rounding error. But the point is that the next war in Medicare Advantage is going to be what happens inside these plan-owned medical groups. So expect a lot more scrutiny of both costs, outcomes and patient experience within MA focused medical groups starting about now. 

Matthew’s health care tidbits: How do you tell the price of a drug?

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

As the average THCB reader is probably all too well aware I live in Marin County, California and therefore my kids are on amphetamine-based medication for ADHD. This is annoying as all get out because, as a controlled substance, this medication needs to be re-prescribed every month (no automatic refills allowed). In addition no 90 day supplies are allowed, and the kids must have checkups with their prescribing physician every 3 months (which are not cheap).

It’s not just prescribing which is complicated. Supply is an issue too and frequently pharmacies run out. This is furtherly frustrating because if one pharmacy is out it can’t move the Rx to another, even in the same chain like Walgreens or CVS. The new pharmacy requires a whole new prescription. I discovered last year that Alto Pharmacy, a VC backed home delivery pharmacy, will deliver controlled medications. This has saved me 12-24 visits to CVS in the past year.

But with a new year there are new problems. The “allowed” price, i.e. the price my insurer Blue Cross of Massachusetts had agreed with Alto Pharmacy (and other pharmacies) for the specific generic for one of my kids somehow went from $29 a month to $107. That’s the amount I actually pay until we hit our $4,500 family deductible. Incidentally because it’s a medication we still pay $10 a month after we hit the deductible.

Alto kept telling me that the cash price was around $50. But of course if we pay the lower cash price (either there or elsewhere using GoodRx) that doesn’t count against the deductible. So if we hit the deductible we are out the $50 (which works out to roughly $1200 per year for 2 kids). I kept asking Alto what had changed that made the cost go up? They kept not telling me an answer, other than it cost $107. I asked the good people at Health Tech Nerds slack group if they could guess what was going on. Their consensus was that the formulary tier had been changed. “But it’s a generic”, (I foolishly thought).

Finally I called the pharmacy number on BCBS Massachusetts website, and ended up talking to someone at CVS Caremark– their PBM. In the course of the 30 minute call they ran a dummy claim with several other pharmacies. All came back at the $107 number. They then looked up the formulary to see if it had changed. Meanwhile I looked at the formulary on the BCBS Mass website while this was going on. The medication was still tier 1. So why has the cost to me and perhaps to the Blues plan gone up from $29 a month to $107? (Yes that’s more than a factor of 3!)

While she was talking to me the Caremark rep was also able to Slack with several other colleagues–relatively advanced for an old world PBM I thought. Eventually the answer came back. The med was indeed tier one. But until we spent our deductible the med was tier 2. In other words if we were paying for the drug the price is $107. As soon as BCBS Massachusetts starts paying for it the price goes back to $29 (of which they only pay $19) as we have a $10 copay.

Why this has happened is beyond me? Is Caremark or BCBS Massachusetts suggesting another cheaper drug? I haven’t heard from them. Are they trying to discourage patients from getting to their deductibles? My cynical conclusion is that Caremark is trying to increase the revenue for CVS– its corporate pharmacy–which that accounts for 1/3 of all outpatient Rx.

Otherwise this pricing strategy makes no sense to me. Of course this is just another example of a completely opaque process. And that appears typical for American health care.

Matthew’s health care tidbits: My retina & what it tells us about primary care

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I had a little scare the other night. I was driving home from a weekend in the mountains and I asked my wife if she saw that flashing light. No it wasn’t the cops, and no she hadn’t seen it. Turns out that I had a bright flash if I moved my eye a certain way. Oh, well I assumed I was tired and a good night’s sleep would fix it.

Next morning the flash was still there when I looked quickly to the left and a few weird floaters had appeared. I headed to the Mayo Clinic website and it looked to me like I had a detaching retina. I got on the urgent visit video with One Medical. The NP who answered said it sounded like I might have retina problems and I should get it checked by my ophthalmologist. But my eyesight has always been great (other than me needing reading glasses in my old age) and I haven’t got one. So who, I asked, do you recommend?

