Friday, November 4, 2016

Health Wonk Review is up at Wright on Health

Can’t stomach any further discussion of the election? Then unless you’re a Chicago Cubs fan you should probably steer clear of the Health Wonk Review: Game 7 of Politics Edition, hosted by Wright on Health. But if you’re up for it, there’s a good rundown of presidential related posts plus a few, like mine, that have (almost) nothing to do with the campaign.



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Thursday, November 3, 2016

TytoCare: Comprehensive telehealth exam platform

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TytoCare hopes to take telehealth to the next level by providing a solution that allows clinicians to conduct remote examinations. Patients (or caregivers) will use a TytoCare device to conduct an exam that can be interpreted by a physician over a cloud-based platform with video conferencing.

The company took a step forward recently by obtaining FDA clearance for its digital stethoscope. The approach looks pretty cool, but clearly it will be a challenge to get the devices out to patients ahead of need and to do so cost effectively.

CEO & Co-Founder Dedi Gilad answered my questions via email:

1. What was the inspiration for Tyto?

I founded TytoCare along with Ofer Tzadik, another lifelong leader in Healthcare IT, in 2012. The story is similar to that experienced by most families when at a young age, my daughter suffered from a series of earaches requiring constant medical treatment. With two working parents, it became increasingly difficult to travel in and out of the local physician’s office on a regular basis. The experience was not easy for my daughter either, waiting for hours in the crowded doctor’s office in considerable pain and discomfort. 

After consulting with my pediatrician, I recognized the strong need for change in the way primary care is delivered today. I collaborated with Ofer Tzadik to design a new medical experience, one that would not only mutually benefit both the doctor and the patient, but also serve to strengthen this vital relationship. The result of this endeavor is TytoCare, a company prepared to lower the load and cost of U.S. healthcare services, improve accessibility to healthcare services even from the comfort of home, and reshape day-to-day healthcare as we know it.

2.      Why a dedicated device instead of using a tool everyone already has, i.e., a smartphone?

 TytoCare’s examination tools and complete telehealth platform work with a smartphone or tablet and include a stethoscope, otoscope, tongue depressor, camera, and thermometer. While a smartphone can only offer video and audio technology, Tyto enables the patient to conduct actual exams of the heart, lungs, heart rate, temperature, throat, skin and ears. This cannot be done with video alone and more importantly, it requires an interface and technological infrastructure that simply wouldn’t be cost effective in a smartphone.

 3.    How will distribution to end users work? It seems like logistics will be difficult. For example, do you expect everyone to have a device in place before they need it?

 To begin, distribution will start with health institutions though a full consumer product is coming in 2017. We expect that consumers will see the value in being able to perform live, remote medical examinations at home, in place of rushing back and forth to the doctor’s office. 

 4.  What is the cost of the home and pro solutions?

 TytoPro will cost $999.00 plus a monthly fee based on usage, and TytoHome will cost $299.00.

5.  More broadly, what are the overall economics of the solution? Is there a financial return on investment? How do you think about calculating that? Is it more appropriate for certain segments of patients or providers?

Certainly, and our work with leading financial institutions has reinforced the financial ROI.

 The incredible benefit of the product is that its applications are endless because it simultaneously empowers doctors and clinicians while unlocking the full benefits of telehealth for patients. TytoHome can be beneficial in many different scenarios – for geographically isolated patients and those who lack easy access to medical facilities; those who are turning to urgent care because they cannot get an appointment in time at their regular establishment; patients with chronic illnesses or other conditions that require monitoring and frequent, tiresome trips to the doctor or hospital; school or traveling nurses; and of course, parents at home with kids.

 6. What is the lifecycle for this solution? Do you expect to upgrade the devices over time? Can that be done through software or will it require hardware to be replaced?

We will likely add additional examination capabilities over time, but the majority of upgrades can be made through software updates.

