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Comment by jackcn | Hacker News Reader

Like I've mentioned before, Theranos needs to shut down. The technology doesn't work (and likely it never will since blood constituents are not evenly distributed at small volumes) and its investors and executives are complicit in fraud. While half-completed/non-working solutions are fine in software world and with consumer electronics, a misreading or missed reading of blood parts can easily cost the health or life of a person. I'll be glad to see the SEC/FDA put an end to this.

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I, for one, would mourn the death of Theranos. I live in Phoenix and used their lab service before all the negative press came out. They did the micro-vial testing on me so the blood draw was totally painless, quick, and just a few bucks per test.

The big issue of course, is maybe the results I got can't be trusted, and sadly I think for my next blood draw I'll use a traditional lab so I don't worry about accuracy (even though traditional labs apparently make mistakes all the time[1]).

Theranos does get an F for public relations. I'd love to read an interview with Elizabeth Holmes on her take on all the negative press. Did they really screw up this badly? Are there fundamental limitations in their technology, or did they just bungle execution? Do they feel they are misrepresented in any way by these articles?

The real point is that they were at least trying to do something revolutionary and we only hear the WSJ side of the story and can't know what legal restrictions (or internal bungling) prevent them from sharing another perspective. If somehow they can navigate their way out of the swamp, it'd be a great win to have cheaper/faster/less painful labs available for the masses.

[1] http://www.jsonline.com/watchdog/watchdogreports/weak-oversi...

healthcare is a very hard problem.

While we in the tech community may find it morbidly entertaining to watch Theranos burn to the ground. Someone out there needs to attack healthcare. The not dying motivation is fairly important.

It's better to make photo-sharing apps and sell iphones. While healthcare is very hard, also needs alot of money. My idea would be: create photo-sharing app/telegram/iphones etc to make alot of cash and THEN try real-science-shit (like Elon Musk / ~Paypal Mafia).

The attacking part is great. It's the "fail fast" part that they messed up on. If the machines worked, would we be having this conversation about a company accused of lying to regulators and defrauding investors?

Maybe it's a problem of Theranos setting investor expectations poorly, maybe the regulators are looking to make an example of someone for playing fast and loose in the traditionally tightly regulated healthcare industry, maybe both. Hopefully it's growing pains for a burgeoning biotech market and not actually fraud from the top.

> Someone out there needs to attack healthcare.

All the attacking that needs to be done is political/social, not technical. Want to attack healthcare? Strip middlemen out so that the money flows to providers and researchers (Single payer + pouring additional money into the NIH/NSF, with the results being public domain).

All of these YC startups I see "hacking" healthcare (Dr Chrono, HealthSherpa, etc) are just bandaids on a patient bleeding out from the jugular.

EDIT: Before you chime in to state that single payer can't be done, 58 countries [1] enable it just fine. Governments can be even more accountable than the current breed of private health insurance providers (I cannot replace the board at my insurance carrier, nor can I FOIA them).

If you want to "hack" healthcare and fix the problem, get involved in government and get single payer done.

[1] https://en.wikipedia.org/wiki/Universal_health_coverage_by_c...

Here is a good factual overview of why Single Payer won't make health care cheap in the US:

http://www.bloombergview.com/articles/2014-04-30/single-paye...

My post never said it would be cheap. It would ensure 1) everyone was covered and 2) less funds were skimmed out by health insurance companies, leaving more funding to be used for health providers.

It would also help if a republican Congress didn't require Medicare to _not_ negotiate on drug pricing with for-profit drug companies. Way to leach off the public teat "small government party".

