LIVI telemedicine app expands availability to 1.85 million patients with GPs in Birmingham, Shropshire, Northamptonshire, Southeast

The LIVI telemedicine app, which made news last year with UK partnerships in Surrey and Northwest England last year, has expanded to GP practices in Birmingham, Shropshire, Northamptonshire, and locations in the Southeast, as well as additional practices in Surrey. The Northampton General Practice Alliance and the Alliance for Better Care are among the federations partnering with LIVI.

LIVI offers NHS and private services for video consults with a GP. Patients can also access medical advice, referrals, and prescriptions. Unlike Babylon Health, the patient can use LIVI without having to register with a new, Babylon Health-linked practice and deregistering from the former GP practice. It is now available to 1.85 million UK patients. Known as Kry in the Nordic countries, LIVI also has a presence in France. 

In January, LIVI also acquired some notoriety when their current VP of product, Juliet Bauer, departed her chief digital officer spot with NHS England after an all-too-glowing article about LIVI’s Surrey pilot in The Times–without disclosing that she was joining the company in April [TTA 24 Jan] leading to charges of the ‘brazenly revolving door’ et al.

Allscripts reaches deal with DOJ on Practice Fusion in compliance settlement for $145 million

EHR giant Allscripts settled with the US Department of Justice on compliance charges made against Practice Fusion. Allscripts acquired Practice Fusion, a free/low-cost EHR targeted to primary care practices, in January 2018. A year earlier, Practice Fusion had received an inquiry from the US Attorney’s Office for the District of Vermont examining the company’s compliance with the EHR certification program. According to Fierce Healthcare, after Allscripts acquired Practice Fusion, the inquiry expanded…and expanded…to include additional certification and Anti-Kickback statute charges. Since then, Allscripts has rebranded the EHR as Veradigm.

The announcement was made during their 2019 Q2 results investor call. Their president claimed the $145 million settlement, at this point an agreement in principle with DOJ, is in line with other EHR-DOJ settlements. 

Consider it a final payment on the knockdown price ($100 million) Allscripts paid for Practice Fusion.

Their Q2 bookings were $276 million, up 31% from the prior-year period, but revenue at $445 million was lower than expectations. 

2020 GSK IMPACT/The King’s Fund Awards now open for applications (UK)

The King’s Fund has announced that the GSK IMPACT Awards, which provide funding, training, and development to charitable organizations in health and wellbeing, are now open for 2020 applications. Applicants should be registered charities that are at least three years old, working in a health-related field in the UK, with a total annual income of between £80,000 and £2.5 million. It’s open only to 23 September so you may want to read The King’s Fund page on their work with charitable organizations, their learnings about the challenges they face–and how to apply. Interested in 2019? Read our article on the winners here.

Comings and goings, short takes, and in other news…: Vivify’s new SVP Sales, Parks’ Connected Health Summit, $35M for 3D portable ultrasound, Oxford Medical Sim new pilot

In comings and goings….remote patient monitoring company Vivify Health announced that Chris Fickle has joined them as Senior Vice President, Sales. Mr. Fickle was previously with Qualcomm as senior director, business development including international and in the home health market as general manager of Healthfield and American HomePatient. Vivify currently has customers such as UPMC, Trinity Health, and the Ontario (Canada) Telemedicine Network and provides remote care management through personalized care plans, biometric data monitoring, and multi-channel patient education. Certainly in the umpteenth iteration of their website and June’s MedTech Breakthrough Award, they have apparently bounced back from their bounce-out from their VA award in early 2018 [TTA 14 June 18 and 16 Jan 18].

A reminder that Parks Associates’ Connected Health Summit in San Diego is now open for registration. TTA has been in the past a formal media supporter of the CHS and while not this year, it’s a great way to spend a few days in late August. The location, content around the demand for both clinical and consumer health and wellness solutions aimed at improving the quality of life for people living and seeking support at home, and the speaker list has always been outstanding. Follow their Twitter feed at @CONN_Health_Smt | Hashtag: #CONNHealth19. And register here.