 7. What else should readers know?

TytoCare is a complete end-to-end telehealth platform that provides a telehealth experience comparable to in-person visits. It truly fills the missing link in telehealth between the in-office professional and the at-home patient by delivering comprehensive exam results – of the ear, nose, throat, heart, lung, stomach, skin – as part of a complete telehealth visit. The exam data can be delivered to a clinician via “live telehealth exams” or through the “exam and forward” function – sending the exam results on to be examined by the clinician later.

 TytoCare can be used anytime, anywhere and by anyone. Patented guidance technology directs and enables anyone to collect the right data so a clinician can make the proper diagnosis. The advanced digital exam tools use clinic-grade technology to capture high resolution images and sounds, allowing for more kinds of remote diagnoses and increased accuracy.

The secure cloud-based platform enables integration with existing HER systems and provides analytics for decision support with health alerts. TytoCare offers HIPAA compliance, and the modular product design also supports open APIs so other examination devices can be integrated within TytoCare.


By healthcare business consultant David E. Williams, president of Health Business Group.

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Tuesday, November 1, 2016

PCSK9 experience shows drug market isn’t completely broken



Why isn’t this thing growing?

Everyone knows that the market mechanisms that make most of the US economy efficient are lacking in healthcare. That’s especially true for pharmaceuticals, where drug companies can raise prices at will, and only the government can step in with price controls to put things right. At least that’s what we’ve been hearing in the press and on the campaign trail for the last year or more.

So I read with interest a recent STAT article These pricey cholesterol drugs aren’t selling. And that has the biotech industry sweating, about how the market is blocking high-priced drugs –and preventing pharma companies from doing all the things we’ve been told they can do at will.

No one disputes that the new drugs, Repatha and Praluent, are excellent at lowering bad cholesterol, or LDL. They often succeed where the traditional treatment — an inexpensive class of drugs called statins — fails. The problem boils down to doctors who are reluctant to write prescriptions, insurers who are unwilling to pay for them, and drug companies that have failed to understand a fast-changing marketplace.

The failures could send a chill through the still-booming biotech business, which relies on the idea that the risky, expensive process of developing new drugs can one day pay off big.

Contrary to the views expressed in the STAT article, I think the market is actually doing an ok job here. There are two main reasons why the drugs haven’t sold well:

  • First and foremost, while they are proven to lower cholesterol they are not proven to reduce heart attacks or strokes or to lower death rates
  • Second, most patients do just fine with generic statins, which are inexpensive and have a long track record, compared with the new drugs that have list prices of about $14,000 per year

The result is that doctors who want to prescribe the drugs have to jump through a lot of hoops to get insurance company approval. That’s a hassle and it’s expensive and time consuming, so I sympathize. But by the way, before we get mad at the PBMs and insurers, consider that the experience for prescribers might not be that different under a fully capitated payment model since health system administrators would still be worried about their budgets.

The companies that make these drugs are conducting studies of the impact on outcomes that people really care about: heart attack, stroke, death. If they demonstrate that the drugs are effective on these measures, they will have no problem generating prescriptions or charging premium prices –at least in the United States.

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By healthcare business consultant David E. Williams, president of Health Business Group.




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Monday, October 24, 2016

Why I’m voting against marijuana legalization in Massachusetts


I’m not dead set against the eventual legalization of marijuana for recreational use. Still, I’m strongly opposed to Massachusetts ballot question 4: Legalization,  regulation and taxation of marijuana, and will be voting No.

Why? Because the arguments in favor of approval are not strong enough to make Massachusetts one of the first states to legalize. And some of the arguments against the ballot measure raise serious concerns. Instead I’d like to take five years or so to observe  how things go in early-legalization states like Colorado and Oregon and apply the lessons in Massachusetts.

I thought Massachusetts did the right thing by de-criminalizing marijuana. That kept police and the courts from wasting resources on possession of small amounts of marijuana and stopped lives from being ruined through unfair imprisonment and the stigma of  a criminal record.

Voters then went further and approved medical marijuana, which as I expected, became a precursor to the push for full legalization just a couple years later.

The innovative Citizens’ Initiative Review Project summarized the pros and cons of Question 4. The strongest pros were as follows (quoted verbatim):

  • Legalized and regulated marijuana is safer than black market marijuana because the legalized product will be tested and clearly labeled according to state regulations.

