BY ANISH KOKA

The COVID19/vaccine myocarditis debate continues in large part because our public health institutions are grossly mischaracterizing the risks and benefits of vaccines to young people.

A snapshot of what the establishment says as it relates to the particular area of concern: college vaccine mandates:

Dr. Arthur Reingold, an epidemiology professor at UC-Berkeley, notes that UC also requires immunizations for measles and chickenpox, and people still are dying from COVID at rates that exceed those for influenza. As of Feb. 1, there were more than 400 COVID deaths a day across the U.S.

“The argument in favor of mandatory vaccination for COVID is no different than the argument for mandatory vaccination for flu, measles and meningitis,” Reingold said. “For a 20-year-old college student, how likely are they to die? The risk is very low. But it’s not zero. The vaccines are safe, so the argument of continuing to mandate vaccination fits very well with the argument for the other vaccines we continue to require.”

Safety is a relative term that needs to be constantly updated when you’re talking about administering a therapeutic to “not-yet-sick” individuals. We do not vaccinate against smallpox anymore because the absence of circulating smallpox (thanks to the smallpox vaccine campaign) makes the risks of the smallpoxt vaccine too great to be administered to the public.

We can argue endlessly about what exactly the risk of COVID19 was in the Spring of 2020, or 2021, but there should be little argument in 2023 that the risks of COVID pneumonia striking down a young healthy individual is now extremely low.

The other argument made by public health authorities is that myocarditis, the major adverse event linked to the mrna vaccines (Moderna worse than Pfizer), and Novovax actually happens more commonly with a COVID infection. I have made the case repeatedly since the Fall of 2020 that sars-cov2 (the virus that causes COVID), like the coronavirus family it comes from, has no specific proclivity for the heart, and that the published papers describing COVID19 myocarditis come from highly motivated cardiac imagers finding random bright spots on cardiac MRI devoid of clinical context and epidemiologists striking fools gold in research based on diagnostically sloppy electronic health record billing codes.

More evidence this past week that vaccine myocarditis is very much a real entity while COVID19 myocarditis is mostly a fabrication of academic researchers comes from Scandinavian countries.

A record request from a random Swedish twitter account reveals this impressive chart about myocarditis trends.

Notice that there is no spike in myocarditis diagnoses until the second half of 2021. Sweden, notably took a light approach to mitigation measures in 2020. They kept schools open, and they suffered large losses of life in care homes (as did every country) as evidence of a virus that was circulating widely through the population. And yet, there is no uptick in myocarditis cases in 2020.

This discrepancy isn’t a result of unawareness of COVID related heart issues as some have proposed because in 2020 the hysteria that surrounded COVID and the heart in 2020 was at a fever pitch. Viral videos from China of people suddenly collapsing, and the very bad German cardiac MRI paper I referenced earlier meant that everyone was looking for a tsunami of COVID heart disease. It just never materialized in the real world.

This data that was known to Swedish authorities in 2021, but not publicized to my knowledge, may have been why the Moderna vaccine with 3x the dose of mrna than Pfizer was banned for anyone < 30 years of age in the Fall of 2021 in Sweden.

The other dataset from last week comes from an epidemiological study that sought to understand the differences in prognosis between COVID19 myocarditis and vaccine myocarditis. The epidemiologists involved clearly were unaware about the issues related to the validity of the diagnosis of COVID19 myocarditis compared to vaccine myocarditis, and to top it off, were unable to specify simple things like what the severity or type of the numerically tiny primary outcome events (heart failure) they did find. As a study of prognosis of COVID vs. vaccine myocarditis, it’s a flimsy paper that is of zero clinical value. What is interesting about the study, despite the study authors admonishments not to look, is the number of vaccine associated myocarditis cases picked up during the study period¹.

There were almost 5 times as many vaccine myocarditis cases as there were “COVID19 myocarditis” cases in the time window in Scandinavia that was studied. The study authors caution against making a comparison about rates of vaccine vs. covid myocarditis using these numbers because no attempt to present any denominators for covid infections or people vaccinated is given, but given the multiple other rigorous datasets that have shown spikes in vaccine myocarditis cases after the vaccine and not COVID, it’s hard not to notice that over a common number of years studied, there are a lot more vaccine myocarditis cases being diagnosed.

And so we have a tale of two countries.

One that observed a spike in a novel serious adverse event primarily in young healthy males in the Fall of 2021, and chose to restrict the mrna vaccine that caused the most myocarditis to anyone < 30 years of age, and the other country that in February of 2023 still thinks heart problems after COVID 19 is five times more likely than vaccine myocarditis and recommends all COVID vaccines to everyone over 6 months of age.

If no one was paying attention to what the CDC said it wouldn’t really matter, but apparently epidemiologists and others with a weak handle on reality are still mandating vaccines for college kids.

It is well beyond time for these mandates to end, and well beyond time to strip the powers of the innumerate public health hypochondriacs that are running things. There’s at least a semblance of a debate to have about what powers competent public health authorities should have over society, but there can be little argument that inmates should not be running the asylum.

Anish Koka is a Cardiologist. Follow him on twitter @anish_koka

I have to make the obligatory post-script here that I oversaw the administration of hundreds of mrna vaccines starting in March of 2021 in my cardiology clinic. The vaccine efficacy data for the original data was from thousands of patients and I certainly felt given the devastation wreaked on many of my patients in 2020 that the vaccines were the best chance of avoiding morbidity and mortality. The process to get the vaccines from the city department of health was a somewhat arduous 3 month process, and once the vaccines were on hand, there were daily reporting requirements that I dutifully performed for the many months we were administering vaccines. To accommodate the rush of patients, employees, volunteers, and conscripted children worked multiple weekends to administer the vaccines. So I’m especially disgusted by medical colleagues who label any concerns registered about vaccine adverse events as “anti-vaxx”. Registering concern over a vaccine adverse event does not make doctors or patients “anti-vaxx”. It makes them pro-vaxx!

