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The Health Care Hype Cycle: Which New Trends in Health Care Offer True Promise?

-Jonathan Wakim, MS1-

At the Wharton Healthcare in Business Conference on 2/14, Investor panelists Ali Behbahani, Nancy Brown, Marty Felsenthal, and Harel Gadot shared their experiences working on the frontiers of health care investing to examine whether headline-grabbing trends such as value-based care, digital health, and medical robotics hold true promise for improving our health care ecosystem.

Below are some of our high-level takeaways from their discussion.

Value-Based Healthcare

  • Currently, there is a thin smear of quality measures that is present at most healthcare organizations and until these measures become widespread, value-based care is not truly implementable.
  • The investors commented that from a life sciences perspective, an existing belief is that if a drug improves the standard of care, the system will find a way to pay for it and therefore value-based care has yet to penetrate that space.
  • Behbahani gave his med-tech perspective and mentioned the terminology is more holistic. He noted that one product cannot bring radical change to an entire procedure’s value chain. From an investor’s viewpoint, one must look at how a physician, hospital, and payer can benefit.

Tech Company (Amazon, Google) Involvement in Healthcare

  • As far as major tech company involvement, the investors believe the only real potential problems lie within privacy issues. 
  • These companies will not displace the need and utility of focused healthcare companies that serve vital purposes. 
  • The investors discussed the value of the tech companies in supplying valuable analytics on the front end and providing engagement to customers on the back end. They can contribute to supporting the development of a full care management platform.

Disruptions to Healthcare Based on Upcoming Elections

  • Investors seemed to agree that they don’t see “Medicare For All” being implemented anytime soon, as Medicare Advantage is growing and here to stay.
  • They believe the ACA unleashed a lot of innovation around mechanisms to attain affordability and access.
  • Overall, elections won’t affect investment strategies because as an investor you look further down the line. Investors maintain awareness of what is going on, but the political climate does not sway their decision-making process.

Our Conclusions and Takeaways

Based on the panel, it seems as if there is discord between the hype portrayed by media sources on the future of healthcare and what the investors believe are the true value drivers within the market. Value-based care is the paradigm shift that we idealize in healthcare. However, until quality measures are readily accessible and standardized across institutions it stands as a far-off goal. The panelists believe that big tech company interventions are beneficial for the market overall, as it spurs innovative thinking and provides analytic firepower to push forward digital health. Lastly, it seems as if the political chatter that is on everybody’s mind does not phase the investing ideologies of the panelists – they believe that their long term thinking surpasses any policy change that can be made by current candidates. 

Computer to Clinic: The Role of AI in Healthcare

-Sonia Wang, MS1-

Penn HealthX welcomed Dr. Ravi Parikh for our first event of the semester to talk about what all current and future clinicians should be aware of when utilizing a machine learning model in healthcare.

Dr. Parikh is a practicing oncologist and instructor in Medical Ethics and Health Policy at the University of Pennsylvania.

Machine learning is everywhere, like it or not. With applications extending from recommending products based on previous Amazon orders to recommending the next binge-worthy Netflix show, machine learning has become the poster child for technology applications. It’s also making its way into healthcare. Computer models are being developed to make diagnoses based on pathology slides and imaging tests, as well as to process electronic health records to make use of the massive repository of unstructured data.

But as machine learning models enter the healthcare market, Dr. Ravi Parikh cautions us on our ability to apply models to the clinic. Here are the takeaways from his talk.

1. What is machine learning and how does it differ from statistics?

While statistics focuses on trying to figure out a relationship or an inference from data, machine learning is used to make predictions and find patterns. Models fall into two categories: supervised models, where certain outcomes are specified in the data and we rely on the machine to predict the pre-specified outcome, or unsupervised models, where data is fed into the machine and we allow the machine to find patterns on its own. For areas like healthcare, where relationships are complex and not always clear, machine learning presents a unique advantage.

2. We don’t quite know how to use machine learning as of yet.

Although it’s great to have a machine learning model as a useful tool in the clinic, few machine learning algorithms have actually changed the decisions doctors make, according to Dr. Parikh. Machine learning models present a lot of promise, performing better than standard models of care in predicting 10-year cardiovascular complications, for instance. However, translating that to the clinic presents unique problems. For example, a user interface within electronic health records showing model predictions of hospital re-admission must be easy to interpret, or physicians may simply turn off the model display.