Here we fall into the crux of the problem. One Medical is an excellent primary care service. So good that Amazon bought it for $3bn. But it’s not a multi-specialty group nor is it a system like Kaiser. The answer was, “we don’t really recommend anyone–that’s not how it works.” The NP ended up looking up ophthalmologists near me & sent me a name as a referral in their app. But that’s not a link to anything and it wasn’t one chosen through some analytical process of seeking quality excellence.

I looked up MarinHealth (my local hospital)’s website and searched ophthalmology. That referred name was on it. I called. The doctor was out this week. They gave me another name. That doctor’s office gave me another name and that third office could see me that same day. I felt some pressure to see them right away as in the case of a detached retina Mayo says “ Contacting an eye specialist (ophthalmologist) right away can help save your vision”. The good news is having spent a couple of hours at the ophthalmologist’s my retina needs watchful waiting not surgery.

But the bad news is that for me, like 90% of Americans, there’s no easy way to get referred into a trustworthy system for specialty care. This can be even worse. My friend Sarah McDonald explains in her book The Cancer Channel how, after being diagnosed with a rare incurable cancer by a head & neck surgeon, the all encompassing support she received was to be given the number of a specialist at UCSF who couldn’t even talk to her for 3 weeks.

Mike Magee talks about the role of the health care system being to reduce patients’ “fear and worry”. Our lack of a specialty care referral system, especially when potentially serious and urgent care is on the line, is a big reason why there is so much fear and worry. I wish I had a concierge advocacy system like Included Health or Transcarent which could get me to the right place and work with me through the experience. But like most Americans at the time I need reassurance the most I’m calling a list of phone numbers hoping someone can see me.

We have primary care, we have specialty care. But we don’t have a system that cares.

Bad Backs & Deductibles

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

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

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

Looking good on the gurney!

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

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

3) Go to the ER

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

Continue reading…

THCB Quickbite: Julian Flannery, CEO, Summus

Julian Flannery is CEO of Summus, which I can’t pronounce (it’s Sue-mus like lawsuit not Sum-mus like math, despite the 2 Ms!). It’s a multidimensional referral platform which combines primary and specialty virtual care for employers, a white-label service for hospitals to deliver their specialty care, and now a peer-to-peer escalation model for specialists to talk to AMC-based specialists & get 2nd opinion reviews. Around 1.4m members on the platform and it’s seen massive usage growth in last 12 months–Matthew Holt

OK, trying more AI to write this

by MATTHEW HOLT

In the far oft halcyon days of last month, I used an AI system from Lex.Page  to write something about digital health. In the past few days the world has gone nuts about a new AI author called ChatGPT. So I tought I would compare and contrast.

Last month Lex.page was asked about Digital Health and it said

Digital Health is one of the most rapidly growing and important sectors in health care today. It is a broad term that encompasses the use of technology to improve health and health care.

Today I asked ChatGPT the same thing. In fact I just wrote “Digital Health” as the Q and this was the A

Digital health, also known as telehealth, is the use of digital technologies to deliver healthcare services remotely. This includes the use of video conferencing, mobile health apps, remote patient monitoring, and other digital tools to provide healthcare services to patients. Digital health can be used to improve access to primary care, reduce costs, and improve patient outcomes.

OK, pretty much a longer version of the same thing but with more details. So then I went BACK to Lex.page to ask it. But I had to ask it “What is Digital Health”

Digital health is a term used to describe the use of technology to improve healthcare. It covers everything from diagnostic tools and monitoring devices to electronic medical records and healthcare analytics. It’s an exciting and rapidly evolving area that has the potential to revolutionize the delivery of healthcare.

So in a month Lex.page has gotten a lot better!

Last month Lex.page said in response to my question/statement, “The biggest challenges for primary care are”

-Access to care

-Cost of care

-Quality of care

So it seems that digital health can help with all of those things. By providing tools that help patients better self-manage their health, digital health can help to improve access to care. By providing tools that help to lower the cost of care, digital health can help to make care more affordable. And by providing tools that help to improve the quality of care, digital health can help to make

I put the same sentence into GPTChat and at the bottom it told me Warning: Your text ends in a trailing space, which causes worse performance due to how the API splits text into tokens. But I asked it anyway and it gave me

A: 1. Accessibility: Ensuring that everyone has access to quality primary care services.

