Pre-Surgical Complications (Part 1)

By MATTHEW HOLT

Strap in for the tale of why your hero is spending most of his life down YouTube rabbit holes of cardiology videos while blundering his way around many many medical centers and exposing many problems with American health care even before he gets close to the operating table. Yes it’s Matthew Holt’s pre-surgical complications – the complications that have arisen before he even gets his failing aortic valve fixed. And yes this will be a multi-parter!

Introduction and a decent bit of context

Last summer after a lot of back and forth I discovered that I had aortic stenosis. (I won’t replay the whole story of how the referral to the echocardiogram didn’t happen three times and therefore I nearly didn’t have the test and therefore never found out because I already have elsewhere) 

Amazingly this has nothing to do with my bad lifestyle. It’s an inherited heart disease in which the valve that governs the flow of blood between the two main chambers of your heart is starting to fail. Often that means people get very short of breath, start to faint or have severe chest pains but in my case I had none of that. What I did have was the measurement on an echocardiogram showing that my aortic stenosis was “severe” because I have what’s called a bicuspid aortic valve. This is a genetic defect that my father landed me with–well I’m blaming my father but who exactly knows as he’s dead!  

Essentially instead of having three leaves on the valve (like a Mercedes symbol) I have two and over time they’ve been steadily picking up more calcification and opening less. That means that more and more pressure is required from the heart to squeeze blood between the two chambers which is bad for the heart and by extension bad for me. That’s pretty strong agreement amongst cardiologists that if you can get this condition fixed before you become symptomatic it’s better than waiting. If you get symptomatic, it’s urgent and your chance of a heart attack and death becomes pretty high (like 25-50% a year!)

But of course it’s not that simple – either from the standpoint of getting it fixed or from the standpoint of how to get it fixed within the American health care system in all of its beauty. And you can expect it, as it’s me, to hear a lot about customer service, insurance, online access to information and of course interoperability. There might also be some AI thrown in for good measure!

So our story starts with me getting the results of the initial echocardiogram. I of course put that report into ChatGPT and later Claude and after finding out what it meant I discovered there were basically two main treatments for aortic stenosis, either something called a TAVR (Transcatheter Aortic Valve Replacement) or open heart surgery. A TAVR is essentially similar to a stent in that the artificial valve is put in a catheter up your leg and opened up in the place of the current valve, pushing that to the side. Open heart surgery, or a SAVR (Surgical Aortic Valve Replacement) –  is what it sounds like: they open up your chest sternum and then cut into the heart, taking out the old valve and sewing in a new one. 

I saw the echo report in Mychart. And then heard nothing for weeks from anyone either at Marin Cardiology where I had the Echo or from my PCP team at One Medical. To be fair, I didn’t push for much and I had a secret backup plan involving my friends at Included Health which (among other things) has an expert second opinion service. They got me an early opinion from one of their expert cardiologists, Dr Alan Yeung at Stanford. His comprehensive report basically laid out the two alternatives and said that because I was young (yes this is the only area in which I’m considered young these days) the guidelines suggest that I should have open heart surgery. He also suggested that I stop vigorous exercise including snowboarding. Of course I ignored that advice and decided that I would get a TAVR at the end of the ski season and, because it has been bothering me for a while, a knee replacement in the summer.

I met with my PCP at One Medical and was referred to Dr Sammy Elmariah, his favorite cardiologist at UCSF. 

That referral actually went very smoothly. I was invited by phone, and then found on my UCSF MyChart that I had a bunch of appointments and imaging set up for late January. That first day I had what’s called a gated CT where they basically look at your entire body and see whether you could be eligible for a TAVR including whether your arteries are strong enough, but also they look at your heart. CHatGPT told me I was fine for the TAVR.

I then met with Dr Elmariah at UCSF Cardiology, He basically told me that he wouldn’t do a TAVR on me and that I should have surgery. (As part of the cardiology consult they also book you a consult with a cardiac surgeon, in this case Dr Ramin Beygui). Dr Elmariah’s team also suggested I get another echocardiogram and were able to get me one that day including getting prior authorization from Blue Shield of California within a couple of hours. I was actually pretty impressed. 