Dr. Parikh’s checklist for moving machine learning into the clinic includes:

  1. Using meaningful clinical endpoints.
  2. Benchmarking against meaningful standards (such as physician intuition).
  3. Ensuring that algorithms are generalizable and interoperable.
  4. Clarifying how clinicians should act on predictions.
  5. Auditing performances after training and adjusting the models accordingly.

3. We need to understand and address the problems with AI (i.e. bias).

Algorithms can automate bias because of biased data generation. Machine learning models can perpetuate current biases in data, especially when there is an underlying inequity in healthcare delivery and an intrinsic bias in the data. Incomplete data can lead to inaccurate predictions, giving faulty models that give biased predictions. To address this, it may be better to use unbiased data sources before clinician decision-making or to track outputs continuously and “stress-test” models using simulated datasets to check bias in real-time. Machine learning presents so much potential, but we need to understand the data before we proceed.

Dr. Ali Behbahani – Venture Capital in Medicine (Episode #20)

On the 20th episode of the Penn HealthX Podcast, I sat down with Dr. Ali Behbahani, who led a workshop on “Thinking Like a Venture Capitalist” at our 2017 Penn HealthX Conference.

Dr. Behbahani earned his undergraduate degree in Biomedical Engineering, Electrical Engineering, and Chemistry from Duke University. After graduation, he worked in healthcare investment banking at Lehman Brothers and venture capital at Morgan Stanley Venture Partners. He then attended the University of Pennsylvania, where he earned a dual MD/MBA degree from the University of Pennsylvania School of Medicine and the Wharton School. After graduation, he went to work for New Enterprise Associates, where he is now a partner on the healthcare team.

Here are some key takeaways from the discussion:

1. Don’t be afraid to take time to explore your interests

Dr. Behbahani took an unusual path to medical school. Throughout undergrad, his goal was to attend medical school. As graduation approached, he stumbled across the world of investment banking, where he ended up working. After two years of investment banking, he was accepted to medical school and planned to attend. However, an opportunity to work in venture capital arose, so he deferred his medical school acceptance to take the job. Had he simply taken the straightforward path and gone directly to medical school, Dr. Behbahani might never have known about venture investing. He stressed that it is okay to take a year or two to explore something you love doing, especially early in a career, and that taking such a break set him on his ultimate career path. However, he eventually had to make a decision that did close some doors. While it is possible to balance certain fields like medicine and research, it is challenging to be really good at both clinical medicine and investing. This reality further highlights the value of taking time early in a career to explore various interests – it is much easier than trying to change careers later in life.

2. Venture investing lets him make an impact on a societal level

Working as a physician is an amazing way to impact lives one at a time. However, research and venture capital work together to change the way medicine is practiced, creating change on a societal level. Bringing a novel therapeutic to market requires a large amount of capital, which venture capital can provide. A large part of Dr. Behbahani’s work involves attending conferences and meeting with thought leaders in various fields of medicine. He stays abreast of changes in medical practice, and with each investment into a new field, Dr. Behbahani learns about new diseases and treatment that were not covered in medical school. Thus, his career in venture investing is one of lifelong learning.

3. Venture investing gives insight into the “bleeding edge” of scientific innovation

Dr. Behbahani spends his days evaluating cutting edge medical technology. He splits his work between seeking new investment opportunities, performing due diligence on investments he is considering, and managing companies in which he has made investments. When approaching an investment, he gets much more excited about companies that could change the way medicine is practiced than those that make incremental improvements on what already exists. We are living in an era with a proliferation of nontraditional therapeutics which are changing medicine and helping patients like never before. It is an exciting time to work in venture capital, where he sees therapeutics when they are still in the lab and works to bring them to the clinic.

 

You can learn more about NEA and Dr. Behbahani at NEA’s website, http://www.nea.com/.

– Logan is a second-year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn Health-X in 2017, and is an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –

Alastair Blake – Learning From the U.K Health System (Episode #19)

For our 19th episode of the podcast, Logan and I sat down with Alastair Blake to discuss the U.K health system, and why Alastair is interested in health policy and consulting. Alastair is a British-trained physician who went to Cambridge. He performed his residency in London, and has worked in health policy for the NHS. He is currently a Wharton MBA student, and plans on working full time after graduation with the consulting firm, McKinsey.

