TSR's Small Incisions - 10/27/2024
Hot healthcare takes from the Surgeon's Perspective
A rundown of stories from across the healthcare ecosystem — health tech, health policy, digital health, value-based care, and more — with commentary.
Presented by Commons Clinic
This week:
A Healthcare AI story that’s not about Gen AI (but still cool)
Adventures in Opacity: Medicare STAR Ratings
Loss of joy (and what to do about it)
The World’s Least Inspiring Bot War
Wellness for Everyone
Digital Health IP-uh-oh?
ICYMI: My thoughts on HLTH
AI model can predict health risks, including early death, from electrocardiograms (Medical Xpress)
In healthcare, generative AI is garnering a lot of attention and investor focus has shifted to streamlining administrative tasks. We can’t forget about predictive and causal AI. Using an EKG tracing, this model was able to predict a patient’s risk of worsening disease and early death. Clinical applications of AI must pass a higher bar than back-office implementations. But their impact could be much greater — personalizing care and finally making headway on reducing costs and improving outcomes. Artificial intelligence won’t replace cardiologists any time soon, but AI models can see subtle patterns and make complex connections humans can’t. Though we’re still years away from the model being reliable enough for regular real world clinical usage, the future of predictive and causal AI in healthcare is bright. (Provided we have the patience and rigor to do it right.)
Trick Or Treat: The Fuss Over Medicare Advantage STAR Ratings (Sachin Jain via Forbes)
A nice explanation of Medicare Advantage STAR ratings from Sachin Jain. STAR ratings are a key feature of MA and one of the mechanisms by which plans benefit financially. A few big players like United and Humana experienced a drop in the recently released 2025 ratings. Both companies’ stock prices took a hit. Like many things in healthcare, the rules around MA STAR ratings are complex, opaque, and hard to parse — especially for patients who don’t know how to access them. Some plans engage in tactics to artificially inflate their ratings without improving care. MA is purported to be a form of value-based care, proving the point that no payment model is free from perverse incentives or system gaming. As he points out, Sachin is President and CEO of SCAN Health Plan which successfully sued CMS last year over STAR rating methodology. Other MA plans are following…suit. Whatever you think about Medicare Advantage, the complexity and brittleness of the STAR Ratings system is wild. There has to be a better way.
Why we aren't happier: The loss of joy in health care (Physicians Practice)
The loss of joy in healthcare permeates many areas and has trickle down effects that create a vicious cycle. Respect for our profession is in decline. We’ve gradually lost autonomy and control, are increasingly emotionally exhausted, and are overburdened with clerical work. These factors contribute to a lack of purpose and meaning in our work and personal lives. Moral injury leads to burnout. What’s the solution? For me, getting involved in startups, finding work-life harmony with side gigs, low level “biohacking,” and finding joy in the small day-to-day moments have been extremely effective. The practice of medicine is still incredibly rewarding when you strip away the external factors that deplete joy. Beyond that, I believe solving the loss of joy problem in healthcare is a tremendous opportunity to innovate that doesn’t get enough attention. Building a practice model that emphasizes clinician autonomy, agency, and purpose would go a long way to restoring joy.
Broken processes, only faster! This isn’t exactly the healthcare AI arms race we all wanted. Use of algorithms to deny care has already garnered scorn and regulatory scrutiny. Dueling claims review bots seem so…uninspired. We already have a version of this game; it just moves at a slower pace. Shouldn’t AI resources (and associated costs) be leveraged in a more productive way? Devising a faster way to deny claims is hardly revolutionary. It’s sad that we have to use technology to address self-inflicted wounds and manufactured complexity. Sure, it’s great that AI tools will reduce the prior authorization and claims adjudication processes that bog down practices. But wouldn’t it be better to use AI tools to eliminate the need for these things in the first place?
"Concierge wellness" becomes a new primary care (Axios)
Somewhere in the morass of longevity and “concierge wellness” is a worthwhile concept that centers around cardiometabolic health optimization. If wealthy patients want to pursue unproven treatments to cheat death at their own expense, so be it. Wellness is a broad term that could certainly apply to using methods of exercise, dietary changes, biometric data, and blood panel monitoring to promote overall health and disease prevention. Putting a patient on a medication isn’t a failure when it’s needed, but the goal should always be to minimize pharmacological treatment as much as possible. The key here is to offer evidence-based approaches and do things that are backed by data, not the ability to separate a fool from their cash. Holistic care and the mind-body connection sound like new age BS, but years as an Orthopedic Surgeon have led me to believe that’s not the case.