  • Question 4 will create a large number of regulatory, law enforcement, legal, and licensure jobs that are supported by taxes on the sale of marijuana.

  • Question 4 would give patients and health providers ready access to marijuana without committing a crime. Legalization could help people avoid opiates, addiction and worse problems. 

The first point is accurate, however there is an implicit assumption that legalization will eliminate the black market. Colorado’s experience indicates that the black market may continue to thrive alongside the regulated, legal market, and that the official market is the province of middle and upper class white people, while the poor and minorities are priced out. So that’s not such a strong argument.

On the second point, it’s weird that one of the strongest arguments for a libertarian-oriented law would be to create large numbers of government jobs. That’s a terrible rationale as far as I’m concerned.

On the third point, there is already ready access to medical marijuana for patients and health care providers, thanks to the legalization of medical marijuana. There are some hints that people may be substituting marijuana for opiates. That’s probably a good thing and we should follow it closely.

The strongest “con” arguments from the Review Project include the views I expressed above about the black market and large number of new government jobs. The cons include two additional, compelling points:

  • Although in development, at this time there is no definitive method of testing for impaired drivers.

  • There is conflicting evidence of an increase in teen use or motor vehicle accidents in states that have legalized recreational use.

Beyond the Review Project’s findings, there are other good arguments against legalization. Marijuana is addictive for some people, it affects the developing brain in negative ways, and “edibles” are too easy for kids to get ahold of and to consume before or during school.

Please join me in rejecting Question 4 in Massachusetts in this election. If you do, I promise to be open minded about reviewing my stance in a few years, once evidence is in from other states.

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By healthcare business consultant David E. Williams, president of Health Business Group.


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Friday, October 21, 2016

Health Wonk Review is up at Health System Ed

Health System Ed hosts the election edition of the Health Wonk Review, where healthcare bloggers do their very best to keep democracy alive. This edition leads off with a set of opportunities for bi-partisan cooperation in healthcare. Amen to that!

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Thursday, October 20, 2016

The case for healthcare cooperation with Cuba


I learned quite a bit from a brief Perspective in the New England Journal of Medicine (The United States and Cuba –Turning Enemies into Partners for Health).

A June Memorandum of Understanding (MoU) between the US Department of Health and Human Services and the Cuban Ministry of Public Health lays out a wide variety of areas for cooperation, including infection diseases like Zika, plus cancer and chronic conditions.

Thanks to the embargo, products developed in Cuba aren’t available in the US because they are not allowed into the FDA approval process. As a result, certain drugs like Heberprot-P, to reduce amputation risk for diabetic foot ulcers, aren’t available in the US even though they are on the market in many other countries.

We don’t need to copy the Cuban health system, but there are some lessons to be learned from Cuba’s experience with population health, community-based programs, disease control, and chronic care management.

It isn’t possible to fully implement the MoU now, because the embargo remains in place and only Congress can lift it. If Democrats take control of Congress, that could happen soon. If not, the author argues that the President has the authority to allow Cuban products into the US regulatory process just like products from any other country. He’d also like to see the President allow US students to attend medical school in Cuba, where some have been offered scholarships.

These all sound like good ideas to me and I hope they are implemented.

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By healthcare business consultant David E. Williams, president of Health Business Group.

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Tuesday, October 11, 2016

Mass Health Quality Partners: 21 years young


Barbra Rabson, MHQP President and CEO

Health Business Group is a sponsor of the upcoming anniversary party for Massachusetts Health Quality Partners (MHQP). I asked MHQP’s President, Barbra Rabson to reflect on the first couple decades.

MHQP is about to celebrate its 21st anniversary. What are you celebrating?

We are celebrating the courage and vision it took 21 years ago to found MHQP, and the amazing two decades of progress we’ve made since our inception. Our 21st anniversary is symbolic of our coming of age and reaching a level of maturity. MHQP has become an important part of the Massachusetts healthcare landscape over the decades thanks to the commitment and hard work of our diverse stakeholders – including patients, physicians, hospitals and payers.  More than 40 sponsors and over 300 people are gathering on November 2 to celebrate MHQP’s unwavering commitment to reliable healthcare measurement and transparency and our pioneering work in the Commonwealth and the nation to systematically capture the patient voice and integrate it into care improvements.

At our anniversary celebration we will be honoring the vision of MHQP’s Founding Circle –Blue Cross Blue Shield of MA, Fallon Health Plan, MA Business Roundtable, MA Hospital Association (MHA), MA Medical Society (MMS), Harvard Pilgrim Health Care (HPHC), Tufts Health Plan and the State (Governor Charlie Baker was a founding member of MHQP when he was Secretary of Administration and Finance).

We will also be awarding MHQP’s first award in honor of the late Richard Nesson, MD, a founding visionary of MHQP when he was the Chair of the MHA Board in 1995 when MHQP was established.  We are delighted that Susan Edgman-Levitan, the executive director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital and the founding president of the Picker Institute will be the first recipient of MHQP’s H. Richard Nesson Award.

How has the environment changed in MA over the past 21 years? What role has MHQP played in that?

The healthcare environment is drastically different than it was when MHQP was founded in 1995.  When MHQP first started collecting and reporting comparative statewide performance information, we were the only game in town.  For example, MHQP’s first in the nation statewide patient experience survey of acute care hospitals and public release came a full decade before CMS developed the hospital H-CAHPs survey! Likewise, when MHQP began collecting and reporting statewide clinical and patient experiences measures for ambulatory care, MHQP’s data was the only reliable source for quality benchmarks for our provider organizations.  Before MHQP’s comparative quality reports, Massachusetts provider organizations only knew their own performance scores, they had no comparative benchmarks or best practices to drive performance improvements.  Physician leaders  (Barbara Spivak, Tom Lee and others) have told us MHQP’s performance reports were invaluable to them because our reports became the writing on the wall that they needed to make significant investments in their organization in the form of electronic health records and quality improvement infrastructure to advance their performance to the level they aspired to.

Another big change is that our reimbursement systems now provide millions of dollars of incentives for provider organizations to improve performance.  When MHQP first started the term ‘pay-for-performance’ had not yet been coined.  MHQP has always [encouraged] improvements through public reporting of reliable and trusted comparative performance information – relying on physicians’ intrinsic motivation to perform as well as they can. Now that provider compensation depends heavily on measurement we need to work harder to make sure we have accurate and fair measurements of quality care.

Finally, back in 1998 when MHQP first starting reporting on patient experiences of care, patient experience was not considered a core measure of quality.  MHQP’s statewide collection and reporting of patient experience helped draw national attention to the importance of listening to patients, and in 2001 the IOM introduced the concept of patient centered care as a key element of quality care in the Crossing the Quality Chasm Report.

Kindred organizations to MHQP have arisen around the country over the last couple decades. How do you relate to them?

MHQP was one of the first regional health improvement collaboratives (RHICs) to be founded in the country. Gordon Mosser (founding CEO of ICSI in Minnesota) and I organized the first meeting of regional collaboratives in 2004.  As a founding member and past Board chair of NRHI (the Network for Regional Healthcare Improvement), it has been very gratifying to see so many new RHICs being established.  There are now more than 40 across the country.  I have been told by many of the younger RHICs that MHQP was a role model for them when they were first starting out, and I take great pride in that.

What does the future hold?

Great question, and one I have been reflecting on as we have been looking back on our first 21 years. One of the biggest challenges (and one of our greatest failures as a health care system) has been that we have not done a good job engaging our patients as a resource to help us improve outcomes. In many cases we have actively refused to seek input from patients, and when given feedback we have ignored it.  We are now trying to make a 180 degree shift on this, to better engage patients in the co-production of solutions, and it is not easy because it requires a shift in mindset.  I believe that MHQP’s two decades of experience capturing the patient voice and integrating that voice into care improvements positions us extremely well to support our practices and healthcare systems as they embark on this journey.


By healthcare business consultant David E. Williams, president of Health Business Group.

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