Footnote:

1. Recall that vaccine myocarditis cases are straightforward, usually previously healthy young men complaining of chest pain who have evidence of cardiac muscle cell necrosis and supporting cardiac imaging, while COVID myocarditis cases are almost always older, very ill hospitalized patients with pre-existing (sometimes undiagnosed) cardiac disease who have myocardial injury related to the stress of the primary diagnosis. The other COVID19 related myocarditis is not acute myocarditis, but an autoimmune condition that usually occurs months after recovery from COVID called MIS-C myocarditis. Important to note this entity has a lot of overlapping features with an autoimmune diagnosis called Kawasaki’s, and is now so rare that the CDC no longer tracks it.

BY ROSEMARIE DAY

When the Affordable Care Act (ACA) was signed into law twelve years ago today, Joe Biden called it “a big f-ing deal.”  Little did he, or anyone else at that time, realize how big of a deal it was. Just ten years later, America was engulfed in a global pandemic, the magnitude of which hadn’t been seen in a century. Two years after that, the numbers are chilling: over 79 million people were infected, at least 878,613 were hospitalized, and 971,968 have died.

As bad as these numbers are, things would have been much worse if the ACA hadn’t come to pass. The ACA created an essential safety net that protected us from even more devastation. Covering over 20 million more people, it is the single largest health care program created since the passage of Medicare and Medicaid in 1965. Thanks to the ACA:

• The estimated 9.6 million people who lost their jobs during the pandemic didn’t have to worry as much about finding health care coverage if they got sick from Covid (or anything else) – they could shop for subsidized insurance on the public exchanges or apply for Medicaid. This helped millions of people to stay covered, which saved thousands of lives. In fact, the overall rate of uninsured people has not increased significantly during the pandemic, thanks to the safety net of these public health care programs.

• The 79 million people who got Covid didn’t have to worry about whether their infection’s aftermath would result in acquiring a pre-existing condition that would prohibit them from buying health insurance in the future (if they couldn’t get coverage through their jobs).

• Those who were burnt out from the pandemic and joined the Great Resignation did not have to worry that they would be locked out of health insurance coverage while they took a break or looked for a new job. According to the Harvard Business Review, resignation rates are highest among mid-career employees (those between 30 and 45 years old), a stage of life when health insurance is critical, given the formation of families and the emerging health issues that come with age. 

The ACA’s remarkable safety net framework made it far easier for policy makers to deploy federal funds during this unprecedented emergency. The American Rescue Plan Act , a $1.9 trillion coronavirus relief bill signed by President Biden on March 11, 2021, included provisions that built on the ACA, including more generous premium tax credit subsidies. Its predecessor, the Families First Coronavirus Response Act (FFCRA) of 2020 enhanced Medicaid funding and required states to provide continuous Medicaid coverage.

• For working- and middle-class people, the health insurance exchanges (both state and federal) provided one-stop shopping with enhanced federal subsidies which made health insurance more accessible for people who lost their employer-sponsored insurance. Many Americans who needed health insurance turned to the ACA marketplaces to find a plan. Amid the recent surge in resignations, the Biden administration announced that sign ups hit an all-time high of 14.5 million when open enrollment ended in January 2022.

• For lower income people, the Medicaid program was there, stronger than ever, thanks to 38 states opting into the ACA’s expansion of the program. An increased federal matching contribution helped states to finance Medicaid enrollment during the worst of the economic downturn and prevented Medicaid disenrollments.

• Additional benefits from these measures included reducing health disparities, ensuring mental health coverage, and helping new moms with more robust coverage.

Despite the ACA’s strong foundation and the many good things worth celebrating on its twelfth anniversary, there are difficulties ahead. The expanded premium subsidies and enhanced Medicaid funding are only temporary – both are set to expire this year. With that will come a loss of insurance coverage as people struggle to afford what’s on offer. On top of this, the public health emergency will be unwinding which will bring continuous Medicaid coverage to an end. And there are still too many uninsured people in this country (27.4 million). Retaining the expanded ACA benefits and finding other ways to build upon the ACA’s foundation are critical issues for the mid-term elections this fall.  

A recent study shows that support for the ACA and universal health care has increased during the pandemic. We shouldn’t “let a good crisis go to waste.” We need to make our voices heard and commit to building the future. We’ve had to expend far too much energy over the past decade defending the ACA and protecting it from repeal. The pain we’ve endured during this pandemic should not be for naught. Now is the time to assume an expansive posture of building toward universal health care. Retaining the expanded ACA benefits is an important incremental step. As difficult as the pandemic has been, it is providing a once-in-a-century opportunity to address America’s unfinished business in health care. The ACA is an excellent foundation. Let’s build on that so that we have a lasting cause for celebration.

Rosemarie Day is the Founder & CEO of Day Health Strategies and author of Marching Toward Coverage:  How Women Can Lead the Fight for Universal Healthcare (Beacon Press, 2020).  Follow her on Twitter:  @Rosemarie_Day1

By MIKE MAGEE

It is fair to say that the vast majority of Americans know more about viruses today than they did 24 months ago. The death and destruction in the wake of COVID-19 and its progeny have been a powerful motivator. Fear and worry tend to focus one’s attention.

Our collective learnings are evolving. We have already seen historic comparisons to other epidemics. Just search “The 10 worst epidemics” for confirmation. But one critical area which has been skimmed over, and only delicately probed (if at all) is the ecology or “the ecological point of view.”

For those interested, let me recommend “Natural History of Infectious Disease” published in 1972 by Nobel laureate and Australian biologist Sir Macfarlane Burnet and his colleague David O. White.

Chapter 1 begins: “In the final third of the twentieth century, we of the affluent West are confronted with no lack of environmental, social, and political problems, but one of the immemorial hazards of human existence is gone. Young people today have had almost no experience of serious infectious disease…For the first time in history deaths in infancy and childhood are not predominantly from infection.” But a few sentences on, they add this addendum, “Infectious diseases may be almost invisible, but it is still potentially as important as ever it was.”