I prefer to make the distinction between Corporatism vs. Capitalism in these type of discussions. Corparatism, the big companies and governments as a symbiotic unit, not Capitalism is the problem. I have lived in Montreal with its public health care system for a year, and I now live in a rice farming village in East Java, Indonesia with their public healthcare system, and I grew up in Brooklyn, NY, so I speak from my experience and what knowledge I have acquired. Sure, you can go to the doctors here in East Java, and pay $1 to $2, and walk away with 3 or 4 prescriptions, but I am not sure that is good for several reasons. People go without even a thought to thinking about their ailment or complaint. The doctor doesn't do more than listen, and possibly listen with a stethiscope, and then prescribe generic medications to treat the oral complaint. I have seen my father-in-law come back with 7 medications due to high blood pressure. I checked it with my portable monitor, and he does have high blood pressure. They prescribed a blood thinner, an antacid, and bunch of other meds you would see as possible prescriptions. My twelve year old niece had a blood test at school, and her cholesterol was a bit high. Result: 3 prescriptions, and not a lot about diet change or exercise. Lines are longer the closer to the city you get. Here people are there with sore elbows, headaches, etc... These are people who shake off a lot of hard daily work and bruises. They go at a whim when they are not working, and bored, and the simplest of ailments are perceived. I am anxious about the amount of prescriptions handed out, and the quality. In Montreal, in Spring or in stretches of good weather, there would be lines outside the emergency room. I went and inquired if it was for flu shots, or some other special day since they had setup folding tables and chairs to handle the patient load. The jaded healthcare worker explained this was typical, and made some comment about if somebody sneezes, is bored on unemployment, they head to the emergency room. My daughter needed surgery back in NJ, USA, while I was in SE Asia, and I thought it was going to cost me $16k to $20K, since my coverage had just expired. I asked how much to pay up front in cash to make sure she could get the surgery, and it turned out that if I paid the hospital, the anaesthesiologist and the surgeron each separately the cost would be and was $5k. I asked why, and I was told by all 3 offices, that this was their real price, and that when it goes through the insurance companies they spend up to a year or more trying to collect, and at a 40% rate or less. The gratitude of me pre-paying in cash, was shocking. They never have that, and it makes for less work for them. They were so thrilled. The hospitals and doctors charge a lot more to make sure they cover the administrative costs of tracking and chasing payments, and to cover the costs of the procedures themselves. I guess that's what you get when you let big companies and government intervention do their thing. I am sad at this Theranos thing. I do not know about the truth; I guess we shall soon know. I see the idea of disrupting the labs and innovation as a good thing. So I hope guilty completely, partially or not, it has at least challenged the status quo. I know their are smaller quantities of blood testing kits available, not as small as Theranos, but I sure never heard of them before this fiasco. The benefit of reading HN! The conspiracy side of me, urges me to look at big Lab and Pharma as not wanting this to happen, or at least outside of their walls. They will make a slightly more volume blood test work, and now reap the publicity and sell it to the public and government. My Uncle Victor, who upon seeing my drawing of a car running on water buy using a solar cell to perform electolysis on water and exhaust of water back in 1974 (I had just built a solar oven and purchased a small solar cell, too small) spurned the idea, said to me: The big oil companies, or (pardon the racist, parochial remark here relayed) the 'arabs will come after you'. We used to call him Archie Bunker from All in the Family. A very funny show that would cause many to protest if it were on the TV nowadays. Sweden is always held up as a model of public healthcare, but we forget their financial crisis in the 1990s that started with slow growth once the US ended the gold standard in August 1971. They didn't get out of the 1990s crisis until they started embracing more capitalistic practices, so their healthcare system should not be used as an argument for it to be applied in the US. Not to mention, costs of covering 9.5 million people in a smaller geography, vs. 310 million people in a much larger geography. It is not simply a scaling problem or application.

This piece reminds me of the UNA-bomber pamphlets. The formatting is the best part of it :)

@pinaceae I accidentally upvoted you looking for 'reply' button. I admit I wrote this with little sleep after a game jam, and it is lengthy, and not my best writing, but I was responding to the healthcare aspect of @toomuchtodo's thread. Was your remark intended to be snide? I find it offensive in any case that you would compare what I have written to a murderer. I guess with all of your karma here on HN, you find it easy to hide behind your keyboard without much consequence. I am always eager to hear opposing view points, not for argument's sake, but to learn. Hopefully this can turn into a less ad hominem discussion, and we can both walk away a bit better off for it.

[EDIT] - moved reply to @pinaceae, and deleted from under my comment.