The January echocardiogram showed no progression from the previous August. A few days later Dr Beygui had a video call with me. He was late –and to be sure I don’t mind as I know the time of a cardiac surgeon is way  more valuable than mine but it’s ironic as to what happened next–and told me that I should have the open heart surgery via a mini Sternotomy. He was, I felt, pretty blase about the impact of this on my life and didn’t seem to care that I was looking for a TAVR. Most people in the Reddit heart valve replacement subreddit seem to think that a stenotomy puts you out of commission for between 8 and 12 weeks. Given the TAVR is more or less a one-day procedure and everyone’s fine at the end of week one I was still a bit unhappy about the fact they wanted to go with the open heart surgery approach. But as it turned out it’s much more complicated than me just being too young.

I essentially told Dr Beygui I would consider getting the open heart surgery if either it became symptomatic or if my next echo was much worse. 

About a month later another video visit was put on my calendar at MyChart at UCSF with Dr Beygui for late on a Friday afternoon. I’m not quite sure why. As it  happened I was in Tahoe that week and the Friday was a fantastic powder day during which I’d been snowboarding for about 6 hours and having an amazing time. And feeling great, other than my battered knee hurt.

The knee in question is suffering the after effects of me going one side of a tree and my snowboard going the other back in 2002. After a lot of surgery back then and holding it together I hurt it again a few years back and it is now what is known as “bone on bone”. It’s not unusable and I can still patch it up and snowboard on it, but it certainly isn’t great. I have met with Dr Stefano Bini, the king of new knees at UCSF, many times due to his working in digital health over the years. At virtually every cocktail hour he grabs my leg, plays with my knee and says “come on Matthew, you need to get this replaced”. 

Hence my original plan was to get the TAVR in the late spring and to get the knee replaced in the summer, making me ready to go for the next snowboarding season. 

Obviously the recommendation from the UCSF Cardiology team to not get a TAVR and instead have the open heart surgery with its concomitant longer recovery was not exactly meshing with my plans. 

(Part 2 coming soon)

Matthew Holt is publisher of THCB

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Future of AI and Telehealth in primary care — Panel discussion

A couple of months back I hosted a conversation about my favorite topics, primary care and how telehealth and AI are changing it. The panel was Timm Schneider — Co-Founder & COO, Third Way Health, Jamie Reddick — COO, Graybill Medical Group & Erin Parks, Ph.D. — Co-Founder, Equip. The panel was at a tech heavy conference called TechCon Global in San Diego. Sadly the weather stopped us getting Matt Siegler from Akido Labs. We got into it about tech. incentives, specialty care and the role of AI in access and patient support–Matthew Holt

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Good News on the HIV Front

By MIKE MAGEE

In a 1996  JAMA editorial Nobel Laureate Joshua Lederberg MD wrote “Our fight with microbes is far from over …odds are tipped in their favor…they outnumber us a billion fold, and mutate a billion times more quickly…pitted against microbial genes, we humans mainly have our wits.”

Now three decades later, our scientists remain in a “battle of wits” with this amazing viral foe, but even without a vaccine, have maintained a slide edge for humanity. Experts recently confirmed that we are unlikely to have a vaccine bullet by 2030. And it’s not because we haven’t tried. There have been more than 250 official HIV vaccine trials, with fewer than 10 making it past the safety threshold to test efficacy – and the best performer only had a moderate success rate in triggering some immunity in 31%.

HIV is just a bad actor according to Professor Anna Durbin at the Bloomberg School of Public Health at Johns Hopkins. To start with, it embeds its chemistry in the host’s DNA genome, blurring the boundaries between “self” and “non-self.” Most of our successful vaccines focus in on a protein portion of the virus envelop or capsule. But the HIV virus has a “glycan shield” – a protein envelope that incorporates around 95 different sugar molecules which shield or disguise the viral protein from detection by our immune system. As one expert described it, “The immune system’s antibodies approach the virus and effectively see a blurry cloud of sugars rather than the vulnerable protein underneath.”

The second problem is the virus’s “sloppy gene duplication” is riddles with mutations. This yields dozens of different versions each with endless subtype variations. This is not typical disciplined viral behavior. Today’s measles viral genome for example is nearly identical to its late 20th century version.

And finally, HIV’s favorite target for invasion is the CD4 lymphocyte, otherwise known as the “Helper T-cell.” That happens to be the cellular key that unlocks our entire immune apparatus. This virus effectively decapitates the lead generals of our defensive force. And yet, we’re gaining on the virus. How have we done it?

First, by focusing on two “work-arounds” that trigger “passive immunity” without the help of our own immune machinery. Three decades ago, breakthrough discoveries first offered a glimmer of hope in the form of antiretroviral medications. With a variety of different combined therapy approaches, HIV/AIDS emerged as “no longer a death sentence,” but a chronic disease, like diabetes, that could be managed. In the modern era, this effective approach has spawned PrEP, or “Pre-exposure Prophylaxis,” – a preventive regimen for HIV negative individuals who are at risk of contracting HIV.