Americans are all too familiar with the living biologic organism named COVID-19. By now, they know what it looks like, the role of its outer spikes, its nuclear makeup, and genetic alterations that allow the creation of derivative variants and vaccines. But in addition to its biological science, it also has an ecological life as well.

As the authors say, ecology “deals with the interaction of organisms with their environment and especially with other organisms, whether of their own or different species in the environment.” When ecology is applied to the natural history of infectious diseases, we encounter the discipline of epidemiology – the study of the incidence, distribution, and possible control of the disease.

In the eyes of an ecologist, all living entities are survivalists, and there is little difference (except in size) between a parasitic microorganism and a large predatory carnivore. They all need nourishment. As our experts write, whether the bite comes from inside or out,  “It is just another method of obtaining food from the tissues of living animals.” COVID-19 is an organism that is “smaller and less highly differentiated than its host…and gains its nourishment at the expense of the host’s living substances.”

Checks and balances rule in the world of ecology absent human intervention. The authors illustrate this with an example. In the late 19th century, orange growers in California reached an industrial scale. In 1888, little white cushions began to appear on their trees. Within them were tiny, sap-sucking insects, and the damaged trees’ production of fruit plummeted. The responsible “scale insect”, it was found, was a foreign invader from Australia.

In Australia, its primary nutrition came from the native acacia tree. Orange trees were infested as well but rarely damaged. This was because the insects’ numbers were naturally controlled by a local ladybird beetle.  As the ecologists explained, “If the scale insect is particularly plentiful, the ladybird larvae find an abundant food supply, and the beetles in turn become more plentiful. An excessive number of ladybirds will so diminish the population of scale insects that there will be insufficient food for the next generation and therefore fewer ladybirds.”

But in California, there were no ladybird beetles. And so the agricultural leaders in 1889 imported the beetles, and once they reached adequate numbers in the orchards, the scale beetle “was reduced in importance to a relatively trivial pest.”

Simple, right? Well not exactly. As our experts write, “The mutual adjustment is an immensely complicated process, for all the food chains concerned are naturally interwoven, and for every species, there will be fluctuations in numbers from time to time, but on the whole, in a constant environment a reasonable approach to a stable balance will be maintained.”

For predators of any shape or size (and that includes a virus) , “there is less opportunity for enemies…of restricted prey to thrive at their expense.” Vaccination, masking, and distancing, in effect, restrict us as potential prey to COVID-19.

Another point. Our ecologists remind us that “Most parasites are restricted to one host species (for their nutrition)…and the main problem that a parasitic species have to solve if it is to survive, is to manage the transfer of its offspring from one individual host to another.” That often requires intermediate hosts “whose movement or activities will help the transfer to fresh, final hosts…an increased density of the susceptible population will facilitate its spread.” 

To cite a modern example, a certain percentage of fully boosted and immunized are able to be infected by the Omicron variant and remain asymptomatic carriers and spreaders, especially if they enter dense gatherings where they and unvaccinated and unmasked persons are present in crowds.

One last caution as we continue to investigate the origins of this pandemic: The authors warn that “disastrous disturbances of natural ecosystems” are often the result of “irresistible pressure of technological advance…short term human benefit will sooner or later bring long-term ecological or social problems which demand unacceptable effort and expense for their solution.”

As we corner our biologic adversary, it might be useful to examine this unfortunate disaster closely and thoughtfully, through an ecological lens.

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

By MIKE MAGEE

The power to mandate vaccines was litigated and resolved over a century ago. Justice John Marshall Harlin, a favorite of current Chief Justice Roberts, penned the 7 to 2 majority opinion in 1905’s Jacobson v. Massachusetts. Its impact was epic.

In 1905, Massachusetts was one of 11 states that required compulsory vaccinations. The Rev. Henning Jacobson, a Lutheran minister, challenged the city of Cambridge, MA, which had passed a local law requiring citizens to undergo smallpox vaccination or pay a $5 fine. Jacobson and his son claimed they had previously had bad reactions to the vaccine and refused to pay the fine believing the government was denying them their due process XIV Amendment rights.

In deciding against them, Harlan wrote, “liberty for all could not exist under the operation of a principle which recognizes the right of each individual person to use his own [liberty]…” 

Of course, a state’s right to legislate compulsory public health measures does not require them to do so. In fact, as we have seen in Texas and Florida among others, they may decide to do just the opposite – declare life-saving mandates (for masks or vaccines) to be unlawful. At least 14 states have passed laws barring employer and school vaccine mandates and imposing penalties in Republican-controlled states already.  

So state powers are clearly a double-edged sword when it comes to health care. 

Questions anyone?

Does the Federal government have the power to come to the rescue? 

NO. Judgments thus far refer specifically to states’ rights. These include the 1922 decision, Zucht v. King, where the decision supported a local public school district’s right to require vaccination for admission to the school. In this decision, Judge Louis Brandeis wrote, “a state may, consistently with the federal Constitution, delegate to a municipality authority to determine under what conditions health regulations shall become operative.” 

Can the federal government forcibly require or compel you to get vaccinated in the U.S.(with exceptions for religion and disability)?  

NO.

Isn’t that what they are doing with a mandate? 

NO. A vaccine mandate means the government is “setting a condition on you returning to society or participating in a particular activity.” 

If a state doesn’t mandate masks, distancing, or vaccines and a business decides to, is that legal? 

With appropriate exceptions for religion and disability, when the intent is to protect employees and customers, legal scholars believe YES, although this remains to be adjudicated..

If a business asks me if I’m vaccinated on entry, is that a HIPAA violation? 

NO. HIPAA regulations restrict hospital and health care workers, not store clerks.

Doesn’t the First Amendment give me the right to reject vaccines?

NO. According to legal scholars: “Freedom to believe in a religion is absolute under the First Amendment. However, freedom to act in accordance with one’s religious beliefs ‘remains subject to regulation for the protection of society.’”