Here are a few takeaways from the discussion.

1. There Are Very Few Clinical Voices Representing Physicians and Patients in Government and Industry

One thing Alastair was surprised to find when he was a fellow working with Professor Steven Field was just how few clinical voices there are the higher up you get in government and industry. Even when there were executives and high-ups in government with medical training, they had usually been out of practice for many years, and thus were likely out of touch with the issues of the modern day.

This reminded me of when a cardiology professor told us that he was learning about the Frank-Starling mechanism of the heart in the 60’s when the Beatles came to America. Think about just how long ago many of the current leaders in medicine studied and trained. Many did so before most of the major advancements we’ve seen in terms of drugs and technologies in the last number of decades. It’s important for junior physicians, and students even, to speak up and be a part of the discussion. We are uniquely poised to understand the challenges that come along with modern technologies and how they are impacting medicine and patient care.

2. Contrary to Popular Tropes, the U.K Healthcare System is Neither Perfect, Nor a Disaster

The NHS and the single-payer system in the U.K is often pointed to on both ends of the U.S political spectrum as either an ideal to aspire towards, or a socialistic disaster to avoid at all costs. Obviously, the truth is somewhere in the middle. Alastair believes that the systems of each respective country reflects their values, their history, and politics. There is no one-size-fits all system. Interestingly, the U.K system is actually starting to become more like the U.S system in some respects, and over time the U.S has been creeping towards a more U.K-like system, with the expansion of Medicare and Medicaid.

3. Every System Rations – We Just Do So in Different Ways

The U.K pays way less per-capita on healthcare than the U.S, but there is some rationing that takes place, and often times physicians and hospital systems feel financial pressures, and aren’t able to deliver care exactly as they see fit. There will be tradeoffs in every system – while the U.K rations based on effectiveness of treatments through NICE, we ration in the U.S based on an individual’s ability to pay for their insurance, or their care. Again, it reflects the values of the country, and what we are and aren’t comfortable with as a population.

4. “If you can find money to kill people, you can find money to help people” – Tony Benn

One thing that is notable about how the U.K got to single-payer, is that it was almost entirely based on historical happenstance. Large sweeping changes to something as big as healthcare come very infrequently, and require both a lot of political tact, as well as proper timing when the country is poised for change. For the U.K, this moment was after World War II, when England and London was left in ruins. Many came together and realized, if they could find money during the war to kill other people, why couldn’t they also find money while not at war to help their own people? This video from the movie Sicko features Tony Benn, who used to be a member of Parliament in the U.K. This simple idea has led to a lot of my own personal beliefs on the types of health policies that we should strive to.

A single payer system like in the U.K will not work in the U.S – at least not at the present moment. However, I do believe that in the coming years we will need to asses our values, and what we are an aren’t okay with as a population – the money is there, it’s how we choose to align our values and decide how to spend it. It will take future leadership to help steer the country toward such changes when the opportunities arise, and I hope to be one of those leaders. The only way to be ready to act is to learn now, and – like Alastair – study health systems, and get numerous experiences under our belts. I’m excited to see what happens in the coming years.

– Ryan is a second year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn HealthX in 2017, is the co-host of the Penn HealthX podcast, and founder/editor-in-chief of the Penn HealthX blog. You can contact him at ryan.o’keefe@uphs.upenn.edu –

The Co-Founders of Neuroflow on Start-Ups and Mental Health (Episode #16)

On our 16th episode of the Penn HealthX Podcast, Ryan sat down with Chris Moralo and Adam Pardes, the co-founders of NeuroFlow, a medical device company recently launched out of the University of Pennsylvania.