This regimen, generally combining the two anti-HIV meds, tenofovir and emtricitabine, prevents HIV replication if an individual is exposed to the virus. This cut transmission through sexual contact by 99%, and from illicit dug injection by 74%. The challenge has been access – especially in under-developed countries. But las month, Gilead Pharmaceuticals, teaming up with The Global Fund and PEPFAR (President’s Emergency Plan for AIDS Relief) agreed to provide their new antiretroviral drug, lenacapavir (LEN) at cost. In trials, the drug was 99% effective in keeping individuals HIV negative. As important, it is a twice a year injectable that could make a world of difference in developing nations, especially when it comes to transmission of the virus from HIV+ mothers to newborns through pregnancy and breastfeeding.

Scientists have known for some time that this population is key to combating HIV/AIDS. The chances of a newborn contracting HIV from an infected mother are 1 in 2. Contrast that with unprotected sex (1 in 72) and IV drug use (1 in 158), and it was clear to policy makers where to focus. Three decades ago, 1 in 4 infants born in Uganda were HIV+. That translated into 32,000 HIV infected children per year. Today it is less than 5000. How? 1) All expectant parents are HIV tested. 2) If positive, they receive anti-retroviral meds.

The latest WHO stats show progress is indeed possible:

“At the end of 2024, 77% of people living with HIV were accessing antiretroviral therapy, up from 24% in 2010. Globally, there were 1.1 million pregnant women with HIV in 2024, of which an estimated 84% received antiretroviral drugs to prevent mother-to-child transmission. At the end of 2024, there were 1.4 million children aged 0–14 years living with HIV globally, down from 2.7 million in 2010.” Clearly there is still work to be done. One in six pregnant women with HIV is still not under treatment.

The second “work-around” is equally promising. It is what the NIH has labeled a “passive immunization strategy” – monoclonal antibodies. Research in animals, dating back to 2014, found that animals with long-standing HIV sometimes develop “broadly neutralizing antibodies” that effectively stop a whole range of different genetic subtypes of HIV. A decade later, synthetically engineered copies of these natural antibodies are being tested. Challenges remain, including the need for continued infusions, perhaps every six months, to keep formally HIV+ individuals in “permanent remission.” 

A summary report in Smithsonian magazine six months ago stated, “This year, researchers reported a breakthrough that suggests a ‘functional’ cure for HIV—a way to keep the virus under control long-term, without constant treatment—may indeed be possible. In two independent trials using infusions of engineered antibodies, some participants remained healthy without taking antiretrovirals, long after the interventions ended.”

The final word goes to Johns Hopkins Bloomberg School of Public Health’s Morgan Coulson, who recently wrote, “The history of HIV vaccine research is a long record of promising ideas that didn’t translate into protection in large trials. What makes the current moment different is that researchers have, for the first time, demonstrated they can deliberately guide the human immune system toward producing the kind of antibodies known to neutralize HIV broadly. Whether that initial success can be built into full protection is the central question for the next decade of research.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

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Ben Salter, SafeRide Health

Ben Salter is the Chief Product Officer of SafeRide Health. They are one of the biggest players in non-emergency medical transport (NEMT) working predominantly for health plans that have Medicaid or Medicare Advantage members. Getting people to their appointments is a big deal–think disabled or sick people who will miss clinical appointments if they can’t get there. Ben showed a demo of how their system works, what it looks like for call center staff or members using it directly, and how that then actually gets someone a ride to where they need to go–Matthew Holt

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Medicaid Budget Cuts: Hospital will bear the burden, we will pay the price

By LINDA RIDDELL & THOMAS WILSON

Recent discussions over Medicaid budget cuts invite us to look more deeply into the house-of-cards that, when it collapses, will hit the states and low-income households hardest. But we will all be harmed.

Some states get 80% of their Medicaid funding from the federal government, as a recent Wall Street Journal article, “Medicaid Insures Millions of Americans. How the Health Program Works, in Charts” pointed out. Even states relying less on federal funds will be hard pressed to shift their resources to replace the federal share. The ripple effects are clear: states are likely to reduce Medicaid enrollment, forcing low-income people to skip care or find free care, and hospitals will shift resources to cover care they are not paid for. Dollars cut from Medicaid do not vanish; they simply shift to different corners of the healthcare system. Ouch!