Didn’t the FDA “Emergency Use Authorization” require vaccine mandates? 

NO. This authorized the sale and distribution of the vaccine but did not require anyone’s use of it.

Is President Biden doing all he can, within the powers of the Executive Branch, to protect Americans from the pandemic? 

Legal expert, Georgetown Law professor Lawrence Gostin, says YES. “While states have near plenary power to protect the public’s health, the federal government’s powers are limited…(Biden) is acting fully lawfully pursuant to those powers.

1. the president “is using his executive power to order vaccinations for the federal workforce. (this includes members of the Military.) 

2. He is using his spending power through Medicaid and Medicare to ensure vaccine mandates in health care settings. 

3. And he is using the Occupational Health and Safety Act to mandate vaccinations in all businesses of 100 or more employees. All of these are comfortably within the president’s power.”

Biden could go farther and attempt, by providing financial rewards to states that mandate vaccines, or through the Commerce Claus to limit non-mandated states interstate travel, to extend compliance, but these would most certainly generate extended legal challenges. Federal Law under Title VII of the Civil Rights Act of 1964 and Title I of the Americans with Disability Act also require vaccine exemptions for religious and medical reasons to be in place. (Nationally, less than 1% have claimed these exemptions.)

As for the states, it’s a messy affair. While Texas Governor Abbott grandstands, the federal District Court in Texas in Bridges et al v. Houston Methodist Hospital refused relief for any of the 117 employees suspended and threatened with termination if they refused to get vaccinated. The decision read: plaintiffs “can freely choose to accept or refuse a COVID-19 vaccine; however, if [they] refuse, [they] will simply need to work somewhere else…Every employment includes limits on the worker’s behavior in exchange for his remuneration. This is all part of the bargain.”

In another recent case, the US Court of Appeals for the Seventh Circuit in Indiana, and the Supreme Court in an appeal, denied relief to eight Indiana University students barred from attendance because they refused to comply with mandated vaccination. Students had chosen not to apply to the university for a medical and religious exemption, which if granted would permit attendance if they wore masks.

States nationwide generally require entering students to have proof of up-to-date vaccines to prevent 11 childhood diseases.

Over a century ago, the fight over vaccines was no less heated than it is today. A New York Times editorial at the time of the Jacobson 1904 decision, tagged the dispute as  “a conflict between intelligence and ignorance, civilization and barbarism” 

On the “intelligence” side, Nearly 60 top medical organizations released a joint statement on July 22^nd in support of mandated vaccines for all health care and long-term care workers as a “logical fulfillment of the ethical commitment” to patients.

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

Episode 23 of “The THCB Gang” was live-streamed on Thursday, August 27th! Watch it below!

Matthew Holt (@boltyboy) was joined by some of our regulars: health futurist Ian Morrison (@seccurve), WTF Health Host Jessica DaMassa (@jessdamassa), health care consultant Daniel O’Neill (@dp_oneill). The conversation revolved around how providers should reshape some of their practices amid the pandemic, what the large Teladoc-Livongo merger brings to the marketplace, and how there are still lots of potential ways start-ups can fit their models into care practices in the industry.

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

Even before Covid19, virtual care for chronic conditions was a hot and competitive area, with the heat turned up by Livongo Health’s IPO last year and big funding rounds for companies like Omada Health, Virta Health, and One Drop. Another contender in the space, Vida Health, has been best known for taking a “platform” approach to chronic condition management before “platforming out” became the-move-to-make for scaling health tech companies. Their digital health biz actually started out with a “whole health approach” to helping patients manage all their conditions at once, integrating care for diabetes, hypertension, COPD, high cholesterol, mental health conditions, and more from the get-go. Contrast that to some of their biggest competitors, who have adapted to that approach by adding on treatments for co-morbidities as their core businesses evolved.

Is there a benefit to starting out with a holistic care model that those who build it along the way can’t capture? We caught up with Vida Health’s founder & CEO, Stephanie Tilenius, to find out what advantage starting out as a platform play has brought to her business, which just closed a $25M funding round in April and is now available to more than 1.5 million people through employers and health plans.

How will the company scale from here? How will they remain competitive in such a crowded space? Stephanie talks through some of Vida Health’s post-pandemic plans AND how lessons learned from her “previous life” as an exec in Big Tech during that industry’s growth era of the 2000s & 2010s has shaped her thinking about the uptake of technology in healthcare. Not only did Stephanie work at eBay, PayPal, and Google during the birth of the online payment era, BUT she also helped take an online pharmacy company (Planet Rx) public during the dotcom boom.

*** Hear more from the ‘who’s who’ of health tech and health innovation as they work to make digital health, telehealth, remote monitoring, and data analytics a bigger part of the future of the healthcare industry.

Subscribe to WTF Health’s YouTube Channel: https://www.youtube.com/wtfhealth Follow Jess DaMassa on Twitter: https://twitter.com/jessdamassa Visit WTF Health: https://www.wtf.health

Jessica DaMassa, the emerging ‘It girl’ of health tech interviewing, chats it up with the ‘who’s who’ of the health innovation set on ‘WTF Health – What’s the Future, Health?’ Catch 100’s of interviews with leading health tech startups and the VC investors, accelerators, health insurance companies, pharmas, and hospital systems helping bring their new ideas into the healthcare establishment. From AI and Big Data to virtual care, digital therapeutics, payment model innovation, health policy, and investing, Jessica helps you spot the trends and figure out what’s next.

To learn more about WTF Health, find out where Jess will be next, or throw some dollars at our show, check out www.wtf.health.

Sponsored by Bayer G4A, Livongo Health, GuideWell Innovation, Teladoc Health, OneDrop & The Health Care Blog

There are few better positioned to speculate on what’s next for telehealth than Roy Schoenberg, co-CEO & President, of Amwell. After 15 years, more than $710M in total funding, and probably the best analogies out there for describing telehealth’s potential as a disruptive technology, Roy weighs in on just how unprecedented COVID19 has been for the uptake and evolution of virtual care.