I surmised that it had more answers so I kept hitting submit! It got to another 12 answers with no new question!

Q: A: 2. Cost: Finding ways to make primary care services more affordable and accessible to all. Q: A: 3. Workforce: Recruiting and retaining a sufficient number of primary care providers to meet the needs of the population. Q: A: 4. Technology: Incorporating new technologies into primary care to improve efficiency and patient outcomes. Q: A: 5. Coordination: Improving the coordination of care between primary care providers and other healthcare professionals. Q: A: 6. Quality: Ensuring that primary care services are of the highest quality and meet the needs of patients. Q: A: 7. Education: Educating patients about the importance of preventive care and the value of primary care services. Q: A: 8. Mental Health: Integrating mental health services into primary care to better address the needs of patients. Q: A: 9. Population Health: Developing strategies to improve the health of the population as a whole. A: 10. Data: Utilizing data to inform decision-making and improve patient outcomes. A: 11. Payment: Developing new payment models that incentivize quality care and reduce costs. Q: A: 12. Social Determinants of Health: Addressing the social and environmental factors that influence health outcomes.

OK so those are all separate statements, but it’s pretty damn impressive. How is Lex.page doing? Well I asked it’s chatbot the same statement and it now answered:

The biggest challenges for primary care are likely to be related to access and cost. In many areas of the world, access to quality primary care is limited by geography, poverty, or both. Cost is also an issue, especially in countries with expensive healthcare systems. Additionally, many primary care providers struggle to effectively manage chronic conditions, such as diabetes and hypertension, due to a lack of resources, funding, and staff. Finally, the rapid advancements in technology have presented a challenge in terms of staying up to date with the latest medical developments.

That’s not only pretty smart but it’s quite an advance on the answer it gave me to the same vague question/statement just 31 days ago.

We are seeing a technology emerge right before our eyes.

Presumably the next step is to set it to read some of my favorite pieces on THCB and just have it write for me! Then I will be happily replaced by a robot!

THCB Quickbite: AJ Loiacono, CEO, CapitalRx

AJ Loiacono, CEO of CapitalRx, in a quickbite interview with The Health Care Blog’s Matthew Holt. CapitalRx is up to 1.5m members serviced both as a PBM and as a tech company administering pharmacy benefits using its tech platform. AJ says they’ve demonstrated to the market that they can service customers of any size, and the employer groups are starting to ask the right questions about pharmacy costs.

I’m trying to get AI to write this!

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By MATTHEW HOLT

So it’s a new world in blogging about health care, and when I want to write about Digital Health or primary care, I’ve been told that this system at Lex.Page can do it for me

So here goes and lets see what it says about Digital Health or primary care

Digital Health is one of the most rapidly growing and important sectors in health care today. It is a broad term that encompasses the use of technology to improve health and health care.

OK so it wrote that. Which isn’t bad but not too helpful

Perhaps I can ask it whether it thinks that digital health will have a big impact on the future of primary care

The system at Lex writes that it does think digital health will have a big impact on the future of primary care.

So now it’s just spitting back at me what I asked it. Not too sure how to get it to write more for me

I then asked it to follow this sentence — The biggest challenges for primary care are

-Access to care

-Cost of care

-Quality of care

So it seems that digital health can help with all of those things. By providing tools that help patients better self-manage their health, digital health can help to improve access to care. By providing tools that help to lower the cost of care, digital health can help to make care more affordable. And by providing tools that help to improve the quality of care, digital health can help to make

That is pretty damn good given it’s a machine just guessing what I want it to write, even if it didn’t finish that last sentence. I can imagine that pretty soon I’ll be able to spit one of my talks into it and it will be able to write an article out of it quickly. I’ll be playing around with Lex and I can give some invites — if you want one, let me know.

Russ Johannesson, CEO, Glooko

Russ Johannesson has been CEO of Glooko since 2018. In that time the diabetes data platform has expanded internationally, made a couple of acquisitions, and added support for digital therapeutics and distributed clinical trials. He brought me up to date with the latest–Matthew Holt