A Deep Dive into the Facts

Fact 1. Low-Income Households Already Spend More of Their Income on Health Care: Recent Consumer Expenditure Survey data reveals that the lowest 20% of households—roughly corresponding to those enrolled in Medicaid—saw the share of their income spent on healthcare (red in Figure below) rise from 8% in 2005 to 11% in 2023. In contrast, the highest-income 20% devoted only 2% in 2005, rising to about 4% of their income to healthcare in 2023.

Fact 2. Necessities Consume a Majority of Low-Income Households’ Income: Low-income households spend about 57% of their income on essentials like food and housing (blue in figure). This leaves little to nothing for other expenses. These families have an almost inelastic budget where any additional expense, even one as critical as medical care, forces painful trade-offs. In contrast, high-income households have from 38% to 53% of their income (purple in figure) left over after meeting all basic and other costs.

Fact 3. Affordable Care Act Led to Reduced Uninsured ED Visits: In 2016 — two years after Affordable Care Act provisions took effect —  many states expanded Medicaid, and all introduced health insurance exchanges. These changes brought emergency department visits by uninsured patients down by half—from 16% to 8%.

Fact 4. Uncompromising Obligations at Hospitals: Under the U.S. Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must treat and stabilize every patient who arrives, regardless of their ability to pay. With around 70% of all hospital admissions arriving via the ED, a surge in uncompensated care in the ED will directly affect admission rate, the hospital’s core function.

Examining the Key Inferences

Inference 1. Rising Uninsured Populations: Cutting Medicaid budgets is likely to lead to states shrinking enrollment and boosting the number of uninsured individuals.

Inference 2. A Resurgence in Uninsured ED Visits: If Medicaid budget cuts reduce enrollment, the previously achieved reductions in uninsured ED visits could return to the high rates seen before the ACA.

Inference 3. Hospitals Caught in the Crossfire: Budget cuts will force hospitals to provide more uncompensated ED care. The response is likely to be reducing staff, the hospital’s largest cost center  — a move that directly affects the quality and timeliness of both primary and specialty services. Washington state offers a cautionary tale, where hospital leaders predict longer wait times and lower service levels due to state budget cuts.

Broad Impacts Beyond the Numbers

The health system must pick up the $880 billion slack, not by magically creating money but by shifting resources from other programs.  The healthcare system has its priorities set by the budget scramble–not by the community’s health needs. Health disparities between the rich and poor will widen, and progress made on having more people insured will reverse.

Staff cuts will lengthen wait times and decrease service quality, not to mention they will burn more people out of their health service jobs. The ripple effects of Medicaid cuts will eventually touch all who seek medical care and pay for health insurance.

A Call for Political and Community Action

Now, more than ever, it is time for political stakeholders to recognize that the real cost of Medicaid cuts is borne not just by states but also by communities. Stakeholders, policymakers, community leaders, and the general public must stand up for their own interest in having a sustainable health care funding approach.

Toward a More Equitable Future

The case against Medicaid budget cuts is not merely about dollars and cents—it is about the future of our healthcare system and the health of millions of Americans. Cutting Medicaid benefits may create short-term savings on paper, but it undermines the health infrastructure that serves everyone.

A thoughtful and balanced approach would protect vulnerable populations while ensuring hospitals remain viable centers of care, especially for rural areas. In rural communities, the health sector creates 14% of jobs; rural hospitals are generally the largest employer and since they serve more Medicaid and Medicare patients, they will be the hardest hit by these budget cuts.

The shift in where healthcare dollars are spent could change every layer of healthcare delivery—from the ED’s ever-growing responsibility to inpatient admissions to primary care’s dwindling resources. It is a call for all of us to rethink how healthcare is funded and to stand in solidarity with those at risk of being left without medical care.

Looking Ahead

Beyond the immediate fiscal challenges, this issue invites a broader discussion on healthcare reform. How can we restructure funding to improve efficiencies? Could community health cooperatives or expanded telehealth services help lessen adverse effects?  These questions deserve robust debate and decisive action.

In these turbulent times, every stakeholder—from local communities to federal policymakers— needs to find solutions that prioritize human health over short-term budget tactics. The stakes are high, and the choices made today will shape healthcare access and quality for decades to come.

Linda Riddell, MS is a population health scientist specializing in poverty and is the founder of Gettin’ By, a training tool helping teachers, doctors, case managers, and others work more effectively with students, patients and clients who are experiencing poverty. Thomas Wilson, PhD, DrPH is an epidemiologist focused on real-world issues and board chair of the non-profit Population Health Impact Institute 

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Medicaid Should be Abolished. But Not Like This!