Q3 2024 Digital Health & Healthcare IT Public Comp Sheet and Valuation Guide (Pitchbook)
Pitchbook doesn’t paint a rosy picture: “Consumer facing digital health companies have continued to face headwinds from crowded markets and limited patient demand for virtual-first models.” A few thoughts here. Defining who the “consumer” is in healthcare isn’t always easy. While most assume it’s the patient, that’s not necessarily the case. Patients may be the end users, but your real customer is often the clinician who champions your product. Second, virtual models work best when they have some connection to in-person care. (Oshi Health is an example here). As we anticipate IPOs for two of the largest virtual MSK companies, it will be interesting to see if the next wave of startups has solved these issues. “Companies that are able to turn a profit over the next year are likely to be more appealing to public investors.” The days of inorganic growth and promises of future profitability may be gone, favoring those who expand strategically and sip investor money. (Of note, Sword founder “V” Bento reported positive cash flow for Q3 2024 last week. No word on whether the same is true for Hinge).
Un-HLTH-y (The Surgeon’s Record)
I appreciate the thoughtful feedback on my "Un-HLTH-y" blog post. Healthcare is evolving and will rely heavily on collaboration from all. It's good to hear that clinician presence at meetings like this is growing. At the same time, I still think there’s more work to do to bring the voices of practicing, front-line clinicians—those delivering care every day—into the bigger conversations about the future of healthcare. I’ll always advocate for the clinician's voice, not just at conferences but in all situations where important discussions and decisions are taking place. It’s true I wasn’t at HLTH. It’s fair to say that, if you haven’t experienced something firsthand, your opinion is underinformed. That’s kind of the point. It’s why I advocate for spending time in a clinical setting (and for amplifying the voices of those who have). If you haven’t had a chance to read the post yet, I encourage you to check it out and share your thoughts. You might be surprised by the message. Whether you agree or disagree, it’s a conversation worth having.
Ben Schwartz, MD, MBA
Editor-in Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
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Dr. Schwartz,
I have been following your writing for a while now and relate to most of what you say. I keenly follow the healthcare space and have been searching for answers for the last 7 years as the Founder/CEO of a health tech startup. While there is no shortage of opinions from clinicians like Dr. Dorn, Li, Walker, etc (and my wife who is a physician leader at a large NYC health system) and non-clinicians, I have yet to come across a discussion on the root cause of the current state. So hear me out!
The health system is simply not set up for handling the volume it currently supports. The fundamental process of diagnosis and treatment involves too many steps, each of which consumes time and effort. For healthcare to improve the number of patients treated by the system needs to reduce by 80%. Imagine how much better the system would serve the remaining 20%. We have no one to blame but ourselves. Until we as individuals take responsibility for our own health, we will fail the 20% that truly need the system as it stands today.
We have convinced ourselves that our actions have no consequences. An unhealthy diet and no exercise which leads to elevated BP, cholesterol, A1C all can be treated with taking a pill. GLP1 makes it worse. Little or no exercise leading to MSK issues can be easily fixed with joint replacement, etc. You get the point. Most pharmaceutical intervention is designed to treat our poor choices. So why bother, surely it is not my fault that my own health is poor. Everyone else is to blame except me is the prevailing attitude. Hence if my BP is elevated, I end up consuming scarce healthcare resources in terms of the doctor’s time, diagnostic lab tests and eventually hospitalizations. This takes away resources from the 20% of the population who really need it.
No amount of efficiency improvement, AI or other future technologies can keep up with the increased demand for the current health system. Imagine if you were stuck on a desert island but magically had access to your own health condition. If you knew for sure, there is no access to any pharmaceuticals or health professionals, I am sure most people would figure out how to keep themselves healthy. These same people, when they are in the real world, have no compunction in lining up for a doctor’s visit at the first sign of discomfort.
This lack of self-responsibility extends to other spheres beyond healthcare. By nature, we tend to look outwards before introspection. This is also fundamentally why religion and philosophy have done little to elevate the human condition. For example, Buddha clearly diagnosed the problem of human suffering, but his prescription has little or no chance of succeeding because it is not for the faint of heart.
I am still waiting for the pill to attain nirvana! In the meantime I will keep myself distracted with technology and process improvement, payment models, VBC, etc.