Summary of the article: A single payer system works well everywhere else, but is politically impossible in the US.

That is a sad indictment of US politics.

Well, its politically impossible now, but people opposed to it are dying every day.

Same sex marriage, marijuana decriminalization/legalization, etc all took time. This'll take time as well. I just wish people didn't have to suffer and die because of their fellow citizens' shortsightedness.

"Progress occurs one funeral at a time."

There's hundreds of factors affecting the efficiency of a singe payer system in the US compared to other countries, including population size, illegal immigration, crime rates, etc.

Solutions for one country may not work for another

The problem with the U.S system is everyone has their hand out for money. In America, Money is considered the universal yardstick for success and universally effective solution to all problems. The health care industry grew 20% last year? Fantastic!

It's a perfect example of the civilizational collapse process that Joseph Tainter, a professor of archeology, wrote about in his book "Collapse of Complex Societies"[1]. A society will get some sort of civilizational process that works to create wealth in their society. The civilization will continue to increase complexity to exploit this process and when the process starts returning negative marginal returns the collapse process begins because the whole civilization can't switch into reverse. This happened to the Romans with their conquer and receive tribute process for example. It eventually started yielding negative returns and they couldn't reverse course. The inertia was just too great.

[1] http://www.amazon.com/Collapse-Complex-Societies-Studies-Arc...

You need a politically strong somewhat lefty government to ram it through against the vested interests who are rich from the present system. Single payer was opposed similarly in the UK but we had a landslide left wing government after WW2 who got it done. A shift in the US towards say Sanders could do it but it doesn't look like that's happening this time around.

That factual piece only makes one real argument, which is that reducing income flows to the healthcare sector would be politically untenable.

That argument applies equally to based solutions to the problem which are not proceeding because of regulatory capture.

Something has to give.

two things struck me as a little odd.

One, the private costs are off the chart with regard to our peers, but the government spending is just "more than average". but more than average is presented as being just as bad as the outlier we are in the first case.

Two, medicare is responsible for the most expensive health years of a person's life. The time when our bodies just start to fall apart and require a lot of specialized care. Medicare's cost controls seem really good when their youngest clients are 65. Comparing their costs to a private company, who insures working adults, seems like a shallow analysis.

I think the argument is that US government financed health care that only pays for maybe half the population is already more expensive then paying for 100% of the population in other countries.

So it's a stretch to imagine that having the US government take on many more patients would lower costs.

> So it's a stretch to imagine that having the US government take on many more patients would lower costs.

Sure, given your current system, it won't. So change your current system.

While converting from our current patchwork system of government healthcare (a system that's been fragmented in large part due to insurance industry lobbying) will have a high initial cost, it will ultimately be more efficient. As it stands, the insurance companies add enormous overhead (office buildings, sales, advertising, etc), without actually providing any care.

That is in their opinion section, and is written by a columnist with an ideological bent so I would hesitate to call it a factual overview.

For those wondering why the US health care system is so much more expensive than any other country, I recommend this nice series of posts from Dr. Aaron Carroll: http://theincidentaleconomist.com/wordpress/what-makes-the-u...

Fair enough. It's a reasoned argument based on facts, but the conclusions are certainly opinions reasonable people can disagree with.

I suppose I got carried away by my agreement with it.

The Carroll posts look both very interesting and devastating for my productivity...

In the US, I think the current grass roots movement towards Direct Primary Care plus catastrophic coverage or a health savings account is more politically and logistically viable.

Single Payer would be great if you can trust the uh, payer. But our government is delightfully corrupt, so I'm sure a lot of people with more rare medical conditions would end up with worse treatment than they can get now.

Is it better that the majority who have common ailment get easy and very cheap treatment, at the cost of having a more expensive treatment for rare ailments?

"Single Payer would be great if you can trust the uh, payer. But our government is delightfully corrupt"

Lucky for us the health insurance industry we have is a paragon of virtue whose integrity is beyond reproach!