By MATTHEW HOLT

A long time ago in a different country, there was a landslide election from a population looking for change. And change they got. Americans had been campaigning for national health care since 1917. There had been failures in 1933 and 1946 and 1961. But in 1965 they got it. Sort of.

But a weird thing happened in the Congress. Out of the political sausage making came a plan that “Cared” for those over 65. While another plan came out that “Aid”ed the poor. (Stole that from the wonderful Adimika Arthur). Weirder still, the Medicare program was and is a Federally-funded program. The Medicaid program was a state-administered program, even though it was at least half funded by the Feds. 

That meant that Medicaid was always vulnerable to the whims of states. Of course many states already had demonstrated dismal records in how they treated their poorer and minority populations in the past (think slavery, Jim Crow, KKK, separate schools, drinking fountains, buses…you get the idea).

So while Medicare became the savior program for anyone who made it to 65, and later for those who were disabled or had kidney disease, Medicaid was a program for poor people that then got treated poorly. (Stole that from Jonathan Cohn). And right now in 2025 it is under severe threat yet again.

Before we get to that threat, it’s worth looking at the program. Medicaid has evolved and now covers most nursing home care (for “poor” seniors), care for the disabled, and even pays Medicare Part B premiums for people too poor to pay their own.  It also covers health insurance for poor people under 65 and in those states that accepted ACA Medicaid expansion, that’s a considerable number. Of course these are people under an imaginary line that makes them too poor to buy on the exchanges set up by the ACA. And usually Medicaid includes the CHIP program, an insurance program that covers poor children set up under Clinton in 1997.

This chart from the venerable KFF shows that while 75% of people on Medicaid are, poor, under 65, and not classified as disabled, 50% of the money goes to those who are not.

This all results in a bizarro world in which there is one Federal government program for people over 65 and the disabled, and then an entirely different state-based one, which spends 1/2 of its money on people who are over 65 and disabled and who are also in the Federal program. This is plain stupid and always has been.

Of course there is more to it than that.

Many states that don’t share that confederate heritage have done a lot with Medicaid. Oregon for example has always tried to increase coverage and spend money on community care in a different way. Physician and three time Oregon governor John Kitzhaber is very vocal about what they did before the ACA and how Medicaid should change to reflect these new realities. 

Since 2012, under an 1115 waiver, Oregon Medicaid has been provided through new Coordinated Care Organizations (CCOs)— community-based organizations charged with providing quality medical care, while focusing also on community health. They operate on a global budget indexed to a per member per year a growth rate that is lower than medical inflation. CCOs are also required to maintain enrollment and benefits, while meeting rigorous metrics around quality, outcomes and patient satisfaction.During the first 5-year waiver period, Oregon enrolled an additional 384,000 people and operated within the per member per year growth rate. All CCOs met the required quality and outcome metrics, and realized a net cumulative savings of $1.1 billion.

In fact Oregon is by no means the only state that has done something different. California massively expanded coverage post the ACA and now 15m people or over ⅓ of its population is on Medicaid. Along with that, there has been a ton of experimentation within the program. Those 1115 Waivers, which are required to spend that Federal money in a way not envisaged in the 1965 Act have worked overtime in the Golden State on a state and county level. The overview is that Medicaid here has been changed into a more comprehensive program called CalAIM (California Advancing and Innovating Medi-Cal) which covers all kinds of things not in traditional Medicaid including doulas, community health workers ( who might also be barbers!) and in some counties housing and food.

Despite these improvements I wouldn’t suggest that you deliberately move to Oregon or California and become poor. (Stole that line from my late boss at Harris, Bob Lietman)

But there’s a ton more happening in Medicaid nationally. Since the 1990s most care has been steered into private health plans, although many are publicly run. But Centene and Molina especially have built very profitable business on Medicaid in a similar way to how United, Humana et al have mined Medicare Advantage.

And although not strictly speaking operating via Medicaid itself, we have also built out lots of other funding sources for safety-net providers. This includes the 340B program which hospitals use to make money on drugs, DiSH payments which go to hospitals who treat more of the poor, and then there’s about $35bn+ in federal funding to FQHCs which treat a lot of uninsured and Medicaid populations.

So we have built this incredibly bloated mess of a program. It is mostly administered by organizations that are commercial or county plans that don’t look like the plans regular employed Americans get their coinsurance from. Those plans purchase care from a network of facilities (FQHCs, county hospitals et al) that get much of their money from Medicaid, or use a bunch of other ways to raise funds. And those provider institutions don’t look much like or share much clientele with the regular doctors and health systems where most employed Americans or those on Medicare get their care.