“Historically, people thought, could telehealth be as good as a physical visit? The reality of COVID,” says Roy, “has literally opened the door to the question, can telehealth be better?”

From the near-term “new wave” of telehealth that has already begun to “eclipse the urgent care telehealth” to how Amwell’s clientele of clinicians, healthcare delivery systems, and payers are shifting to accept the idea of the technology as “the start of healthcare,” Roy talks of a future of telehealth that is “entrenched inside the system.” And how Amwell is meant to act as “facilitator.”

“When we start thinking about telehealth as a switchboard — not as a product, but as an infrastructure for the redistribution of healthcare — we’re talking about a completely different experience for us as Americans on what healthcare is available to us and how we can consume it.”

“To me, and I’ll fast forward to the end here, we want to get to the point that telehealth changes our expectation when we grow old as to where we can grow old. We want to be in a place where we can stay at home…where we don’t have to be in the ‘belly of the beast’ to get healthcare.”

How far away is this future that Roy describes, midway through telehealth’s biggest year yet? Is the appetite there among incumbents? And what of those Amwell IPO rumors? How might that kind of funding help rush things along? Tune in to this episode of ‘WTF Health – What’s the Future, Health?’ with Jessica DaMassa to find out.

Full Transcript of the Interview:

Jessica

Hey, it’s Jessica DaMassa with “WTF Health – What’s the Future, Health?” We are getting insight scoop on everything happening in health tech from some of the biggest names in the industry. And so what conversation about telehealth would be complete without this guy right here? We have Roy Schoenberg. He is the president and co-CEO of Amwell. Roy, it is so exciting to talk to you. How are you?

Roy:

Thank you. It’s great to be with you, Jessica.

Jessica DaMassa:

Oh my gosh, I can’t imagine how busy you must be.

Roy:

We don’t complain. We can’t complain. Telehealth seems to be the name of the game right now. So we’re riding the wave, I think with many others, but it is a big time for telehealth.

Jessica DaMassa:

Oh my gosh. Okay. So I want to hear all about exactly what kind of a big time this is. And Amwell… obviously, your company, you’re one of the leaders in this category and there is lots of news going on about not only the industry, but also about Amwell. We’ve heard some IPO rumors that we may or may not address later. You guys closed a massive funding round, $194 million in May. So tell me a little bit, I guess about, let’s start with what’s going on. So what have you been putting that funding to use for so far?

Roy:

Well, I’m sure that everybody at this point is a little bit aware of the role of telehealth in COVID. It started off maybe even four or five months ago as the thing you use for convenience maybe to, in the middle of the night, if your child is crying or you have a rash or a flu to get a simple antibiotic. And it has literally almost overnight became the first line of defense for everything in healthcare. Not only that most Americans, especially during March and April, and now actually more so in some parts of the country, were asked to stay at home and socially isolate. And not only that they were concerned about COVID, but anything else that they had going on in terms of healthcare, all of the places that you would normally go to get healthcare were locked up, physician offices and urgent care centers and retail clinics. And nobody wants to be in a waiting room of a hospital right now. All of these disappeared.

Roy:

At the same time, a lot of the clinicians of all the different disciplines were also home. Many of them were told, “You can’t come in if you’re a primary care physician or whatever it is, you’re going to be isolating, sheltering in place as well.” So they were stuck in their homes. And the reality is that at that point in time, telehealth became from a novelty or from something that people thought, “Oh that’s a good way for healthcare to modernize,” became almost overnight the only way by which clinicians could do their job and practice their art and do what they were responsible for doing with their patients. So literally within the course of a couple of weeks, we have seen an incredible, we call it unprecedented, the title where fill in the blanks in terms of what kind of giant word you want to put in there.

Roy:

But we’ve seen an incredible, incredible hiking in telehealth. It started off with a wave of urgent care telehealth, which everybody’s familiar with. That was, and it is still about 10 times what it was at the beginning of this, some time in March. But I think more importantly, we’ve seen an entire avalanche of a new kind of use of telehealth where clinicians who actually have a relationship with patients with chronic patients and cancer patients and so on, physicians who are in a hospital are now using telehealth in order to support, maintain, and follow up on those patients. And that wave of telehealth has somewhere along the way eclipsed the urgent care telehealth, which was the name of the game just until February or March. And that has grown in some cases 30 times, 40 times the volume that it was a couple of months ago. And what people say is that this, I think the term is that that genie is not going back in the bottle or that toothpaste is not coming back into the tube. And that really is forcing everybody to completely rethink how the healthcare system should operate in a world post COVID. So it’s definitely been a fun time in telehealth.

Jessica DaMassa:

All right. I want to unpack some of this stuff, because you said a lot there. I want to address this toothpaste that has come out of the tube. I don’t think I’ve heard that one yet in reference to telehealth. That’s pretty cute. And so I want to go back though to what you’re talking about in terms of how unprecedented this is. And I would like to get your input on this. Amwell is a company that’s been around since the beginning. You guys have birthed the sector more or less with a few others. 15 years, is this really as unprecedented a time in telehealth as we think it is?

Roy:

Yeah. So you really can break it down to a lot of the historical barriers of telehealth, which I think everybody has heard about over and over again, so they’re not that interesting to repeat. Reimbursement, licensure, all of that kind of fun stuff. I think we’ve seen over the last couple of years a growing acceptance of telehealth by consumers, funnily enough, who are for lack of a better word, are open to embracing technology that makes their life better. So there was less of a concern there and that worked really well. The part that really, really changed is actually on the clinician side of things.

Jessica DaMassa:

Tell me more about that.

Roy:

That’s kind of a little bit of an unusual observation, but I would say that historically, and that’s true for us and for Teladoc and for other companies as well, most of the telehealth that’s out there in terms of volume that’s doing urgent care is utilizing clinician services of clinicians who are participating in telehealth programs. But the vast majority of healthcare doesn’t happen with the clinician that are on our network or Teladoc network or whatever it is. Most healthcare happens by clinicians who are in their offices in the hospitals and everything else. And for the most part, adoption by them has been growing steadily, but nothing to write home about. Nothing that is a headline in the newspaper. That changed.