Is it actually corrupt? I hear a lot of hot air about the USG being corrupt, but I almost never hear about quid pro quo scandals... just politicians asking for money because their constituents demand expensive campaigns. We don't like what the government does sometimes, e.g. NSA etc, but I think we have an honest disagreement with them on the best way to protect the country (though they use shady tactics to get their way).

Essentially, it looks to me like government is incentivized to do their job, and most of the problems are due to the way people vote (though gerrymandering and voter disenfranchisement schemes like voter ID are a big problem). The soon as voters change their tune, politicians flip on a dime. I've seen it time and again.

So that said, I'm tired of this corruption meme. Can we talk about implementing good systems instead of assuming other people are out to get us?

Maybe we should outsource much of our government operations to people from western Europe. I propose a new law that only people from Iceland are allowed to run for Congress!

Single payer manages to function in plenty of countries with worse corruption than the US. The US is one of, if not the only rich country without a universal healthcare system.

In my country, we have a single payer - the NHS - and we also have private insurance which people can buy, or more commonly be given as a perk by their company, on top of that.

Result? Everyone gets generally great healthcare, nobody has to worry about bills if they get in an accident or fall seriously ill, and people who fetishize "great customer service" (mostly shorter wait times for certain things, though they don't have facilities to handle nearly as much as the NHS does) can get what they want too.

Have you considered that maybe the reason we don't have single payer when so many other countries do is precisely because our government is corrupt?

Well said.

> If you want to "hack" healthcare and fix the problem, get involved in government and get single payer done.

So we can turn what health technology gets developed into even more of a political game? Building a board of government insiders as opposed to scientists and clinical experts is exactly the kind of move that would work especially well in a single payer system. You want to know what healthcare would look like when governments were the only payors worldwide? Look at defense contracting. Or aerospace. He who had the best lobbyist would win.

If I could change one thing about the commenting on the state of our health care system it would be to require everyone who says "oh we just need single payer" to spend a year working for an insurer, a hospital, and a health technology manufacturer. Then come tell me that changing who pays will fix all problems. Here is a following not-comprehensive list of things that would not be fixed just be going to single payer:

- the US subsidizing all health tech (drug/device) development

- fee-for-service payment structure leading to perverse incentives

- malpractice fears leading to risk-averse, defensive medicine

- poor reimbursement rates yielding waiting lists to be seen by a doctor

- bureaucrats in CMS (the payors) exerting influence on the FDA to not approve new technology because they feel it is too similar to existing technology

- regulators creating vague rules that get applied differently from case to case, making them impossible to plan for

I could go on. I do agree with you that a lot of startups in the space are putting a bandaid on a bleeding jugular. But saying "let's get government more involved" neglects the fact that we're in this problem in part because government is very involved and has been since WWII.

There are three ways you can make healthcare better and cheaper for everyone:

- Make health technology cheaper

- Change the way health care is paid for (I credit Oscar for trying to make it in this space but for various reasons think they're unlikely to succeed)

- Change the way that health care is delivered

There are a number of startups tackling the latter (telemedicine, doctors on demand, drugs delivered to you, etc). Unfortunately the Affordable Care Act has many provisions that make it difficult to innovate in this space, because of the view that it's much easier to control costs when the point-of-care is controlled by a few big hospital systems.

I run a startup that's trying to tackle my first solution: making health tech cheaper by making it easier for startups to get their products through regulators and disrupt incumbents.

But even if we're wildly successful and can start lowering health tech costs across the board, the problem won't be fixed until we fix the payment structure, which will require innovation in payment models, not a one-size-fits-all government plan.

...to spend a year working for an insurer, a hospital, and a health technology manufacturer

Living decades in a "single payer" country gives you another outlook: that's a solved problem. You're just doing it wrong. Everybody that has seen it working knows it's wrong and will shrug off whatever ellaborate argumentation you choose.

fee-for-service payment structure leading to perverse incentives

Wouldn't a single payer system make this easier to change? I guess there is a high chance that a single payer law might codify the payment structure and do it in a bad way, but at least then there is a clear path to improving the structure. Legislation modifying the single payer system to work better would probably be less controversial than legislation modifying our current system.

