Weekly Health Tech Reads | 11/19/23

Women's health research investment, prior auth benchmark data, Humana VBC report, and more!


Sharing our perspective on the news, opinions, and data that made us think the most this week


Summary: The White House Initiative on Women’s Health Research, led by First Lady Jill Biden, has been established as of November 2023 with the explicit aim to bridge significant research gaps in women's health. In order to do so, the initiative will call upon various executive departments and agencies to focus on advancing research, forming policy recommendations, addressing health disparities, and promoting women's health, both through public and private partnerships. The initiative has committed to making concrete recommendations on steps to advance women’s health research to the President within 45 days of its establishment.

Emma Sugerman's Reaction:

Emma Sugerman is the Co-founder and COO of Mavida Health, a maternal mental health company. Prior to Mavida, Emma worked in various senior roles at Charlie Health, Headspace, Lifestance Health, among others.

  • This is a big deal! The initiative represents a significant milestone, addressing the historical underinvestment in women's health research. For too many years, female populations in research studies were regarded simply as “tiny men” - and often left out of research studies altogether. (Before 1993, it was not a requirement to include women in studies.) This of course has evolved, but we continue to have a limited understanding of how broader conditions specifically affect women, as well as how conditions that only affect women behave.

  • This is acknowledgement from the highest levels of leadership that relying on medical research that is composed primarily of men has led to a substantial gap in understanding how various health conditions uniquely affect women’s physiology, hormones, and overall health - and led to significant gaps in prevention, diagnosis, and treatment of women’s health conditions.

  • I am thrilled to see this much-needed attention brought to the field of women’s health through research - but as ever, we still have a ways to go. Increasing funding for research and development of solutions in women’s health is a phenomenal first step in increasing funding for building in women’s health solutions overall. And, of course, the need continues to increase investment in research around health issues for other marginalized communities and groups. Excited to see what’s next!

HTN Slack Convo (h/t Jayne Jang Belz)


Sharing a visual or two from the week that made us think

Cohere Health published a whitepaper benchmarking prior authorization practices across health plans, drawn from a database of over 100 plans.

Sam Stearns' Reaction:

Sam Stearns is the VP of Payer Solutions at Cohere Health, a clinical intelligence company focused on transforming utilization management. He worked in leadership roles at Optum Analytics and Verisk Health before joining Cohere. He shares his reactions to the report’s findings:

There is substantial variation in prior authorization practices across health plans, as illustrated in the chart above. On average, health plans require prior authorization for almost 2,400 different CPT codes.

  • National and Insuretech plans require prior authorization for 60% more codes vs. BCBS plans, and regional and provider-sponsored plans manage ~2,500 codes on average.

  • This variation reflects substantial differences in utilization management practices across lines of business (e.g., Medicaid plans manage ~2,700 codes on average vs. 2,180 in MA and 2,360 in Commercial), as well as plan-level differences.

  • BCBS plans manage the fewest number of prior authorization codes, reflecting a historical focus on maintaining strong relationships with local providers to secure competitive network discounts.

The benchmarking results illustrate a simple but common problem creating administrative burden: helping providers understand what codes require prior authorization.

Some plans report that as much as 30% of prior authorization submissions are for codes that do not require authorization. Federal and state governments are developing legislation to improve the prior authorization practices, most notably CMS proposed rule 0057-P, which includes new requirements for transparency and prior authorization APIs starting in 2026.

These developments point to growing industry momentum to make the prior authorization process more digital, transparent, and automated to reduce the burden for providers and help members get faster access to care.

Humana released its latest annual report on the state of VBC. As always, it's worth perusing to see the current state of value-based care inside Humana. On the whole, Humana reported 70% of its members were in VBC relationships, a slight increase from 68% last year and 66% in 2017. Humana highlighted in this report that VBC physicians earn 3.4x the Medicare fee schedule, and those in "advanced stages" (presumably downside risk?) earned 6x the Medicare fee schedule. It would be quite interesting to know what the numbers look like of members and PCPs in "advanced stages" of risk contracts with Humana. Humana notes in the image above the goal isn't to get all providers to advanced stages of risk, but rather meet them where they are, which seems like a growing theme in the space.


A round-up of other newsworthy items we noticed during the week

According to a recent STAT report, UHG subsidiary naviHealth has been using an algorithm to move members from rehab to home care faster than appropriate in some situations. The article dives into how naviHealth case managers felt pressure to stay within 1% of the algorithms recommended timeline, even if they felt differently. It's an interesting look into the perils of attempting to standardize care delivery using algorithms for the industry as a whole.