This Editor has been following handheld ultrasound since GE Healthcare debuted the VScan in what seems an eternity ago (only 2010!) –and yes, it’s still around–Mobisante demonstrated at TED by no less than Eric Dishman in 2013–and last year the locally-based Butterfly IQ hit the market at about half the price and raised $250 million. Now Redwood City, California startup Exo Imaging has gained a $35 million Series B round to develop its portable ultrasound that through AI assistance generates a 3D image. Release. Mobihealthnews

The UK’s Oxford Medical Simulation has picked up another pilot of their Oculus Rift VR headsets to simulate in-practice interactive patient treatment at the OxSTaR (Oxford Simulation, Teaching and Research) center, part of  John Radcliffe Hospital, Oxfordshire. We covered OMS in April with their pilot with Health Education England Wessex at the Portsmouth and Southampton Hospitals. Mobihealthnews

 

Technology will help ease, but not replace, rising workforce demand in long-term care: UCSF study

A just-published research paper by researchers at the University of California, San Francisco Health Workforce Research Center on Long-Term Care, has come to the not entirely unsurprising conclusion that the current technology targeted to the LTC area is helpful but won’t displace any workers from their jobs in the immediate future. The qualitative study evaluated 13 current health tech technologies in 14 areas for their potential impact on the care of older persons as it affects LTC workforce recruitment, training, and retention. 

Some key findings were: 

  • Technology will not even come close to replacing the LTC workforce. At most it will aid LTC workers.
  • Tools such as data collection and remote patient monitoring systems that distribute data to the care team can improve staff’s understanding of client behavior and manage day-to-day tasks
  • Technology can also address workforce recruitment, retention, and staffing efficiency, such as predictive analytics used in identifying candidate suitability, improved staff management in shift scheduling, work location, and clientele, and real time location tracking, can improve the work environment
  • Technologies that monitor health and activity measurements, integrating with predictive modeling, can benefit clients, family caregivers, and care teams, but may suffer from complexity and duplication in their category. 
  • Educational tools also improve care delivery by instructing on proper caregiving techniques, increasing knowledge on medical or behavioral conditions, and by promoting sympathy/empathy

Some of the barriers included:

  • It comes at a cost which LTC is reluctant to pay
    • Initial and ongoing cost with lack of third-party Medicare/private reimbursement
    • Dependence on unattractive long term subscription-based models 
  • Threats to privacy and the security of health data
  • Potential differences in product specificity or acceptance among diverse racial and ethnic groups
  • Technology lacking user-centered design and not developed/tested in conjunction with real-world LTC 
  • Funding: only two US VCs fund LTC tech is a bit of an exaggeration, but the pool of interest is shallow nonetheless

The overall conclusion struck this Editor as less than enthusiastic, perhaps because We’re Not There Yet and it’s still so far away.

The appendix lists the 13 companies surveyed with summaries of each health tech company interviewed: Alma’s House (Sweden), Arena (staffing/recruitment), Canary Health (education/caregiver education), CarePredict (wearables/alert monitoring), Clear Care (management). Embodied Labs (education), Intuition Robotics (ElliQ), GrandCare (monitoring/client engagement), Honor (staffing), La
Valeriane (documentation), LifePod (voicetech/monitoring), UnaliWear (wearables/monitoring), VisibleHand (documentation/EHR).

The study was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS).com. UCSF summaryThe Impact of Emerging Technologies on Long-Term Care & the Health Workforce (full text)  Hat tip to Laura Mitchell of GrandCare via Twitter

Can a smartphone camera, app, and device detect viruses at low cost?

A team of researchers led by the University of Tokyo’s Yoshihiro Minagawa has developed a mobile-based portable viewing and diagnostic platform for viruses, which may be a breakthrough in diagnostics for rural and underserved global areas. The viewer is about the size of a standard brick and performs the digital enzyme assay using cavities lit with an LED to create light spots detectable by the camera.  The smartphone camera fits on top of a lens on the top of the box. Right now it detects only about 60 percent of what can be detected by a fluoroscopic microscope, but its speed and portability are major assets in these early tests, as well as versatility in possibly detecting other biomarkers. Mobile imaging platform for digital influenza virus counting (Lab On A Chip–Royal Society of Chemistry) Supported by the ImPACT Program of Council for Science, Technology, and Innovation (Cabinet Office, Government of Japan) Also Mobihealthnews APAC.

FCC reforming Rural Health Care Program to improve telehealth funding in addition to Connected Care Pilot (US)

The Federal Communications Commission (FCC) voted last week to adopt a 151 page “report and order” which will reform how the agency distributes money for rural telehealth support and broadband services through the Rural Health Care Program. Rural telehealth has been one of the FCC’s most popular programs with demand exceeding funding.