And you thought separate but equal was abolished in the 1950s!

Now of course, Medicaid is under great threat, as in some ways is the ACA. The Trump Administration, featuring a South African immigrant wandering around with a literal and figurative chainsaw, has promised cuts. The most common number suggested is $880Bn over 10 years. Now that is a big chunk. $90B – the annual equivalent – is around 15% of Federal spending on the program. Of course this is a program that spends plenty in Red states, but of course plenty of that spending in red states is on black and brown people, and many white Trump voters don’t realize that it also covers plenty of their white political allies. Wendell Potter and Joey Rettino pointed out that given many states call it something different than Medicaid, it’s possible a bunch of Trump voting low-information voters in red states may not realize it covers them!

Even so a 15% reduction, in a program that is spread thin like peanut butter and already pays low fees to providers and nursing homes, will be trouble.

The other question is around regulation. Those ubiquitous 1115 Waivers allow lots of programs that aren’t in the original regulations, and of course getting or renewing a waiver from the new HHS and CMS may be tricky. For sure the Republicans are obsessed with making sure anyone on Medicaid is working. Those “work requirements” were rolled out in a few states during the last Trump Administration. They ended up saving no money, and were unnecessarily honorous. But given the desires of the current Administration to be as cruel as possible, it’s highly likely that ideology wins out here and work requirements or other silly shit may be imposed on every state.

So the current fight is going to be the Dems in blue states trying to keep Medicaid as is. Well see how that plays out, and whether the Trumpers can keep their thin majority together when some of them realize what it means. 

But that’s not what we should be doing with Medicaid. Instead we should take the plunge that the Clintons tried to take but that Obama and the ACA ducked. 

We shouldn’t reform or defund Medicaid. We should abolish it.

If instead we should use that Medicaid money to create a proper universal health care system, and put people on Medicaid on the same financial and delivery platform as Medicare and commercial insurance. Whether we do that in a multi-payer world as the Japanese and Germans do, a mostly single payer version like the French or Taiwanese or a nationalized system like the UK and Sweden, it would remove the second class health care status of the ⅓ of our citizens who don’t have Medicare or good private insurance. In addition, it would enable our clinical professionals to practice medicine the way they wanted to when they were young and idealistic, and not have to worry about how much each patient would pay, as they’d get the same amount no matter who they were treating.

Let’s get the political momentum going to argue for equal treatment for all in America, and not keep around a welfare program that emerged from a political mistake in 1965. 

Matthew Holt is the Publisher of THCB

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I’m on the Baker Health Podcast

It was great fun to talk about the health care system with Dr Zeyad “Z” Baker on his podcast, so I thought I would share it here–Matthew Holt

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Bevey Miner, Consensus Cloud Solutions

Consensus is taking fax data, received by rural clinics, post acute, substance abuse clinics, home health et al, and helping them put it into their systems of records–which are in general not FHIR-enabled. They allow those facilities & services to receive referrals from acute care hospitals. By 2027 many of these standards are going to need to be FHIR enabled. Bevey Miner, EVP at Consensus, is a health care veteran who is working on both a policy and technology level to improve access to care, and thinks a lot about what unstructured data means in a world where we are trying to use data for AI and more. Super interesting chat about the murky backwaters of health care data and services. As Bevey says, “Not everyone is going to be Epic to Epic to Epic”–Matthew Holt

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Linus Health–In-depth demo of cognitive health tool

The decline in cognitive health, especially that leading to Alzheimer’s and other brain diseases, is one of the most feared conditions by patients and their families. It’s also one of the most expensive. But if we can predict it early there are things we can do to prevent or ameliorate it. The issue has been finding an easy and comprehensive way to monitor it as part of primary care. The team at Linus Health has been building a diagnostic solution for exactly that and claims that it’s now the right time to roll it out as part of general primary care. CEO David Bates, John Showalter, Chief Product Officer (a primary care doc) and Alvaro Pascual Leone, a neurologist and Chief Medical Officer, took me through an extensive end to end demo. This is a long and fascinating look at the state of play in neurology diagnosis, and discussion about what the future of brain health looks like. Matthew Holt

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Health Care in Abundance

By KIM BELLARD

A recent report from Moody’s Analytics, by chief economist Mark Zandi, had an eye-opening fact: the top 10% of earners in the U.S. – those who make $250,000 or more – now account for just shy (49.7%) of half of consumer spending. If that strikes you as unusual, you’re right. It is a record since at least 1989. Thirty years ago the comparable percentage was 36%.

“The finances of the well-to-do have never been better, their spending never stronger and the economy never more dependent on that group,” wrote Dr. Zandi. He added: “Wealthier households are financially more secure and thus more able and willing to spend their income. That is, they save less than they would otherwise.”

The rest of us are struggling to hold our own against inflation, not always successfully. It’s why companies like Costco and Walmart are trying to target upscale shoppers, while “value” oriented firms like Big Lots, Family Dollar, or Kohl’s are closing stores or even declaring bankruptcy.

This extreme bifurcation, of course, made me think of healthcare, where – as is famously known – half of all spending is attributable to only 5% of patients. In case you’d forgotten, in healthcare, half the population accounts for 97% of all spending, so the other half accounts for a measly 3%.

Now, you might say, neither of those is surprising: rich people spend more, and sicker people cost more. But somehow neither of those seems right to me.

I started thinking more about this after reading a recent New York Times op-ed from Ezra Klein. In it he makes the following assertion:

The answer to a politics ofscarcity is a politics of abundance, a politics that asks what it is that people really need and then organizes government to make sure there is enough of it.

Mr. Klein didn’t coin the phrase “politics of abundance,” but he and Derek Thompson did just write a book on the topic (Abundance) that discusses their thoughts at more length. I have not read the book, but I saw a quote from it that I quite liked: “What is scarce that should be abundant? What is hard to build that should be easy?”

And so we’re back to healthcare.

We seem to live in a country where healthcare is too scarce. A new analysis suggests that we have a looming shortage of hospital beds, and if you live in a rural area, it’s already here. If you believe the Association of American Medical Colleges, we have a looming physician shortage, and if you’re looking for primary care, it’s already here. We’re facing nursing storages, pharmacist shortages, nursing home worker shortages, home health worker shortages, to name a few. We even have shortages of many critical prescriptions, including some needed for cancer treatments.         

Despite all these shortages or would-be shortages, of course, we manage to spend way more than other countries on healthcare. One can only imagine how much we might be spending if there were no shortages. I take that back: I’m not sure I can imagine.   

In the category of things that are scarce that should be abundant, and/or things that are hard to build that should be easy, I’d probably put housing at the top but healthcare as a close second. The trouble is, when we pour more money into healthcare, as we are wont to do, we don’t seem to fill any of our many shortages, much less improve the quality of care or outcomes.

In his article, Mr. Klein recounts the long saga of California’s Prop 1A, which called for a high speed rail line between Los Angeles and San Francisco. Other countries have high speed rail lines, most notably Japan, so certainly the richest state in the richest country should be able to build such a line. But, nope, 15 years later the predicted cost of the line has ballooned 300%, not much of the line is actually complete, and there is no end in sight, much less money available to complete it.

It reminds me of ACA: important goals, lots of money spent towards achieving them, some key accomplishments to show, but oh-so-far from achieving what we actually need.

We can’t keep going on the way we’ve been going on. We need to make scarce health care abundant, and to make things that are hard to build in healthcare easy to build.  Finally, we may be approaching technologies that would allow those.

It starts with A.I., as everything seems to these days. Healthcare, to my surprise, has started to embrace the use of A.I. Whether it is to assist physicians, to handle the too-many administrative tasks, to develop new drugs, it’s clear there will be a role for A.I. in healthcare.

My worry is that our healthcare system will absorb A.I. the way it did digital, making use of it but not using it to drive costs lower or to increase access. My worry is that it will be used to make more money for the people already making money in the system. My worry is that it be used to put a shiny new coat on our healthcare system, not to revamp or to reinvent it.

Here’s my plea: let’s use A.I. to make health care abundant – and cheap. Let’s make A.I. make building resources used in healthcare – be they people, devices, drugs, or buildings – easy to build. Simply adding A.I. into our existing system won’t do those. We have to design it towards those ends.

And let’s not stop at A.I. I’ve long been a fan of robots – be they full-sized, nano, or anything in-between – in healthcare. We know we have people shortages, especially for caregiving, and we should be planning for how robots can help fill those. But we need to use them with the abundance mentality: make them cheaply, use them ubiquitously, make them readily available. I think of how Ukraine has reinvented drones for its war efforts, because American drones were too expensive, too few, and too uncertain. We need that mentality for building healthcare robots.

Same for 3D printing. Medical devices, supplies, even prescription drugs: we should be ramping up use of 3D printing to make them – you guessed it – more abundant and easier to build, not to mention much cheaper. The companies currently making them won’t like it, of course, but our healthcare system doesn’t exist to make them money.  Or, at least, it shouldn’t.

The people and companies currently profiting from healthcare thrive on scarcity – perceived or real—and on making things hard to build. We need healthcare leaders that want us to thrive on abundance.  

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

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Lynda Brown-Ganzert, RxPx

Lynda Brown-Ganzert is CEO of RxPx. The company is the 2022 merger of the company she founded, Curatio, which was a support system for rare disease patients, with RxMx, a complementary service that helped clinicians manage patients on treatment or clinical trials. Lynda says that somehow I inspired the merger! (Although I don’t remember it, nor did she send me my 10%!). Now the company is supporting rare disease patients, funded primarily by pharma, across the globe. Lynda gives a full demo of both the clinician and patient experience–coordinating meds, labs, imaging, appointments, content, symptoms, patient reported outcomes, peer and coach support, and more. And she discusses how a great PE takeover works. (Not all of them are!)–Matthew Holt

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Katherine Saunders, FlyteHealth

Katherine Saunders is the co-founder and CMO at FlyteHealth. She was one of the first 20 obesity fellows in the US. FlyteHealth is the specialized online obesity clinic that resulted from her desire to scale what works for individuals to combat their obesity–by the time people get to FlyteHealth 99% of them are ready for medical treatment. Katherine explains how FlyteHealth manages the whole of the patient’s experience with MDs, NPs, dieticians and more. Yes, we talked about GLP1s too!

Meanwhile if you want to know about the science of obesity, here’s Katherine’s TedTalk.

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Jonathan Bush, Zus Health

It’s always fun to chat with Jonathan Bush. You kids today may not remember that he was the first CEO to take a cloud-based (Health 2.0!) company public back in 2007! Athenahealth didn’t end up challenging Epic because a cosmically evil hedge fund took it (and him) down as it was on its way to try to do that, but Jonathan has moved on and is now building a clinical data integration company called Zus Health. We talked Zus, digital health, whether there will ever be value-based care and more. 20 mins of digital health gold right here–Matthew Holt

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Sleep: Watch This Space

By MIKE MAGEE

In case you’ve missed it, sleep is all the rage in neurosciences these days. They are fast at work rebranding it “the brain’s rinse cycle.”  The brain, protectively encased in an unyielding bony casing, lacks the delicate lymphatic system that transports used body metabolites to breakdown and extraction sites in all other parts of the body.

But in 2012, neuroscientist Maiken Nedergaard, identified a unique network of delicate channels (“tiny passages alongside blood vessels”) inside the brain that collect and discharge brain metabolites and waste materials including amyloid. This system, or “ultimate brainwasher” as some labeled it, was formally titled the “glymphatic system.”

That same study also suggested that flow through the glymphatic system is enhanced during portions of the sleep cycle. Now 12 years after the original research, the same team, in a study in mice published in the Proceedings of the National Academy of Sciences USA journal, found that regular contractions or oscillations of tiny blood vessels in the brain, stimulated by adrenaline cousin, norepinephrine, generated the brain scrubbing liquid flow through the channel system. The focal contractions, normally occurring ever 50 seconds, speed up the pump to every 10 seconds, in sync with peaks of norepinephrine release during sleep.

Sleep deprivation appears to not only interrupt this cycle, and allow harmful wastes to accumulate, but also disrupts other mental health functions that scientists are just beginning to understand. For example, researchers in 2021 established that “sleep deprivation impairs people’s ability to suppress unwanted thoughts.” They were able to identify a special location on the brain cortex responsible for storing away memories, and  suppressing and delaying their future retrieval. They further demonstrated enhanced activity at the site during REM sleep. As the lead investigator noted, “That’s interesting because many disorders associated with debilitating intrusive thoughts, such as depression and PTSD, are also associated with disturbances in REM.”

The new work may help explain destructive recycling of historic conflicts among and between Silicon Valley AI uber-competitors. They may not be getting enough sleep, recycling historic grudges and grievances.

As the sleep scientists reported in the December, 2024 publication, “The functional impairments arising from sleep deprivation are linked to a behavioral deficit in the ability to downregulate unwanted memories, and coincide with a deterioration of deliberate patterns of self-generated thought. We conclude that sleep deprivation gives rise to intrusive memories via the disruption of neural circuits governing mnemonic inhibitory control, which may rely on REM sleep.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

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