Primary care startup Forward made headlines this week, announcing a pivot to focus on health kiosks alongside an announcement that it has raised $100 million in Series E financing. With the funding, Forward is launching twenty-five kiosks, called CarePods. CarePods will be located in malls and office buildings, and cost $99/mo for unlimited access. According to the TechCrunch article, Forward has plans to launch 3,200 kiosks within the year, which is... a lot? Forward seems to generate one of two pretty strong reactions for folks. On the one hand you can see why tech optimists look at the vision of low cost healthcare at scale using AI and see why they're excited. On the other hand, when you suggest you're going to launch 3,200 kiosks in the next year - at a $99/mo subscription, without taking insurance - that vision feels a lot more like a hallucination than anything else.
Link (Techcrunch) / Link (Forbes)

One Medical announced three partnerships in the past week or so, including Hackensack Meridian Health in New Jersey (link), CommonSpirit Health's Virginia Mason Francisan Health in Seattle (link), and the Health Transformation Alliance (link). The first two partnerships seem like typical One Medical relationships with health systems in local markets to coordinate care between primary care and specialty (and presumably benefit from health system payor contracts). One Medical will be building new clinics in NJ with Hackensack, it already has clinics in Seattle. The third partnership, with HTA, appears to be more of a go-to-market relationship as HTA will offer One Medical services to the ~60 companies it works with.

Consolidation in the mental health space is heating up with two recent deals. UpLift, a telemental health company, announced it will acquire Minded, a women focused digital psychiatry provider. Additionally, BehaVR and Fern Health are set to merge to create digital care management platform for chronic pain, called RealizedCare.
UpLift/Minded Link / Slack | RealizedCare Link / Slack (h/t Kevin Wang)

A new rule announced by the Biden Administration this past week will implement new billing codes to allow private insurers to pay for care navigation services for cancer patients, as well as Medicare members.
Link / Slack (h/t Kevin Wang)

AristaMD and Sitka, two startups in the eConsult market, have merged together and announced a new $16.5 million in funding.


A collection of notable startup financing rounds across the industry

Better Health Group, a VBC provider group, raised $175 million growth financing to support new risk-based partnerships, strategic acquisitions, and help open de novo clinics. The existing group operates 1,200 owned and affiliate groups across the country.

Sunnyside, a mindful drinking app, raised $11.5 million in Series A funding to launch AI-powered drinking support coach.

Fortuna Health, a Medicaid enrollment platform, secured $4 million in Seed funding to pursue state expansion and expand partnerships with managed care organizations (MCOs) and health systems.
Link / Slack

Layer Health, a clinical note analysis startup, raised $4 million in Seed financing. The company is leveraging LLMs to support various clinical administrative functions, such as clinical document review, RCM functions, quality measurement, and more.
Link / Slack (h/t Ben Lee)

Coverself, an insurtech startup, secured $3.4 million in additional funding, extending its Seed round to $8.2 million in total. The company plans to use the funding to develop gen AI capabilities and hire additional sales and marketing staff.

Pathway, an AI-based clinical decision support platform, raised $5 million in Seed financing. The startup's primary product, Pathway AI, is an open-sourced knowledge tool available to help clinicians with nuanced medical queries.

BeMe Health, a teen-focused mental health company, raised $1.5 million and inked a new partnership with BCBS Kansas. Through this strategic partnership, BeMe will provide mental health support to ~20,000 teens across Kansas.

Lunit, an AI-driven cancer diagnostics and therapeutics company, announced it recently secured $150 million in fresh capital to support new product development, hiring, establish a CVC, and make US/Europe based strategic investments.


A round-up of posts from the broader healthcare community this week that made us think

Evaluating the Behavior of Call Chaining LLM Agents by Benjamin Baker, Evan Poe, Nazem Aldroubi

An interesting deep dive into Oscar Health's work building a GPT-powered assistant to help answer queries about claims processing. It covers challenges faced with GPT-4's current functionality and an overview of how the Oscar team built its current claims processing tool.

A neat slide deck presented at Stanford on various applications of ChatGPT in internal medicine. The materials walk through different case study examples of AI scribe tools.

This article highlights 5 use cases of AI to solve payor issues, including member and provider services, care management and coordination, claims processing, utilization management, and more.

The Redesign Health team put together an article worth checking out that digs into how alternative financing models can help strength the broader Medicaid program.

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