Roy:

And the reason for that was that almost overnight, a lot of the health care institutions, we don’t think about it when we think about COVID, but a lot of the health care institutions out there, the way they survive is by essentially doing patient encounters, which translates to a lot of fun stuff like claims, submissions, and adjudication and everything else, but that’s how they get paid. And that’s how they pay for the buildings and everything else.

Roy:

And that disappeared overnight. So suddenly the financial reality of the healthcare industry that is tightly driven to the volume of patient encounters was under an existential threat. And the translation of that was, it is no longer to be the discretion of everybody to decide if they want to try it out or taste it and maybe opine on it and maybe try it on a Sunday afternoon when they have time. We have to, as an industry, transition to telehealth to survive. And that drive to telehealth has a completely different kind of firepower than the curiosity about telehealth. And the result of that is that the number of clinicians around the country that have been not only exposed to telehealth, but have been literally asked to transition everything they do into telehealth in order to continue to work in the institutions that they belong to, that has forced a completely different adoption curve of telehealth to clinicians.

Roy:

And the one thing that we all know, like it or not, healthcare is driven by the clinicians. We as patients, we actually do as we’re told. We’re probably the one person that it doesn’t matter how strong our character is, when we sit in the doctor office and the doctor tells us, “This is what you need to do,” we say, “Yes. Okay. That’s what I’m going to do.” So the reality is that a lot of healthcare is really driven by the physician’s decision of what’s the right thing to do next. And the fact that physicians now, in huge numbers, are telling their patients to use telehealth, that is a very different reality than before COVID. And to me, that is kind of the secret ingredient of why that toothpaste is not coming back.

Jessica DaMassa:

Okay. How do you make sure that that stays the case? How do you prevent these clinicians from going back? Right now they’re more or less, as you said, they’re forced to deliver care this way because inpatient visits are not necessarily an option, especially in some places that are hotspots. So how do you make sure that their experience with telehealth right now is so sticky that they want to stick around and continue to provide telehealth or deliver certain kinds of care via telehealth services, as opposed to returning back to the same old office visit and what they’re comfortable with? How do you do that?

Roy:

I think, maybe to be a little bit humble about it, I actually don’t think you can make clinicians do anything. Or maybe that’s an exaggeration, but for the most part-

Jessica DaMassa:

Spoken like a true clinician, right?

Roy:

Well, years ago when I was doing clinical care, but the reality is that what they do is driven from true good motivation of, I want to do something that is the right thing for the patient and something that allows me to sustain my ability to care for the patient long term, which is to maintain a practice and have a life and everything else. And it is the balance of those that at the end of the day drives what they do. I think the reality is… it’s not about, payment is important. Of course you have to pay clinician for the work they do like any other person that works.

Roy:

But I think that the experience the clinician had over COVID is that their ability to interact with a patient is so gratifying and liberating to the patients that they care about, that it is going to be almost unreasonable for them to withdraw those services and say to patients, “Hey, even though you are 82 and you’re frail, and you have all of these different things that make it really hard for you to keep the cadence of followup that we need to do to take care of you, and even though we actually did it really, really well over the last three months in telehealth, take the bus.”

Roy:

At some point, that doesn’t make any sense anymore. And when all the pieces of the puzzle that are necessary, like making sure that it is encrypted and secure and making sure that it is paid for and making sure that it is tied into the EHRs and it’s tied into the scheduling system and how my staff as a clinician can support me in handling patient. When you’re taking all of these barriers out of the equation, which many of them have been taken out of the equation, you’re left with a, I don’t call it a humanitarian or human question of, how can I say no to this when this is such a powerful way to make the life of my patients better?

Jessica DaMassa:

Yeah.

Roy:

And that will resonate differently with different people. But I think at the end of the day, this isn’t about Amwell persuading people. It just makes sense. And that’s very powerful.

Jessica DaMassa:

No, it is very powerful. And I’m curious too, as you talk about some of the things that have traditionally provided barriers against uptake have been kind of lifted in all of this. And I think it’s interesting to hear you talk about what you feel like individual clinicians are learning about telehealth as a result of having some of those old constraints lifted. What are some of the other things that you have been learning about the appetite for telehealth, maybe on the consumer side, or I know that private practice product that you guys just launched is giving you kind of these insights into the physician part of things. But you’ve got a lot of health plan clients. I mean, some big health plan clients, and you guys have big healthcare provider clients as well. So what have you been hearing on that side? What new things have been revealed now that the restrictions have been lifted on that side of the world as well?

Roy:

So where do I start? How much time do we have? I think we are, as I said, we’re in a very unique position. I think very unlike many of the other telehealth operators out there. The difference with us is that we’re kind of equally footed. We have one very strong foot on the consumer, employer, payer side of things, and we serve big chunk of the country there. And we have an equally strong footing on the clinician side of things, on the provider and practice, and very importantly hospital and delivery network and health system part of things. And the systems are actually built to bridge the two. Now, this isn’t the pitch for one architecture or another, but the fact that we are essentially being a conduit between the patient side of things or the consumer side of things and the delivery side of things opens up the door to real opportunities that we never thought about.

Roy:

So for example, I can tell you that we are turning a corner in thinking. Historically people thought about, could telehealth be as good as a physical visit? For more than a decade, that was the name of the game. Can it be safe and good enough and whatever it is? The reality of COVID has literally opened the door to the question, can telehealth be better? And the reason for that is not to say that a remote physician is better than a physician that’s in front of you.