The new policy will, according to the order:

  • Reduce fraud, waste, and abuse (FWA)
  • Streamline and simplify the calculation behind the discounted communication rates that healthcare providers pay
  • Move to create a database of rates (transparency)
  • Simplify the application process
  • In the likely event that demand for the RHCP exceeds its funding cap (currently $571 million), the program will target funding to the most rural areas (based on rurality tiers) and those facing shortages of health care providers
  • Directs the Program Administrator to take additional actions to increase transparency in the program and applicants receiving timely, complete information

According to Modern Healthcare, subsidies on the telecom rates will be based on the median rates telecommunications providers charge for similar services in the state and the rurality tier (how rural the location is) for the healthcare provider. There is some bi-partisan debate on delaying the change due to local concerns, the level of funding (generally seen as too limited) and the relative experience of the Universal Service Administrative Company to determine those rates. Some urban areas do receive funding in the program, which is a puzzle to this Editor, but was probably baked in from its start in 1997 when certain neighborhoods had little connectivity. The FCC is also proposing a cap on Universal Service Fund programs, one of which is the RHCP. Sen. Marsha Blackburn also entered a bill which would direct the FCC to develop guidance on cross-state telehealth in the Telehealth Across State Lines Act of 2019. POLITICO 2 Aug.

The RHCP is separate from the Connected Care Pilot, which moved ahead in July and will bring telehealth services directly to rural low-income patients and veterans. The Notice of Proposed Rulemaking (NPRM) was issued on 10 July. One wishes that this bickering Congress would understand the importance of both programs. FCC release, TTA 20 June

Comings and goings, short takes and upcoming events: MedStartr Wed night, Mad*Pow acquired, Teladoc’s new COO, JAMA ponders telepharmacy, NHS London anxiety apps partner (updated)

MedStartr Hyper Accelerator Pitch Night is tomorrow (Wednesday) night, 6pm, 31 July at Rent 24 in midtown Manhattan. Presenters are from the fourth MedStartr Hyper Accelerator Class including several MedStartr Venture Fund II portfolio companies. Attend through the Meetup link–still only $20 for presentations, snacks, drinks but may be higher tomorrow or at the door. If you missed it, follow MedStartr on Meetup.

And 31 July is also the deadline to apply for the summer session of Health Wildcatters’ Texas Healthcare Challenge on 9-10 August. More information here.

Our friends over at The King’s Fund have several upcoming events of interest:

And our friends at UKTelehealthcare remind us that there are several events coming up where they are organizing or supporting. Click the link on the right sidebar advert for more information on:

  • 1st-2nd October 2019 – HETT (Health Excellence Through Technology, formerly The UK Health Show), ExCel, London
  • 10th-11th October 2019 – Suppliers’ Forum and Providers’ Forum, Barnet & Southgate College
  • 22nd October 2019 – Cambridgeshire TECS MarketPlace,The Burgess Hall, Westwood Rd, St. Ives PE27 6WU

The Mad*Pow design consultancy is being acquired by Tech Mahindra of New Delhi. Mad*Pow’s original focus was on design for health, financial wellbeing, and social impact, and in early days held several interesting NY-area meetings. Tech Mahindra is the digital tech offshoot of the Mahindra multi-national industrial and IT giant. Yet in the Mad*Pow email to industry contacts, “Exciting News! Mad*Pow and Tech Mahindra Enter Formal Partnership” it was positioned as a majority stake and that they would continue to operate under their own name in Boston–neither of which were mentioned in the Tech Mahindra release. Hmmmm……

Verily she rolls along to Harvard. Luba Greenwood is departing the Alphabet/Google subsidiary to lecture at Harvard and work on several boards. She joined them as head of strategic business development and corporate ventures in February of 2018. She will be lecturing at The Paulson School of Engineering in a joint course with the Harvard Graduate School of Design. Mobihealthnews points out other recent key departures at Verily and a puzzling ‘why it matters’ about educating the next generation of digital health employees on a variety of viewpoints where digital health can lower versus increase costs.

Teladoc has a new COO, David Sides, who is joining from a CEO position at Streamline Health, a revenue cycle management company. The previous COO/CFO left after investors alleged insider trading and an inappropriate employee affair. Cited in Modern Healthcare is Mr. Sides’ experience in international markets, where Teladoc has been expanding through acquisitions. Teladoc announced today increased revenue for 2nd Q but earnings are still in the loss column. Yahoo Finance His position at Streamline is being taken by their chairman, Wyche T. (“Tee”) Green, III who will serve as Interim President and CEO. Release. Streamline is on NASDAQ and trading today at $1.35. 