Chris is a US army veteran who holds an undergraduate degree from the United States Military Academy and an MBA from the Wharton School at the University of Pennsylvania, where he was a student when he co-founded NeuroFlow with Adam. Adam is a bioengineer by training, who is currently on a leave of absence from a PhD program at Penn while he works on NeuroFlow. The two met through the InSITE program at UPenn, where they were brought together by their shared interest in entrepreneurship. To hear more about the NeuroFlow story, check out their website at http://www.neuroflowsolution.com/

In the podcast, Chris and Adam spoke about what they have learned through the process of starting Neuroflow. Here are some key takeaways from the discussion:

1. Think years ahead but act in the moment

One of the biggest challenges of running a startup is balancing the long-term vision with taking the steps necessary to succeed today. Chris and Adam learned through their fundraising that investors that investors cared much more about the problem, the market, and the team than the exact solution. The solution itself is likely to change as the company grows – initially, the goal of NeuroFlow was to create a device to help treat PTSD, but the company has since pivoted and the first product is now a clinical tool to help measure stress levels using validated biochemical markers. While the product itself changed, there was no change in the problem that they were trying to address – the long-term vision remaining the same, but the team changed the specific actions they were taking day-to-day to align with their new game plan.

ptsd_brain1

2. Define a set of values and live by them

In the course of a couple short years, NeuroFlow has grown from an idea shared by Adam and Chris into a team with 15 members working toward a common goal. As the company grew, Adam and Chris had to think carefully about how to align the goals and values of the team. They drew on their past experience, particularly Chris’ time as an officer in the US Army, to establish a set of values for the company. Importantly, they stressed that having a set of values only matters if you truly espouse and live them. Having these values gives the team a shared set of principles to guide their work and to keep pushing hard even when the hours are long.

3. They’ve had a lot of proud moments along the way

Chris, Adam, and the team are hard at work taking Neuroflow from an intriguing idea to a working product. They shared some of their most challenging and their proudest experiences from working on the company. One moment that was simultaneously challenging and proud was when they first hired team members. As Adam and Chris stressed, once they hired a team, that team was relying on them to continue to exist and to succeed. Their team members left comfortable, stable jobs at established companies to work on NeuroFlow, and Adam and Chris feel a sense of responsibility to their employees. Another proud moment that they shared came from seeing the fruits of their labor. Chris described the emotion of the first time a doctor went live with NeuroFlow on a real patient, and the pride that followed from seeing their work in action.

We are excited to follow NeuroFlow as they continue to grow and launch their product. Check them out at www.neuroflowsolution.com.

– Logan is a second-year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn Health-X in 2017, is an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealtphX blog. You can contact him at  john.brock@uphs.upenn.edu –

Aaron Bholé – Drug Pricing and Orphan Drugs (Episode #14)

On the 14th episode of the Penn HealthX Podcast, Ryan sat down with Aaron Bholé, a first-year medical student at the Sidney Kimmel Medical College (SKMC) in Philadelphia.

Aaron graduated from a 3+2 program at Cornell, where he earned an undergraduate degree in neuroscience and an MBA. While at Cornell, he interned with FileVision USA and Northwestern Medicine. At the SKMC, Aaron is a part of an organization called the Physician Executive Leadership program, which is similar to HealthX at Penn. He is also combining his business and medical knowledge through an internship with Militia Hill Ventures in Philadelphia. Aaron holds a specific interest in drug pricing, and Ryan and Aaron delved into the topic during their discussion.

Some key takeaways from the discussion:

1. Prescription drugs cost hundreds of billions of dollars per year

Given the heightened visibility of drug pricing in the media spotlight over the past year, it is not a surprise that drug spending accounts for a substantial portion of healthcare spending. Currently, prescription drugs make up nearly 10% of all healthcare spending in the US, according to the Kaiser Family Foundation. Given that healthcare now costs the United States $3.3 trillion dollars per year, prescription drugs cost Americans over $300BB annually.

2. Specialty drugs receive more news coverage, but generics can also be expensive

Much of the news coverage around drug pricing focuses on extremely expensive specialty drugs, such as Biogen’s Spinraza for spinal muscular atrophy, which will cost $750,000 per patient, generics can also be extremely expensive. While the cost of generics has been declining overall, many drugs have only a single generic manufacturer. As a result, that manufacturer can have significant pricing power. This leads to situations where drugs that have been off patent for decades can see price increases of hundreds or even thousands of percent, as was the case when Martin Shkreli raised the price of Daraprim in 2015, which made him infamous overnight .

3. It takes more than the sticker price to know if a drug price is “fair”

Drug pricing is complicated. One of the biggest challenges in determining a reasonable price for a drug is that the cost must be weighed against the effectiveness of the drug. Two common methods of valuing drugs are to compare the drug to the current standard of care and increase the price in accordance with the benefits (safety, efficacy, adherence) it provides or to place a value on the complications that it can avoid. Thus, an expensive but very efficacious drug could be relatively more cost-effective than a drug with a much lower price tag but less efficacy. As an example, consider Harvoni, a hepatitis C drug that was developed by Gilead pharmaceuticals. The drug was initially priced at $95,000, although with discounts the average cost is about $40,000 for a course of treatment. While the sticker price is high, it cures hepatitis C in over 90% of patients – so even though the price of the drug is massive, it is considered a “high value” treatment.

 

To hear more about drug pricing, orphan drugs, patents law surrounding drugs, and some legal history of drug pricing in the United States, check out this episode of the HealthX podcast.

– Logan is a second-year medical student at the Perelman School of Medicine. He was the co-VP of curriculum for Penn Health-X in 2017, is an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –

Crash Course in Health System Quality Improvement with Dr. Neha Patel

– Logan Brock, MS2 –

For our most recent HealthX Crash Course, we hosted Dr. Neha Patel, MD, MS, who gave a Crash Course on healthcare quality and patient safety. Dr. Patel earned her medical degree at the University of Pennsylvania School of Medicine and completed her residency in internal medicine at the Hospital of the University of Pennsylvania. She has been a practicing hospitalist in the Section of Hospital Medicine since 2009. During her time as faculty at Penn, she completed a Master of Science in Healthcare Quality and Patient Safety at Northwestern University in 2013. In 2016, she transitioned from Interim Chief of the Hospitalist group to become Associate CMIO at Penn, in a role that was specifically created for her to develop Penn’s mHealth strategy. Additionally, she serves as the Director of the Healthcare Leadership in Quality Residency Track, which prepares physicians for leadership roles in health system by providing hands on experience improving healthcare quality. To top it off, she serves as Director of Mobile Strategy and Applications at Penn Medicine. Here are some key takeaways from her talk:

Work Within a Framework – It Doesn’t Matter Which

The key to successfully implementing quality improvement projects in a hospital system is to use a framework that allows problems to be approach systematically. While this is crucial to ensure effective quality programs, it is less important which specific framework is followed. There are a number of different change management systems that are used in healthcare, including Six Sigma and the Model for Improvement. While these models differ slightly in their approach, each provides a method to rapidly design, test, improve, and implement changes to hospital systems, allowing the hospital to continually improve.

Measuring Healthcare Quality is Extremely Complicated

While it certainly isn’t surprising to hear that measuring quality in healthcare can be a challenge, Dr. Patel illuminated just how challenging it really is. In the current healthcare climate, terms like “bundled payments” and “value-based purchasing” are frequently tossed around – however, it can be rather complicated to understand what they really mean. As an example, Dr. Patel brought the current year’s value-based purchasing “domain weighting” chart – essentially, the metrics to which 2% of all Medicare payments are tied in 2018 (here’s an overview of value-based purchasing). The metrics include four categories that contribute to the overall “value” the hospital provides and multiple subcategories within each category. As an example, one sub-category is “pain management,” as reported by patients. The score used for this metric is compiled from surveys randomly given to patients, in which they rate the quality of their hospital stay. Thus, improving the score would likely require massive overhauls in hospital operations, and this is just one of many metrics to which hospital reimbursement is tied. This crash course conveyed the immense challenge of measuring healthcare quality.

Improvement Requires Openness to Evaluation

Dr. Patel highlighted one of the most significant challenges to implementing quality improvement initiatives in the hospital – in order to make changes to improve a process, it is first necessary to admit that the process might be flawed. In a healthcare system where doctors are working as hard as they possibly can to provide the best care they can, it is a difficult shift to admit that there could be room for improvement. Thus, one of the key challenges in improving healthcare quality is allowing the measurement and reporting of areas where care could be enhanced. This is naturally difficult for a profession in which mistakes can have life-or-death consequences, but it is crucial for continual improvement.

 

It was a pleasure to host Dr. Patel and learn more about quality improvement in healthcare and the significant challenges that physician-leaders grapple with every day in their quest to provide better healthcare.

– Logan is a second-year medical student at the Perelman School of Medicine. He is the co-VP of curriculum for Penn Health-X, an occasional co-host of the Penn HealthX podcast, and a contributor to the Penn HealthX blog. You can contact him at  john.brock@uphs.upenn.edu –