Roy:

But rather to say if we think of the way that we envelope a patient that has a serious medical condition and we throw telehealth into it so it allows us to, for example, check up on them for a couple of minutes, three times a week without actually incurring office visits and the whole hoopla that goes around that. Does that allow us to actually be much more attentive to the changes in their condition? Maybe changing their medication more frequently, to understand if there are side effects. If they have cancer, can support them by other ways… by way of nutrition and behavioral support and everything else. Can we actually rethink the way we surround patients with healthcare in the presence of telehealth that will allow us to change the cookbook of medicine, medical practice?

Jessica DaMassa:

Yeah.

Roy:

And I know that this sounds almost pithy, it’s almost kind of high level, but the fact that this conversation is literally now carried in both the health system side of our customers, as well as on the payer side, the health plan, side of our customers, who are saying, “Let’s actually kind of not throw telehealth as an added thing into everything that we offer. Let’s actually think from the ground up and say, maybe telehealth is the start of healthcare. Maybe that is the gate by which people enter when they have an issue.” And I can tell you that that translates into some really astounding conversations, both on the delivery side of healthcare as well as well as on the care side.

Jessica DaMassa:

If you want to gossip about those astounding conversations, feel free to let us know what you’re thinking there. One question I have for you is, I guess from your perspective, what’s the next iteration of this then? You talked about this as like, okay, if this is the way in to developing a better opportunity for care delivery for patients, we’ve been hearing all sorts of things. Just earlier this week, Glen Tullman published on it, an article about this “consumer directed virtual care” as he’s calling it, talking about how telehealth is important, remote monitoring has a place, but there’s also this kind of other set of services that get added on there where we’re looking at data and things are ambiently collected so that patients can kind of take initial steps to prevent things from going wrong before we get there. What do you think is going to get added on to telehealth in order to make this new care delivery model really come to life? What’s the next thing in terms of what you’re looking at right now?

Roy:

So I think, maybe to use an analogy here, and I’m sure that people are sick of Amazon analogies, they’re used everywhere. But, Amazon started by selling books and it was actually a very brilliant choice by Jeff Bezos at the time, because he really kind of introduced the notion of online retail in many ways, and books are a great product to flush the pipes with. They don’t go bad. You know what you’re getting. You ship them, you can track them, you can pack them, they’re square. You can actually pack them very neatly. And he figured out the notion of FedEx and credit card billing and PSI, all of the different kinds of compliance elements and returns. So it was a really, really good way to flush the pipes of online retail.

Roy:

And then he extended it into the store that sells more things. And then further went into the third stage, which is now Amazon sells stuff that actually are not in Amazon warehouses. You have a lot of things that you buy from end producers of merchandise that goes through Amazon to you, but Amazon is not the one fulfilling it.

Roy:

Funnily enough, I actually think that telehealth is going to go exactly through those stages. History tends to repeat itself. Urgent care was the books. It’s the way to get everybody comfortable. It’s not very sophisticated medicine. It’s not life threatening to anybody. It’s convenience. It’s simple. No big deal if it didn’t work very well. Of course, it needs to work very well. But it’s a really, really simple kind of product to get people to feel comfortable. Then, the next step was a lot of the delivery side of healthcare – big  health systems are starting to use telehealth with their own patients that’s a little bit more like the Amazon store that has a lot of Amazon products in its facilities and sends it to patients. So that’s where we see a lot of health system.

Roy:

But the third step is the one that is the most exciting, which is, if we’re able to connect the pipes and make this feel like a network – which, by the way, the technology is built like — we’re able to have a completely different understanding on how healthcare services can travel. Which opens up the door for things that historically we never thought about, like load balancing of healthcare around the country. Think about places in the country that are flushed with healthcare, with good healthcare, and areas around the country that are not necessarily flushed with them. Think about areas that are devastated by hurricanes and fires and viruses. Think about the notion that there are cancer patients in certain parts of the country that don’t have the knowledge of how to treat cancer that exists in large metropolitan areas.

Roy:

When we start thinking about telehealth as a switchboard — not as a product, but as an infrastructure for the redistribution of healthcare — we’re talking about a completely different experience for us as Americans on what healthcare is available to us and how we can consume it. To me, and I’ll kind of fast forward to the end here, what that translates into (and I think that’s the part that I’m personally very, very passionate about) we want to get to the point that telehealth changes our expectation when we grow old as to where we can grow old. We want to be in a place where we can stay at home, where we don’t have to be in the belly of the beast to get healthcare, and all of the different disciplines surround us, rather than force us to go and seek, and, worse, try to patchwork the different disciplines that we need to see. I think that opportunity is right in front of us. And in that sense, telehealth is going to work like retail and it’s inevitable. It’s not me or you or Amwell or anybody else. I think that train is out of the station.

Jessica DaMassa:

All right. I am going to turn your analogy on you, my friend.

Roy:

Sure.

Jessica DaMassa:

And I’m going to ask you if all right, if you’re going to make an Amazon analogy here, to telehealth, right. So if you’re the Bezos here.

Roy:

I didn’t say that. [laughter]

Jessica DaMassa:

I am just saying if you’re…[laughter] Clearly, there’s only a handful of companies that I think at this point, right now, have the capital, the size, the scale, and the reach to be considered the Amazon of telehealth.

Roy:

I think the reach is important.

Jessica DaMassa:

Yeah. Right. Okay. Fair enough. Okay. But I’ve got you here with me right now. And so I’m curious, especially, and not to go… I know you can’t comment on the IPO rumors one way or the other, but the fact that they are there, I think indicates something about the market for this and where things are going potentially next. So as far as you’re concerned, you’re at the helm of this Amazon-like empire here that could completely redefine the way that we grow old in the future. What are you looking at next for the business? You have a lot of funding right now. You’re growing. Things are going well. We know you’ve launched some new products, like I mentioned earlier, that physician private practice one, which I think is very cool. It’s like a Shopify almost for telehealth in terms of private clinician practices. But where do you have your sights set then in terms of what’s next for Amwell?