Speaking of puzzling, JAMA indulges in an editorial around DTC telehealth and the conflict they perceive between convenience it entails and lower-quality patient care. Of course, their definition of telemedicine is primarily around telepharmacy. And like DTC medications, they are concerned about how these companies are appealing and growing. “However, it is clear that the companies want to expand to more complex acute care and disease management; for example, Lemonaid Health has expanded to include laboratory testing. Some companies envision a transformation of their platforms into 1-stop shops for comprehensive care.”

This Editor wonders if JAMA would consider two NHS-approved mental wellbeing services, Good Thinking and My Possible Self, partnering to create a tool to tackle depression, stress and anxiety in London, especially the latter in London.  My Possible Self is part of the DigitalHealth.London Accelerator program. Mobihealthnews

Oral health: more than a public health challenge, an opportunity for telehealth?

Untreated caries in permanent teeth was the most prevalent health condition in 2010, affecting 35% of the global population, or 2·4 billion people worldwide. In 2010, severe periodontitis was the sixth-most prevalent health condition, affecting 10·8% of people, or 743 million, worldwide.

Worldwide in 2015, dental diseases accounted for US$356·80 billion in direct costs and US$187·61 billion in indirect costs.

Is oral health the next big SDH (Social Determinant of Health)? A focus in this month’s Lancet is the neglect of global oral health. Most of our Readers know that oral self-care can be a challenge with older adults due to physical limitations, finances, and access, but oral  and periodontal disease affects nutrition, is a source of pain, tooth loss, consequent low self-regard, low quality of life, and can lead to other diseases such as sepsis and undiagnosed cancers.

The Lancet’s two articles, Oral diseases: a global public health challenge and Ending the neglect of global oral health: time for radical action (open access, registration required on these links) point out the current allopathic model does not fit the wider societal need,  and come down hard on the social and economic origins (very hard on Western dental practice, the sugar industry, and food providers). However, the articles are light on solutions other than universal health care and community based dental practice. Even in less-developed countries like India and Brazil, practitioners don’t migrate to poor, rural areas. It is true, however, that much of dentistry, at least in the US, has an increasing focus on cosmetic restoration.

Here is a wide-open area for telehealth development. Some areas to explore:

  • Creating wider access to dentistry that treats immediate problems
  • Greater access to proactive dental care, whether dental checkups and to encourage better self-care
  • Connecting rural fixed or mobile clinics staffed by technicians or locally trained staff with dentists for remote screening and scheduling care. 

Hat tip to Leah at The TeleDentists for these articles. The articles are also attached as PDFs here and here.

News roundup: docs dim on AI without purpose, ‘medtail’ a mall trend, CVS goes SDH, Kvedar to ATA, Biden ‘moonshot’ shorts out, and Short Takes

Docs not crazy about AI. And Dog Bites Man. In Medscape‘s survey of 1,500 doctors in the US, Europe, and Latin America, they are skeptical (49 percent-US) and uncomfortable (35 percent-Europe, 30 percent-Latin America). Only 20 percent fess up to actually using an AI application, and aren’t crazy about voice tech even at home. Two-thirds are willing to take a look at AI-powered tech if it proves to be better than humans at diagnosis, but only 44 percent actually believe that will happen. FierceHealthcare

This dim view, in the estimation of a chief analytics and information officer in healthcare, Vikas Chowdhry, is not the fault of AI nor of the doctors. There’s a disconnect between the tech and the larger purpose. “Without a national urgency to focus on health instead of medical care, and without scalable patient person-centered reforms, no technology will make a meaningful impact, especially in a hybrid public goods area like health.” The analogy is to power of computing–that somehow when we focused behind a goal, we were able to have multiple moon missions with computing equivalent to a really old smartphone, but now we send out funny cat videos instead of being on Mars. (And this Editor growing up in NJ thought the space program was there to market Tang orange drink.) HIStalk.

Those vacant stores at malls? Fill ’em with healthcare clinics! And go out for Jamba Juice after! CNN finally caught up with the trend, apparent on suburbia’s Boulevards and Main Streets, that clinics can fill those mall spots which have been vacated by retail. No longer confined to ‘medical buildings’, outpatient care is popping up everywhere. In your Editor’s metro area, you see CityMDs next to Walmarts, Northwell Health next to a burger spot, a Kessler Health rehab clinic replacing a dance studio, and so on. The clever name for it is ‘medtail’, and landlords love them because they sign long leases and pay for premium spots, brighten up dim concourses, and perhaps stimulate food court and other shopping traffic. Of course, CVS and Aetna spotted this about years ago in their merger but are working expansion in the other direction with expanding CVS locations and on the healthcare side, testing the addition of social determinants of health (SDH) services via a pilot partnership, Destination: Health with non-profit Unite Us to connect better with community services. This is in addition to previous affordable housing investments and a five-year community health initiative. Forbes, Mobihealthnews

ATA announces Joseph Kvedar, MD, as President-Elect. Dr. Kvedar was previously president in 2004-5 and replaces John Glaser, PhD, Executive Senior Advisor, Cerner. He will remain as Vice President of Connected Health at Partners HealthCare and Professor of Dermatology at Harvard Medical School. A question mark for those of us in the industry is his extensive engagement with October’s Connected Health Conference in Boston, one of the earliest and now a HIMSS event. ATA’s next event is ATA2020 3-5 May 2020 in Phoenix–apparently no Fall Forum this year.

The Biden Cancer Initiative has shut down after two years in operation. This spinoff of the White House-sponsored ‘moonshot’ initiative was founded after the death of Beau Biden, son of Democrat presidential candidate Joe Biden. Both Mr. Biden and wife Jill Biden withdrew due to ethics concerns in April. According to Fortune, the nonprofit had trouble maintaining momentum without their presence. However, the setup invited conflict of interest concerns. The Initiative engaged and was funded by pharmas and other health tech companies, directly for Initiative support but mainly for indirect pledges to fund research. Most of these organizations do business with Federal, state and local governments. Shortly after the formal announcement, Mr. Biden the Candidate announced a rural health plan to expand a federal grant program to include rural telehealth for mental health and specialized services. Politico   But isn’t that already underway with the FCC’s Connected Care Pilot Program, coming to a vote soon? [TTA 20 June]

And…Short Takes

  • Philips Healthcare bought Boston-based patient engagement/management start-up Medumo. Terms not disclosed. CNBC
  • London’s Medopad launched with Royal Wolverhampton NHS Trust (RWT) in a three-year RPM deal. DigitalHealthNews
  • Parks Associates’ Connected Health Summit will be again in San Diego 27-29 August with an outstanding lineup of speakers. More information and registration here.

And in other news, Matt Hancock holds tight to his portfolio as UK Secretary of State for Health and Social Care in the newly formed Government under new PM Boris Johnson. Luckier than the other 50 percent!

 

 

Call9: we’ll be back — with a different model!

“It wasn’t viable in the way that we did it,” Peck said. “We were very far ahead of the curve.”

Call9‘s founder, Tim Peck, MD, interviewed by local business publication Crain’s New York Business, shed a bit more light on the company’s planned reorganization as Call9 Medical. According to Dr. Peck, Call9 Medical will be in a much larger network of nursing homes and add primary care physicians to its services. The reopened company will be backed by its Silicon Valley lender, Western Technology Investment, which apparently forced the closing issue when the company’s cash on hand fell below the amount lent by WTI. No timing for resumption was given.

In the interview, Dr. Peck returned to reasons why the Call9 original model did not work. Insurers would pay for fee-for-service based telemedicine visits in nursing homes but not pay on their operating concept of fewer hospitalizations and better health outcomes that saved money, which had a longer-term payoff. 

Apparently this led to a standoff with controlling (over 50 percent) funder Redmile, which encouraged the FFS revenue stream. “We had to do services in a particular way that in no way brought value to our model,” Peck said. The ‘change in funders’ as noted in TTA’s article on the shutdown now is in a fuller context; Redmile will not be participating in the repositioned company. Confirmed in the article is that a few former investors, WTI, and some former employees will be part of it.

In this Editor’s view, Call9 had trouble accommodating both payment tracks, perhaps because they were overly invested in their concept. In the real world, it seems odd in a company of this size and investment level, which at one point employed close to 200 people and was about 100 at shutdown. Young companies, if anything, learn to be flexible when it comes to getting profitable cash flow into the exchequer, including standing their ground against ‘pilot-itis’–especially when their major investors encourage it.

One of their earliest customers also warned them of another flaw in their model. The author interviewed the CEO of one of Call9’s earliest clients, ArchCare, a Catholic nonprofit LTC organization in New York. ArchCare was able to “get its patients’ hospitalization rates low enough on its own that paying the startup no longer made sense.” “Their model wasn’t able to move the needle sufficiently to justify the ongoing expense,” CEO Scott LaRue explained. 

One hopes that Call9 Medical will avoid those pitfalls in being too far ahead of the curve and recast their telemedicine model to improve health outcomes for our most frail, vulnerable, and poorly served. Hat tip to HIStalk.

Health tech bubble watch: Rock Health’s mid-2019 funding assessment amid Big IPOs (updated: Health Catalyst, Livongo, more)

Updated for IPOs and analysis. The big time IPOs add extra bubbles to the digital health bath. Rock Health’s mid-year digital health market update continues its frothy way with a topline of $4.2 bn across 180 deals invested in digital health during the first half of 2019. 2019 is tracking to last year’s spending rate across fewer deals and is projected to end the year at $8.4 bn and 360 deals versus 2018’s $8.2 bn and 376 deals.

This year has been notable for Big IPOs, which have been absent from the digital health scene for three years. Exits come in three flavors: mergers and acquisitions (43 in their count so far), IPOs, and shutdowns (like Call9). IPOs are a reasonable outcome of last year’s trend of mega deals over $100 million and a more direct way for VCs to return their money to investors. So far in 2019, 30 percent of venture dollars went to these mega deals. (Rock Health tracks only US digital health deals over $2 million, so not a global picture.)

Reviewing the IPOs and pending IPOs to date:

  • Practice intake and patient management system Phreesia closed its NYSE IPO of 10.7 million shares at $18 per share on 22 July. The company earned approximately $140.6 million and the total gross proceeds to the selling stockholders were approximately $51.6 million for a value over $600 million. The market cap as of 26 July exceeded $949 million with shares rising past $26. Not bad for a company that raised a frugal $92.6 million over seven rounds since 2005.  Yahoo Finance, Crunchbase
  • Chronic condition management company Livongo’s picture is frothier. Their 22 July SEC filing has their IPO at 10.7 million shares at $24 to $26 per share offered on NASDAQ. This would total a $267.5 million raise and a $2.2 bn valuation. This is a stunning amount for a company with reportedly $55 million at the end of its most recent reporting period, increasing losses, and rising cash burn. Livongo raised $235 million since 2014 from private investors. Crunchbase 
  • Analytics company Health Catalyst’s IPO, which will probably take place this week on NASDAQ with Livongo’s, expects to float 7 million shares. Shares will be in a range of $24 to $25 with a raise in excess of $171 million. Their quarterly revenue is above $35 million with an operating loss of $9.8 million. Since 2008, they’ve raised $377 million. IPO analysts call both Livongo’s and Health Catalyst’s IPOs ‘essentially oversubscribed’. Investors Business Daily, Crunchbase
    • UPDATE: Both Livongo and Health Catalyst IPOs debuted on Thursday 25 July, with Livongo raising $356 million on an upsized 12.7 million shares at $28/share, while Health Catalyst’s 7 million shares brought in $182 million at $26/share.  Friday’s shares closed way up from the IPOs Livongo at $38.12 and $38.30 for Health Catalyst. Bubbly indeed! Investors Business Daily, Yahoo Finance
  • Change Healthcare is also planning a NASDAQ IPO at a recently repriced $13 per share, raising $557.7 million from 42.8 million shares. With the IPO, Change is also offering an equity raise and senior amortizing note to pay off its over $5 bn in debt. The excruciating details are here. Investors here are taking a much bigger chance than with the above IPOs, but the market action above will be a definite boost for Change.
  • Connected fitness device company Peloton, after raising $900 million, is scheduled to IPO soon after a confidential SEC filing. (UPDATED–Ed. Note: Included as in the Rock Health report; however this Editor believes that their continued inclusion of Peleton in digital health is specious and should be disregarded by those looking at actual funding trends in health tech.) Forbes

Rock Health itself raised the ‘bubble’ question in considering 2018 results. Their six points of a bubble are:

  1. Hype supersedes business fundamentals
  2. High cash burn rates
  3. High valuations decoupled from fundamentals
  4. Surge of cash from new investors
  5. Fraud or misuse of funds
  6. Unclear exit pathways

This Editor’s further analysis of these six points [TTA 21 Jan] wasn’t quite as reassuring as Rock Health’s. As in 2018, #2, #3, and #6 are rated ‘moderately bubbly’ with even Rock Health admitting that #2 had some added froth. #3–high valuations decoupled from fundamentals–is, in this Editor’s experience, the most daunting, as as it represents the widest divergence from reality and is the least fixable. The three new ‘digital health unicorns’ they cite are companies you’ve likely never heard of and in ‘interesting’ but not exactly mainstream niches in health tech except, perhaps, for the last: Zipline (medicine via drone to clinics in Rwanda and Ghana), Gympass (corporate employee gym passes), and Hims (prescription service and delivery).

Editor’s opinion: When there are too many companies with high valuations paired with a high ‘huh?’ quotient (#3)–that one is slightly incredulous at the valuation granted ‘for that??’–it’s time to take a step back from the screen and do something constructive like rebuild an engine or take a swim. Having observed or worked for companies in bubbles since 1980 in three industries– post-deregulation airlines in the 1980s, internet (dot.com) from the mid-1990s to 2001, first stage telecare/telehealth (2006-8), and healthcare today (Theranos/Outcome Health), a moderate bubble never, ever deflates–it expands, then bursts. The textbook #3 was the dot.com boom/bust; it not only fried internet companies but many vendors all over the US and kicked off a recession.

Rock Health also downplayed #5, fraud and misuse of funds. It’s hard to tell why with troubles around uBiome, Nurx, and Cleo in the news, Teladoc isn’t mentioned, but their lack of disclosure for a public company around critical NCQA accreditation only two months ago and their 2018 accounting problems make for an interesting omission [TTA 16 May]. (And absurdly, they excluded Theranos from 2018’s digital health category, yet include drones, gym passes, connected fitness devices…shall we go on?)

Rock Health’s analysis goes deeper on the private investment picture, particularly their interesting concept of ‘net liquidity overhang’, the amount of money where investors have yet to realize any return, as an indicator of the pressure investors have to exit. Pressure, both in healthcare and in early-stage companies, is a double-edged sword. There’s also a nifty annual IPO Watch List which includes the five above and why buying innovation works for both early-stage and mature healthcare companies. 

(Editor’s final note: The above is not to be excessively critical of Rock Health’s needed analysis, made available to us for free, but in line with our traditionally ‘gimlety’ industry view.)

The CVS-Aetna merger hearing draws to a dreary, weary close

The train is moving so slowly on the tracks that even Pauline is getting some shut-eye. The minimal coverage given to last Wednesday’s hearings in the Court of Judge Richard Leon on the CVS-Aetna merger is understandable, as the hearing trod the well-worn path without a hint of when this will all Wind Up:

  • The Department of Justice argued that the concerns over the merger were settled via divestiture of its pharmacy benefit management (PBM) operation
  • The amici curiae witnesses (AIDS Healthcare Foundation (AHF), the American Medical Association (AMA), Consumer Action and U.S. PIRG) countered that it’s nowhere near enough, that the PBM competition represented by a new company would not be enough and higher drug prices would result.
  • Anything said by the DOJ attorneys or the ability to call more witness after the earlier hearing was derided by Judge Leon as “phantasmagorical,” “violating the first rule of holes”, and typified by the generally favorable to the judge Columbus Dispatch as “scolding”.

This Editor found no mention of the five states–California, Florida, Hawaii, Mississippi, and Washington–which were supposed to participate in the hearing to support the DOJ position [TTA 17 June]. One has to presume that they were not very vocal or permitted to be so.

Instead much was made of the judge’s interest in the AIDS Healthcare Foundation (AHF) remedies targeting relief for specialty and community pharmacies:

  • All rival pharmacies should have non-discriminatory access to CVS Caremark’s pharmacy networks at fair reimbursements that cover actual drug costs and dispensing costs.
  • Managed care plans should not be denied access to CVS Pharmacy networks, and that managed care plans’ access should be at a fair price.
  • All Aetna plan members must be allowed to opt out of any CVS/Caremark specialty or other mail order programs.

So the hearings wind down, with increased speculation that Judge Leon will simply disallow the merger sometime in the future, which will set up another round of court actions by the merged organizations on the merits and whether the Tunney Act can even be used in this way. And meanwhile, online pharmacies like PillPack scoop up the cream off CVS Caremark’s business. Healthcare Dive, Yahoo News.

Care Technology Landscape Review: Socitm Advisory for Essex County Council (UK)

A independent report on the UK care technology market was released earlier this month which has both UK and international implications. Commissioned by Essex County Council and produced by Socitm Advisory, it is must reading for those engaged in the procurement and development of local care technology. In a wider sense, the study is part of a larger international trend around community-based health and wellbeing, data utilization and digital tools to promote self-care, mitigate acute illness, and better management of chronic conditions, including social determinants of health (SDH). Digital tools are integrated into care and measured on enabling outcomes, versus being ends in themselves as they tend to be today.

The envisioned emerging care technology solutions framework looks like this: Adrian Scaife of Alcuris Ltd was kind enough to send a link and review copy of this study to this Editor, the link which we are pleased to provide to our Readers. (Download it from Socitm’s website.) He has written a blog post in HousingLIN, Is it time for the next generation of telecare?, which provides a more detailed analysis of the 52-page study and its implications. 

‘Ask Alexa’ if you’re sick, says the NHS

The latest in the NHS’ ‘digital first’ effort in the Long Term Plan is to add Amazon Alexa’s voice search capability to the NHS’ online advice service. Using Amazon’s search algorithm, UK users will be able to ask Alexa about their scratchy throat, sneezing, flu symptoms, or headache with information sourced from the NHS website. In the announcement, Secretary of State for Health and Social Care Matt Hancock said that “We want to empower every patient to take better control of their healthcare and technology like this is a great example of how people can access reliable, world-leading NHS advice from the comfort of their home, reducing the pressure on our hardworking GPs and pharmacists.” 50 million GP consultations each year are estimated to be unnecessary; the NHS is actively campaigning for patient awareness on self-care to reduce the patient load on practices (GP). NHSX is also planning of making more NHS services available to all patients through digital technology. 

Physicians have expressed concern that what seems to be a minor symptom could be the start of something big, like an underlying illness. For instance, heart rate monitors which are present in smartwatches and gym equipment have driven many to their doctor because of normal heart rate fluctuations, but that visit could be also picking up the early symptoms of atrial fibrillation.

The Alexa voice assistant adoption by the NHS makes search information more accessible for those with limited mobility or sight, which can help them feel more connected and enhance safety. It also assumes that internet is both available, affordable, and understandable by these users.

This Editor wonders if Alexa will have an emergency feature which calls for assistance or to a GP if the user indicates a worsening condition or is in distress. Voice recognition, as Readers know, is imperfect; Alexa may be puzzled by regional accents, phrasing, or speech impediments.

Current estimates on voice search fluctuate. The oft-repeated ’50 percent by 2020′ assumes an accuracy in digital voice recognition and Alexa/Echo/Android/Siri usage and sales that at this stage are simply not there. An excellent discussion of the voice search market that cuts through the hyped-up predictions is by Rebecca Sentance on the eConsultancy website.

More on NHS and Alexa: Telegraph, Wired UK

Another round this Wednesday in the CVS-Aetna merger hearings

This time, five states are speaking up loudly. California, Florida, Hawaii, Mississippi, and Washington petitioned the DC Federal District Court’s Judge Richard L. Leon for a hearing on the CVS-Aetna merger, which will be held this Wednesday 17 July. The five states were original supporters of and advisory participants in the Department of Justice’s (DOJ) settlement with Aetna to sell its Medicare Part D business. As co-plaintiffs, the states’ regulators are defending their position that the sale would avoid harmful horizontal market concentration.

Both Judge Leon and the American Medical Association debated in June whether the divestiture of Part D was enough to ensure competition in Part D, since both maintained that WellCare Health Plans was too small to compete with CVS Caremark as a pharmacy benefits manager. Yet WellCare is being acquired by larger Centene, another government-sponsored health plan organization, in a transaction expected to close, pending Federal and state approvals, in 1st Quarter 2020. That merger weakens that argument.

While publications like Barron’s and the New York Post consider it a foregone conclusion that Judge Leon will, after he runs out of hearings, nix the merger [TTA 13 June], whether he actually can under the Tunney Act (1974) is debatable. The Tunney Act has been rarely invoked to stop a merger–especially a merger which is about half-done and a sale transaction which is an important part of the value of the acquiring company in its own acquisition.

The Hartford Business Journal makes the excellent point that every time the industry thinks Judge Leon’s hearings are wrapping up, they continue. This Editor will be surprised if there are any bombshells from this round. On to the next!