I'd like to see the tax advantages around employer health benefits disappear so that people have to take a nice clear look at just how much they are spending on health care, rather than just handing money to providers.

I'd also like to see providers that benefit from regulation be required to provide up front information about the prices of low risk services.

Healthcare like almost every major enterprise vertical is a wicked problem[1] and these problems are pretty much rife with far more than just technical problems. Most of the VC founded ventures are honestly quite terrible at attacking the Fortune 100 that dominates these verticals including reasons like collusion as well as regulatory capture. A $10M+ series A seems like big money to a lot of the people in tech, in the enterprise space of the Fortune 100, that's a rounding error resolved by just firing one or two middle managers. I can hardly afford good sales guys covering all the regions for long enough of a sales cycle that I could confidently ever make a single deal on that alone - the enterprise approach to relationship-focused sales and procurement cycles forces the necessity of well-networked, very expensive sales people, unfortunately. That's the kind of slow-moving, massive capital flows that are at play, and there won't be any company that can attack that problem head on because it's not a technical problem whatsoever. Even worse, because these industries are capitalized heavily as public companies, their board of directors appoint super risk averse leaders culturally and will not move forward without finding a business model that will not cannibalize existing sales. Even still, if such a technology and business model existed, it is simply very, very easy to torpedo these efforts politically within these companies because these companies are already so profitable (think Hollywood-style accounting for a second, not tech company or even i-bank style simplistic accounting) they'd rather get rid of emerging competitors than to actually innovate. After all, in the health insurance space, as long as people (and, more importantly, companies) are paying premiums and subsidizing a sufficient number of costly patients that need care, there's little reason to really try to innovate in terms of technology there. That becomes something up to healthcare providers to try to work at, but they're typically courted by a very, very well capitalized and networked cartel of healthcare companies typically founded by doctors first, not technology people. Doctors may be smart oftentimes, but they're just not technology people fundamentally after decades of practicing medicine.

I agree that the problem must be attacked, but I have my doubts that it would come from a VC funded company in the same vein as most SV companies that have done so well. And as Theranos shows, I have my doubts that the highly kleptocratic cronyism driven private government contracting space will do it either. It may very well require a completely new model that incorporates the best ideas of both funding vehicles to avoid the common pitfalls of enterprise b2b companies.

[1] https://en.wikipedia.org/wiki/Wicked_problem

Well said.

Medical care and health care aren't actually the same thing. And the problem is that actually improving health for humans tends to be relatively cheap and culturally based. It is pretty much not a big money space. It involves things like inventing soap and getting people to wash their hands. And this is a thing most people do not want to hear.

Better drugs and better surgeries are all ooh, shiny! but they really are not optimal. The optimal approach is boring and hard to even see. People who fail to get sick are incredibly hard to measure. Heroic interventions after the fact are far easier to measure and make for more interesting press. They also can be charged big bucks.

The whole thing kind of sucks, frankly.

Good summary. Especially the healthy people being hard to measure. Never heard anyone put it that way before. Now that I think of it, it's usually easier to tie data points to specific illnesses than to a lack of them. I have a feeling I'll be wondering about this in the future.

Quick guess is that healthy relies on emergent behavior of locally interacting cells. Lots and lots and lots of complex behavior with few observable inputs and outputs into the body. The inputs might not have a direct correlation to healthiness. We'd have to have a model of all those processes before we'd see evidence of healthiness in the data points.

It is and so it's kind of absurd that someone would create so much hype around their company before they even had something working.

I would in fact call it irresponsible.

Given that patients relied on the faulty tests to drive healthcare decisions, one might even call it criminally negligent.

Half-completed and non-working solutions do not work in software. If the foundational technology of Facebook was floppy disks and gopher://, Facebook would not have seen the light of day. The problem with Theranos is not that its technology was a failure, it's that it was lying about said technology.

So if it doesn't work at one drop, if the Theranos sensing/sampling hardware is still good, then the fix would be to mix a large enough sample to present to the sensing system...

The one drop tech is the only reason Theranos was ever talked about. We already have equipment that works very well with larger samples.

You're right, I guess there is the small matter of how much more than a drop is needed. If it's 3 drops, that's much better then 3 vials they they sometimes have to draw for covering a range of tests - but it sounds like it might be much larger then a few drops.

Even three drops is much more than one drop, if you're pricking my fingers a bunch of times, I'd rather you just did a traditional draw, it won't hurt when I type later.

Agree completely. Not only do they need to be shut down, but people should go to jail.

It's strange to see the SEC go after them. It's kind of like putting gangsters away for Tax Evasion. If that's the only thing you can pin on them, I guess you have to go with it, but much better to nail them for the real crimes.

> blood constituents are not evenly distributed at small volumes

You're saying they're running into statistical stochasticity? Are you claiming they were sampling femtoliter volumes? That's the how small you'd have to get for your claim to be true.

Actually, yeah. The variance in the amount of quantities present in the blood draws by Theranos is too high to get useful measurements (without very many replicates, defeating its purpose) according to published research: http://ajcp.oxfordjournals.org/content/144/6/885.abstract

I was also utterly astonished when I read this. Even if the experimental error of the instrument was zero, you cannot reduce the biological variance short of drawing more blood or doing multiple measurements. However, this is such a no brainer that the idea that Theranos skipped this step seemed too crazy to contemplate - apparently not though.

Well you also seem to have skipped what that paper is taking about. For cell counts, yes, the stochasticity claim would be true for microliter scale volumes. For molecular constituents of blood, the claim cannot be true until you drop to the femtoliter range. I don't think the company was ever approved for cell counts, but I could be wrong.

Are you trying to model metabolites as perfectly diffusing molecules with D^2 proportional to an idealized Stokes radius?

No. I multiplied 1 nM by Avogadro's number. Do you have any reason to believe that free IgG is not uniformly distributed at steady-state in circulation? ... Because that's what they're testing for.

Many (most) of the things we're interested in measuring in blood are bound to some sort large macro-molecular assembly... be it cells, lipid vesicles, large protein agglomerates, etc.

In the clinic the most common testing is metabolic paneling (levels of various salts, urea, glucose, creatine, etc.), serology (for circulating antibodies), or cell counts (which they weren't doing, as far as I know).

The point, though, is that things like proteins ARE bound up in individual cells, so there are a whole host of tests that will vary based on number of constituent cells. Hemoglobin is one of the examples in the paper.

When you say "I don't think the company was ever approved for cell counts" - well, the company wasn't ever really approved for anything besides a herpes test, that's the issue.

Actually, that paper states that the standard deviation from finger pinpricks is about 5% of the mean value of, for example, platelets. The normal range has a standard deviation of about 25-50% of the mean https://www.nlm.nih.gov/medlineplus/ency/article/003647.htm. So, if anything, this study supports the conclusion that fingerprick tests have clinical utility.

You're wrong; a single red blood cell is several femtoliters. To get a good statistical count of much more rare (yet important) features one can sample much, much more than this and still get anomalies from having too small a sample.

Here's [1] a cool graphic showing the tip of the iceberg.

[1] https://en.wikipedia.org/wiki/File:Reference_ranges_for_bloo...

No, I'm not wrong. You're talking about testing for cell counts, which is not -- as I understand it -- what this company was approved to do. For molecular and protein components of blood on the nanomolar range, you would not encounter this problem until you were sampling in the femtoliter regime. Just use Avogadro's number, and you'll get it.

A lot of those molecules are bound up in cells, they are not freely diffusing in blood. Even those diffusing in blood are not uniformly distributed, blood is highly dishomogeneous.

Routine metabolic paneling and serology does test for molecules that are uniformly distributed in blood. I can't say it any plainer than that. Of course many possible testing targets are inside cells, but these tests were not claiming to look at any intracellular targets, at least as far as I know.

They weren't really clear about what tests they could perform with their technology, but they did say they planned on offering the "full range" of blood tests.

> blood constituents are not evenly distributed at small volumes

Clearly they should have diluted the samples further.

https://www.youtube.com/watch?v=HMGIbOGu8q0

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