Roy:

So I think you actually kind of hit a lot of different of the important kind of things on the head there. First of all, and I can’t comment about IPO rumors or whatever it is, I’m aware of the fact that they’re out there. And it’s great to be in a position where people can talk about those kinds of options, because telehealth is real.

Jessica DaMassa:

Yeah, exactly. Yeah.

Roy:

The adoption curves and the volumes and everything else and, literally, from the Rose Gardens through HHS and Medicare and everything else, telehealth is the name of the game. Which of course makes companies who do telehealth be in the center of things, which of course opens up a lot of opportunity. And you mentioned our funding and so on. The one thing that I would say, however, is that this is also the point where you can make mistakes. You have an avalanche of adoption and we fully feel the responsibility to make sure that we are actually not the bottleneck, that we are the facilitator. We’re the ones that allow natural evolution of adoption of that technology to happen. And if we do a good job, then we actually don’t matter that much. We’re in the background. We are allowing clinicians and patients to interact naturally. We facilitate that under the hood, but it’s not about teaching people how to use Amwell.

Roy:

To do that, that’s actually very, very hard to do. That’s kind of the transition, and I know I use too many analogies, but that’s a transition of when Google was a search engine to “Google” becoming a verb, right?

Jessica DaMassa:

Yeah.

Roy:

You don’t think about it, you Google stuff. And I think that is something that we see on the horizon, where telehealth becomes part of the natural way in which patients and clinicians interact. To do that, however, you have to care about the details. You have to really, really understand clinician workflow. You need to understand their reality. You need to understand the rules of engagement that are very complicated in healthcare. And to do that right, to become transparent, there is tremendous amount of investment that needs to go into there. And that’s a lot of the stuff that we’re doing. You mentioned some of the new products that were introduced.

Roy:

At the end of the day, there is a common theme between all of these, which is try to assimilate into the reality of traditional healthcare. Not create a product, an app for urgent care, which is a godsend when you need it, but is sitting aside of the regular healthcare delivery. But rather be entrenched inside the system. That’s a very, very significant lift. We would not be able to do it unless we were, as I mentioned, equally nested on the payer/consumer/patient side of things, as well as on the provider delivery side of things. But that is an incredible opportunity that we have in front of us. And we’re very serious about that.

Jessica DaMassa:

How do we not mess this up? Because you started that by saying we don’t want to, with all the eyes on this and this opportunity in front of us. And just even listening to you talk about everything up until this point in terms of how thinking around telehealth has changed and the conversation has shifted. So how do we not mess this up? And I say “us,” not just the telehealth companies, but even more broadly, the other health tech companies that are maybe in things that are adjacent? Digital health, digital therapeutics, remote monitoring. How do we not mess this up right now?

Roy:

I think we have to listen. Which is really important when you deal with healthcare. And I think it’s really important to always take a step back and ask yourself if what you’re doing is actually going to move the needle on where it matters. You can move a lot of needles, but for example, I’ll be the first one to tell you that I think that the application of telehealth for urgent care is really, really important. But the vast majority of healthcare paying and expenditure and volume is not in the flu, it’s in diabetes and heart failure and what Glen is doing and some of those things, and maybe that helps Glen in some way. But I think that the reality is we need to look at where healthcare happens, tough as it may be, and find a way for technology to weave into that and give it wings. And if we’re able to do that, then we’ve moved the needle on people’s right to expect better health care experience going forward than what was before. And we are seeing that happening in front of our eyes.

Jessica DaMassa:

All right. Last thing for you, toothpaste back in tube, what do you think? No? Yes?

Roy:

No.

Jessica DaMassa:

Are you sure? No, it’s not going back.

Roy:

It is not.

Jessica DaMassa:

This is it. This is here to stay.

Roy:

This is here to stay. Yes.

Jessica DaMassa:

All right. Well, you have to come back and talk to us if there is any news in September that we had heard, you have to come back and talk to us, even if you acquire something cool. I would like to hear about it.

Roy:

It’d be a pleasure.

Jessica DaMassa:

Thank you so much for letting me pick your brain.

Roy:

Happy to come back whenever you want.

Jessica DaMassa:

Fantastic. And I have to say, I really like that little Amwell throw pillow behind you.

Roy:

Oh yeah.

Jessica DaMassa:

That is super nice. For a big pillow fight later, right? Right. Thank you so much for stopping by and letting us pick your brain. It’s so exciting to hear about your vision for the future of the sector of the industry. I really can’t thank you enough. Thank you again for joining us. I’m Jessica DaMassa here with Roy Schoenberg, the co-CEO and president of Amwell. Thanks to everybody for watching. We’ll talk to you guys soon. Check out more of these videos up on wtf.health, or find me on YouTube. Just search WTF Health. Thanks so much for joining us.

Roy:

Thanks everyone.

Episode 17 of “The THCB Gang” was live-streamed on Thursday, July 9th! Watch it below!

Joining me were some of our regulars: patient advocate Grace Cordovano (@GraceCordovano), health economist Jane Sarasohn-Kahn (@healthythinker), WTF Health Host Jessica DaMassa (@jessdamassa), and guests: Tina Park, partner at Diagram (@diagramoffice) & Shannon Brownlee, Senior VP at the Lown Institute (@ShannonBrownlee). The conversation focused on asynchronous care, the gap between patients & technology, and the Supreme Court ruling on employers’ ability to limit women’s access to birth control coverage. It was a great and engaging conversation with some of the top health care experts in the field.

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

Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.

Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.

If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt

Episode 11 of “The THCB Gang” was live-streamed on Thursday, May 27th and you can see it again below

Joining me were three regulars, patient safety expert Michael Millenson (MLMillenson), writer Kim Bellard (@kimbbellard), health futurist Ian Morrison (@seccurve), and two new guests: digital health investment banker Steven Wardell (@StevenWardell) and MD turned physician leadership coach Maggi Cary (@MargaretCaryMD)! The conversation was heavy on telemedicine and value based care, and their impact on the stock-market, the economy and the health care system–all in a week when we went over 100,000 deaths from COVID-19.

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt